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Examination of Male External Genitalia
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Fig. 19.7: Carcinoma of penis – proliferative type.
451
Fig. 19.5: Stone in the meatus which is visible.
Stone was extracted later.
Fig. 19.6: Carcinoma of penis earlier operated—total
amputation of penis was done with perineal urethrostomy.
Left side inguinal lymph nodes are enlarged with fungating
secondaries.
lesion. Urethral discharge can be collected by milking
the penis and discharge should be sent for culture,
and cytology.
Entire body of penis should be palpated for extent
of induration. Urethra should be palpated (Figs 19.7
and 19.8).
Fig. 19.8: Carcinoma of penis – ulcerative induration of
glans near corona in front.
Palpation of Lymph Nodes
Horizontal group of inguinal lymph nodes or Cloquet’s
deep node (from glans) may be enlarged. Its size,
number, surface, consistency, tenderness, mobility,
fixity should be checked. Iliac nodes above the inguinal
ligament may be involved due to spread from inguinal
nodes. Involvement of urethra also can cause enlargement of iliac node. In 50% cases initially the
enlargement may be due to infection only. Urethral
involvement is probably due to infection or tumour
(Figs 19.9A and B).
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A
B
Figs 19.9A and B: Carcinoma of penis – palpation of
inguinal lymph nodes both sides.
SRB’s Clinical Surgery
Disorders of Penis
Phimosis (Greek- a stooping up; a closure)
It is inability to retract the prepuce over the glans.
End of the prepuce is very narrow , often like pinhole
(pinhole meatus) (Fig. 19.10).
Causes: 1. Congenital - here the child has pinhole
meatus and ballooning of prepuce occurs when child
urinates. 2. Balanitis (inflammation of glans) and
balanoposthitis (inflammation of glans, prepuce and
sac). It is common in diabetics.
Problems due to phimosis: Recurrent balanoposthitis;
paraphimosis; ballooning of prepucial skin; retention
of urine; formation of prepuceal calculi due to smegma
collection in prepucial sac; carcinoma of penis later.
Fig. 19.10: Phimosis.
proximal to the corona and prepucial skin. As a result
the glans will be swollen, oedematous with severe pain
and tenderness. Retracted narrow prepuce at corona,
acts as a tight constricting ring which blocks the venous
blood flow causing congestion and, oedema of the
glans (Fig. 19.1 1). It is very painful and tender . Often
glans undergoes necrosis or becomes gangrenous.
Paraphimosis is often precipitated by sexual intercourse or iatrogenically after urethral catheterisation.
Paraphimosis
It is inability to place back the retracted prepuceal
skin over the glans. It causes ring like constriction
Fig. 19.11: Paraphimosis. Note the constriction band
and oedema.
Examination of Male External Genitalia
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Balanoposthitis (Greek)
It is the inflammation of glans and prepuce. Inflammation of prepuce is called as posthitis; inflammation
of glans is called as balanitis. It is seen in diabetes
mellitus, candidiasis, venereal diseases like syphilis,
herpes genitalis or drug induced. It can cause phimosis
(Fig. 19.12). In adult there may be underlying
carcinoma of penis. Pain, swelling, discharge and
discomfort are the features. Itching, creamy intolerable
smell, difficulty to retract prepuce, multiple fissuring
in the tip, itchy vesicles with shallow painful erosions
of herpes are other features.
453
Fig. 19.13: Chordee with hypospadias.
drainage. Glans and corpus spongiosum are not
involved.
Fig. 19.12: Balanoposthitis causing phimosis.
Chordee
It is fixed bending of glans penis, more obvious during
erection. It can be ventral or dorsal. Ventral chordee
is associated with hypospadias. During circumcision,
if ventral skin is excised more than needed, it will
cause chordee. Dorsal chordee is rare and is associated
with epispadias (Fig. 19.13).
Priapism
It is persistent, painful erection of penis. Corpora
cavernosa are filled with blood due to defective venous
Causes: Idiopathic thrombosis of corpora cavernosa;
Thrombosis of prostatic venous plexus; Sickle cell
disease; Leukaemia; Secondary deposits in corpora
cavernosa; Spinal injury or diseases and organic
diseases of central nervous system.
Peyronie’s Disease (Induratio-penis plastica)
It is development of fibrous tissue plaque on the
covering of corpus cavernosum and later involving
its full extent resulting in induration of corpus. It is
a slowly progressive disease of uncertain aetiology,
may be due to old trauma, often associated with
Dupuytren’ s contractur e, retroperitoneal fibr osis and
plantar fasciitis. Initial active phase has painful
erection with changing deformity of penis, followed
by quiescent phase where there is disappearance of
painful erection with development of deformity which
is painless. Later indurated plaque is noticed with penile
shortening and erectile dysfunction.
Rams Horn Penis
It is due to filarial involvement of penis where it
becomes thick and distorted resembling horn of a ram.
It is actually elephantiasis of penis (Fig. 19.14).
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Fig. 19.14: Penile oedema and scrotal oedema.
Hypospadias
SRB’s Clinical Surgery
It is the commonest congenital malformation of urethra
wherein external meatus is situated proximal than
normal, over the ventral (under) aspect of the penis.
Classification: (1) Glandular: Meatal opening in glans.
It is the commonest. (2) Coronal. (3) Penile. (4) Penoscrotal. (5) Perineal with split scrotum and meatus
is 3 cm in front of the scrotum. This is associated
with bilateral undescended testes.
Features: (1) Absence of urethra and corpus spongiosum distal to abnormal urethral orifice. (2) Bowing
or bending of penis distal to abnormal urethral
opening (chordee) with poorly developed prepuce
over inferior aspect. (3) Urine soakage over the
scrotum with dermatitis and infection. (4) Associated
congenital anomalies are known to exist. In
hypospadias circumcision is contraindicated as
prepucial skin is required for future urethroplasty.
Epispadias
Here urethra opens on the dorsum of the penis proximal
to the glans. Abdominopenile is the commonest
type. Occasionally it can be glandular or penile. It
is associated with dorsal chordee, ectopia vesicae,
urinary incontinence, and separated pubic bones (Fig.
19.15).
Carcinoma Penis
It is commonly squamous cell carcinoma, but
melanoma, adenocarcinoma from T yson’s gland, basal
cell carcinoma and secondaries may also occur.
Aetiology: Chronic balanoposthitis, phimosis;
sexually transmitted diseases; leukoplakia of glans;
long standing genital warts; Paget’s disease of penis
(Erythroplasia of Querat is persistent rawness of glans
penis); condyloma acuminata (human papilloma virus);
balanitis xerotica obliterans; HIV infection. Circum-
cision during infancy confers total immunity against
carcinoma penis. It is common in Asia and Africa.
Pathology: Infiltrating type occurs in a preexisting
leukoplakia; Papilliferous type eventually attains a
large size forming fungating foul smelling lesion which
Fig. 19.15: Extrophy of bladder with epispadias.
Examination of Male External Genitalia
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often gets infected. Glans penis is the commonest
site (coronal sulcus for basal cell carcinoma).
Spread: Through lymphatics to the horizontal group
of inguinal lymph nodes which become nodular and
hard. Lymph nodes on both sides can get involved.
Later external iliac group are involved (above and
on medial aspect of the inguinal ligament). Once
inguinal lymph nodes are fixed it causes severe
excruciating pain and lymphoedema. Fixed lymph node
status indicates the advancement of the disease. It
may erode into the femoral vessels causing torrential
haemorrhage and death. Carcinoma from penis and
glans spread to inguinal lymph nodes and then to
external iliac lymph nodes. From glans it also spreads
to Cloquet lymph node which is located in femoral
canal. Carcinoma from shaft of penis can spread
directly to the external iliac lymph nodes. It spreads
proximally to the body of penis causing induration.
Urethral meatus may get involved causing alteration
in urinary stream. It is a locoregional malignant
disease. Blood spread is rare.
Clinical features: In an adult, recent onset of phimosis
should give suspicion of carcinoma penis. Lesion is
painless initially but later becomes painful due to
secondary infection often accompanied by discharge
which is foul smelling, purulent and irritating. Altered
urinary stream; everted edge, ulcer, fungation and
induration, often extending into the body of penis are
other features (Fig. 19.16). Palpable hard, nodular
inguinal lymph nodes on both sides may be present.
External iliac lymph nodes may be palpable. Pain,
oedema, tenderness, redness develops once infection
occurs. Incidence is less than 1% of male carcinomas;
glans – 65%; prepuce – 20%; corona, shaft – 10-15%.
Buck’s fascia is resistant for initial infiltration; urethral
involvement only in late cases.
Investigations: Edge biopsy from the lesion shows
squamous cell carcinoma with epithelial pearls.
Broder’s classification: (1) Grading: V ery well diffe-
rentiated (75% epithelial pearls); Well differentiated
(50-75%); Moderately differentiated (25-50%);
Undifferentiated (25%). (2) Only FNAC of lymph node
(No open biopsy for lymph nodes). (3) U/S abdomen
to see external iliac lymph nodes. (4) SLNB-Cabana
sentinel node is located above and medial to the
455
Fig. 19.16: Carcinoma penis.
junction of saphenous and femoral vein. It is the first
node to get involved in carcinoma penis. So this
Sentinel Lymph Node Biopsy (SLNB) after isosulphan
blue dye injection into the primary is done to decide
for the necessity for ilioinguinal block dissection.
Staging of carcinoma of penis
Jackson’s staging of carcinoma penis
Stage I—Tumour involving only 90% five year survival
glans/prepuce / both
Stage II—Tumour extending 70%
into body of penis
Stage III—Tumour having 50%
mobile inguinal nodes
Stage IV —Tumour spreading 5%
to adjacent structures / fixed
nodes
TNM staging
T
No primary tumour
0
Tis Carcinoma in situ
T
Tumour < 2 cm without deep invasion
1
Tumour between 2-5 cm with minimal deep invasion
T
2
T
Tumour > 5 cm with deep invasion / urethral spread
3
Tumour spread to adjacent tissues
T
4
N
No nodal spread
0
Mobile regional nodes – unilateral
N
1
N
Mobile regional nodes – bilateral
2
Fixed regional nodes
N
3
M
No distant spread
0
Distant spread present
M
1
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SRB’s Clinical Surgery
Note:
Dresslers quadrangle – upper border is formed by
line joining anterior superior iliac spine and pubic
tubercle; laterally line joining anterior superior iliac
spine and a point 20 cm below it; medially pubic
tubercle and a point 15 cm below it. Nodal block
dissection for carcinoma penis should cover this area
adequately.
Buschke-Lowenstein Tumour
It is verrucous carcinoma of penis (5-15% common).
It is a curable malignancy; it is locally destructive;
locally invasive. It is large exophytic, dry, verrucae
like growth. It neither spreads through lymphatics nor
through blood. HPV 6/11 viral aetiology is proposed
(Fig. 19.17).
Fig. 19.18: Genital warts.
These warts are moist, multiple, with serous discharge.
Intraepithelial neoplasia and carcinoma of penis may
develop in these lesions at later period (Fig. 19.18).
Other Conditions
Morgagni Follicles Infection
These are pair of follicles which open laterally behind
the lips of external urethral meatus. Once it gets infected
only, these openings are seen as exuding pus. Often
it is seen in urethritis.
Fig. 19.17: Verrucous carcinoma of penis.
Venereal Warts/Papillomas
It is the commonest benign lesion which can occur
in uncircumcised or circumcised individuals. Sites are
glans, corona, frenulum, and urethral meatus. It is
sexually transmitted disease where trauma occurs
during intercourse. Human papilloma virus is the cause.
Tyson’s Gland Infection
Tyson glands are pair of sebaceous glands which
secrete smegma which are located on either side of
the frenum and ducts open into the prepucial sac. When
infected, presents as tender firm swellings on the
undersurface of the glans on lateral aspect, usually
as a complication of gonococcal urethritis.
Meatal Ulcer
It is seen in young boys usually 1½ years after
circumcision. Abrasions over the exposed unprotected
meatal mucosa by napkins cause ulceration and
scabbing. It causes small red ulcer in the meatus which
often heals eventually causing meatal stenosis that often
leads into retention of urine. Shortened anteroposterior diameter of meatus causes an acquired pinhole
meatus. Secondary urinary infection is common.
Examinations in Chronic Abdominal Conditions
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Examinations in
Chronic Abdominal
20
Chronic abdominal conditions comprises of vast
number of diseases. Often diagnosing and managing
many of them is a clinical challenge to a surgeon.
Exact clinical approach and a brief outline of different
conditions are discussed here. Detailed discussion is
beyond the scope of this book. Students are requested
to refer SRBs Manual of Surgery , 3rd edn or any other
surgical textbooks for explanations.
History taking begins with—
Name:
Age:
Sex:
Occupation:
Address:
Congenital pyloric stenosis occurs in newborn.
Duodenal ulcer occurs before the age of 35 years.
Gastric ulcer occurs after 35 years. Carcinoma stomach
occurs in old age. Chronic pancreatitis, gallstone
diseases and hiatus hernia occurs in middle aged.
Congenital pyloric stenosis is common in male
infants. Peptic ulcer, carcinoma stomach is common
in males. Gallstone disease, hiatus hernia is common
in females.
Peptic ulcer is more common in professionals and
executives. Old dictum ‘Hurry; Worry; Curry’ is
probable cause for peptic ulcer in India.
Gallbladder disease is more seen in north east India
like Bihar. Peptic ulcer is more common in south India.
Conditions
History
History of Present Illness
Pain
Pain in chronic abdomen may be sudden, colicky,
discomfort like, aching, etc. Pain is the one to which
patient comes for consultation with the surgeon.
Duration: Duration of pain often suggests the duration
of the disease commonly but not always. Peptic ulcer
disease, chronic cholecystitis, chronic pancreatitis may
be of long duration. Periodicity of pain is important.
It is seen in peptic ulcer disease. Patient develops pain
for certain period of time like few weeks or months;
later for certain period patient is symptom free for
few weeks or months. Peptic ulcer pain may be
seasonal. Chronic diseases are usually of long duration.
Site: Patient should be asked to point out the site of
pain with one finger. It may give clue about the origin
of the pain. Often pain is vague and diffuse in nature;
it may not be possible to pinpoint the site of pain.
Duodenal ulcer pain is pointed in duodenal point
2.5 cm right and above the umbilicus. Gastric ulcer
pain is in epigastrium in midline or left sided. Pain
of chronic cholecystitis is towards right side lateral
to right rectus muscle in right hypochondrium.
Radiation of pain: Penetrated peptic ulcer pain radiates
from epigastrium to back. Patient with chronic
pancreatitis also develops radiating pain to back.
Anastomotic ulcer pain is on the left of umbilicus (as
stoma is towards left side) which radiates to left iliac
fossa or to back.
Relation with food: In duodenal ulcer, pain is relieved
by food intake probably due to neutralisation of acid
in the stomach. In gastric ulcer, pain increases after
taking food. Pain appears early within half an hour after
food intake in gastric ulcer, in 3 hours after food intake
in duodenal ulcer. Pain on empty stomach is called as
‘hunger pain’. It is a feature of chronic duodenal ulcer.
It usually occurs in early morning. Patient gets up early
morning due to pain. Pain of carcinoma stomach is
continuous without any relation to food.
Relieving factor: Pain is relieved by taking food in
duodenal ulcer. In gastric ulcer pain is relieved after
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vomiting or induced vomiting. Patient develops pain
after food and so puts his fingers over the pharynx
and induces vomiting after which pain is relieved.
Nature of the pain: One should ask whether pain is
mild or severe. Whether it is burning or griping or
colicky type of pain. Often pain is more by movements.
Initial periodicity of pain may change to become
continuous type of pain if duodenal ulcer causes pyloric
stenosis or gastric ulcer causes tea-pot or hour glass
contracture.
Nausea and Vomiting
Feeling (sensation) imminent desire of vomiting is
called as nausea. It may or may not proceed into vomiting. It is observed in chronic diseases like pancreatitis,
carcinoma of stomach, peptic ulcer with complications,
hepatitis and chronic cholecystitis. It can occur in
carcinoma of pancreas, small bowel diseases, subacute
obstruction by diseases like abdominal tuberculosis.
Vomiting is a feature of pyloric obstruction, gastrointestinal irritation. Vomiting is forceful oral expulsion
of gastric contents. Regurgitation is appearance of
previously swallowed food in the mouth.
Nature and quantity of vomitus: It is important to ask
content, colour, quantity, smell of vomitus. Vomitus
may contain undigested food particles, blood, coffee
ground coloured material. Pyloric stenosis causes
projectile vomiting containing undigested food.
Bleeding peptic ulcer, oesophageal varices, carcinoma
can cause haematemesis. Large quantity , rapid bleed
causes frank blood in the vomitus. Small quantity of
blood mixed with acid of stomach forms acid haematin
presenting as ‘coffee ground’ vomitus.
Haematemesis
Vomiting blood is called as haematemesis. Chronic
peptic ulcer is the commonest cause (65%). Other
causes are acute ulcers, acute erosive gastritis, oesophageal varices, Mallory-W eiss syndrome, carcinoma
of stomach, gastric polyps, lymphomas, leiomyomas,
portal gastropathy, bleeding disorders, pernicious
anaemia, thrombocytopenia. Gastric antral vascular
ectasia is a rare endoscopically confirmed condition
which shows segmented dilated vessel meshes in the
antral mucosa (watermelon/tiger stripe stomach). It
is often associated with achlorhydria and hypergastrinaemia; Osler-Weber Rendu syndrome, aorto-
duodenal fistula, Crest syndrome are other rare causes.
Dieulafoy’s disease is gastric arteriovenous malformation which is covered by apparently normal mucosa
which occurs in proximal stomach along the lesser
curve. It occurs in proximal stomach near OG junction
(within 6 cm) along lesser curve (80% of cases).
Bleeding often may be severe and torrential. Profuse
rapid bleeding causes haematemesis with frank red
blood; slow small bleed causes coffee ground vomitus.
Haematemesis should be differentiated from haemoptysis. Haemoptysis is blood in the sputum during
coughing. Its content, colour should be asked to
differentiate properly . Gastric ulcer more often causes
haematemesis. In pseudohaematemesis, patient ini-
tially swallows the blood coming from upper respiratory tract and then vomits it out (Figs 20.1 and 20.2).
Frequency: Repeated persistent vomiting is observed
in pyloric stenosis, gastric ulcer. Vomiting is not a
feature in duodenal ulcer.
Relation to food and pain: V omiting after taking food
is a feature in gastric ulcer (in 2 hours). Recurrent
late vomiting (evening or 6-8 hours after food) is a
feature of pyloric stenosis. Vomiting is not related to
food intake in cholecystitis and pancreatitis. V omiting
or inducing vomiting relieves the pain in gastric ulcer.
Vomiting will not relieve pain in cholecystitis,
pancreatitis, and carcinoma of stomach.
Fig. 20.1: Causes of haematemesis.
Examinations in Chronic Abdominal Conditions
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heart burn (pyrosis). It may be a feature of gallbladder
disease, hiatus hernia, and pancreatitis. Heart burn
is sensation of warmth or burning situated substernally
or high epigastrium radiating to neck or arms. Belching
is repetitive eructations.
NON-ULCER DYSPEPSIA
Fig. 20.2: Bleeding duodenal ulcer causing
Melaena
It is passing dark, tarry, foul smelling stool per anum.
It is a feature of upper gastrointestinal bleed. Common
cause is peptic ulcer bleed. Duodenal ulcer more often
causes melaena (Fig. 20.3).
Fig. 20.3: Typical melaena – black tarry stool.
Flatulent Dyspepsia
Dyspepsia is a vague terminology which includes
feeling of fullness in the abdomen after food, belching,
Jaundice
Y ellowish discolouration of sclera and mucous membrane is called as jaundice. It may be due to neoplasia
like carcinoma head of pancreas, periampullary carcinoma, Klatskin tumour, cholangiocarcinoma, nodes
compressing porta hepatic, carcinoma of gallbladder,
hepatocellular carcinoma, secondaries in liver; biliary
stone disease; hepatitis, cirrhosis , pancreatitis, pseudocyst or due to haemolytic causes. In broad day light
jaundice is confirmed by examining sclera, skin, nail
bed, under the tongue, soft palate. Its duration,
progression, persistent or intermittent, painful jaundice
(in biliary stone) or painless jaundice (carcinoma)
should be assessed. Progressive jaundice is a feature
of carcinoma head of pancreas, nodes compressing
porta hepatis, Klatskin tumour; intermittent jaundice
is a feature of periampullary carcinoma (due to
sloughing of the ampulla), stone in common bile duct.
Presence of itch marks on the dorsal aspect of the
hands, forearms and back suggests obstructive
jaundice.
Bowel Habit
It is very important to ask history regarding proper
bowel habit in chronic abdomen patients. History of
diarrhoea, constipation, blood in the stool, painful
defecation, tenesmus, alternate constipation and diarrhoea, clay coloured stool (seen in chronic pancreatitis,
obstructive jaundice where fat is not digested due to
SRB’s Clinical Surgery
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deficiency of pancreatic enzymes) silvery stool (seen
in periampullary carcinoma where blood from the
tumour necrosed area gets altered as haematin which
mixes with fat). Large, loose, fatty offensive stool may
be seen in chronic pancreatitis. Inflammatory bowel
disease, carcinoma colon, small bowel diseases,
colonic polyps, colonic tuberculosis can cause
diarrhoea or diarrhoea alternating with constipation.
Dark tarry coloured melaena is also typical. Diarrhoea
is an increase in daily stool weight more than 200
gm. There may be increased stool liquidity and
frequency more than 3 times per day. Stool may be
semiformed. Pseudodiarrhoea is increased frequency
without increase in stool weight which is seen in IBS,
hyperthyroidism, proctitis. But for all practical purpose
increased frequency may be considered as diarrhoea.
Diarrhoea is called as acute if it lasts for 1-2 weeks;
chronic if it is for more than 2 weeks. Constipation
is frequency of defaecation less than 3 times a week
often with hard stool or with difficulty to pass.
Appetite
Loss of appetite is an important feature of gastrointestinal malignancy whether it is stomach, small
bowel, colon, and rectum. Appetite is increased in
peptic ulcer. Appetite is normal in gastric ulcer but
patient fears to take food due to pain. Aversion to
fatty food is a feature of gallbladder disease (gallbladder dyspepsia). Loss of appetite occurs in early
gastric cancers. Loss of appetite is progressive and
significant in malignancy. Feeling of adequateness/
satisfaction after meal is called as satiety. Early satiety
is a feature of GI malignancy especially in carcinoma
of stomach. Anorexia is lack of desire to eat. Sitophobia
is fear of eating due to anticipated abdominal discomfort seen in IBS, chronic mesenteric ischaemia.
Loss of Weight
Progressive loss of weight is seen in GI carcinomas.
It is also observed in pyloric stenosis. More than
10 Kg weight loss in 6 months is called as significant
weight loss which needs proper evaluation. Often
patient might not have weighed his weight at all earlier.
Then it is better to ask how much muscle mass is
reduced or loosening of clothes occurred. Often it is
better to ask relatives about their observation of the
changes in the patient earlier and now.
Fever
Abdominal tuberculosis may present with evening rise
of fever. Fever may be due to malnutrition, secondary
infection. Cholangitis, pancreatitis, cholecystitis, and
ulcerative colitis can cause recurrent episodes of fever.
Even malignancy can cause fever due to pyrogenic
response or tumour necrosis.
Past History
Past history of typhoid, tuberculosis, jaundice is
important. Previous history of any surgery or abdominal surgery – indication, duration of hospital stay ,
whether it was an emergency or elective procedure,
postoperative recovery , drain placed or not, any biopsy
reports revealed or not, recovery period should be
noted. Long-term treatment for abdominal tuberculosis
may be present. Patient might be taking drugs related
to peptic ulcer for long time. Whether patient was
evaluated prior to therapy or surgery by X-rays,
investigations, endoscopies or not should be asked.
History of blood transfusions for surgery earlier is
also significant.
Personal History
History of smoking, alcohol intake, spicy food, dietary
habits like regularity, interval between each food intake,
type of food intake should be asked. Alcohol and
smoking may lead into cirrhosis and portal hypertension; peptic ulcer disease, carcinoma, etc.
Family History
Certain gastrointestinal malignancies, ulcerative
colitis, Crohn’s disease often run in family.
General Examination
Anaemia, reduced weight is common in malignancy,
abdominal tuberculosis. Oral cavity, teeth, jaundice,
clubbing, respiration, pulse, blood pressure, skin
texture, built, overall look of the patient should be
checked. Malignant cachexia is emaciated skeleto-
nised look seen in gastrointestinal malignancy. Built
is normal in duodenal ulcer; poor in gastric ulcer;
emaciated in pyloric stenosis or carcinoma.
Local Examination
Abdominal examination is essential part of chronic
abdominal conditions. Examination is done in patient
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