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The history • 255
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A
Bladder
Myometrium
53 mm
50 mm
Endometrium
Uterus
Cervix
Contrast spilling
Ampulla
Uterus
Isthmus
Catheter
Fallopian tube
Fig. 11.34 Hysterosalpingogram. The scan assesses the uterus and
bilateral tubal patency.
11.8 Checklist for the obstetric history
• Age
• Parity
• Menstrual history, last menstrual period,
gestation, expected date of delivery
• Presenting symptom
• Past obstetric
history
• Past medical and
surgical history
• Drug history
• Family history
• Social history
11
B
Fig. 11.32 Pelvic ultrasound. A Transvaginal scan of the uterus. B
Scan showing an ovarian cyst.
Inserted through
cervical os
Pulled back to create
Fig. 11.33 Pipelle for endometrial biopsy.
Right ovarian cyst
Endometrial tissue
suction
11.9 Information to be recorded for previous
pregnancies
• Date and gestation of delivery
• Indication for and mode of delivery (e.g. spontaneous vaginal delivery,
operative vaginal delivery (forceps or ventouse) or Caesarean section)
• Singleton or multiple pregnancy
• Any pregnancy complications (take a full history)
• Duration of first and second stage of labour
• Weight and sex of the baby
• Health at birth, mode of infant feeding
• Postnatal information about mother and baby
Social history
Enquire about the use of alcohol, tobacco and illegal drugs.
Check a carbon monoxide level to detect the level of smoking.
Advise all smokers to stop and offer referral to smoking cessation
support. Advise all pregnant persons to avoid alcohol.
Ask:
• who the patient’s partner/support is
• how stable the relationship is
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11.10 Definitions
Term Definition
LMP First date of the last menstrual period (LMP)
EDD Estimated date of delivery: 40 weeks from LMP.
Parity Number of previous births. Written in the format
Gestation Number of weeks þ days of pregnancy counted
Trimester The 40 weeks of pregnancy are divided into
Liquor or amniotic
fluid
Oligohydramnios,
polyhydramnios
Miscarriage Expulsion of a fetus prior to viability
Live birth Birth of a baby with signs of life
Still birth Birth of a potentially viable baby without signs of
Puerperium The 6-week period after birth
Linea nigra A dark line of discoloration in the midline of the
Striae gravidarum Stretch marks–those from the current
• if the patient is not in a relationship, who will give support
during and after the pregnancy
• whether the pregnancy was planned; if unplanned, find out
how they feel about it.
Lower socioeconomic status is linked with increased perinatal
and maternal mortality.
Encourage regular exercise and avoidance of certain foods,
such as tuna (high mercury content), soft cheeses (risk of Listeria)
Fewer than 5% of babies deliver on their due
date; the majority deliver between 37 and 42
completed weeks–this period is called term.
Estimated Date of Delivery (EDD) is most
accurately calculated from an ultrasound scan
measurement of the foetal crown–rump length
or head circumference done at the end of the
first trimester
x þ y, where x is the number of live births and
any births over 24 weeks, and y is the number
of all other pregnancies–babies born before
24 weeks with no signs of life, ectopic
pregnancy, miscarriage and termination of
pregnancy. Multiple pregnancy counts as one
delivery–the number refers to pregnancies
delivered and not to the number of foetuses/
babies
from LMP (although not conceived till ovulation
approximately 2 weeks later or 14 days before
the next period is due)
three trimesters of approximately 13 weeks each
Fluid surrounding the fetus in utero
Too little and excess amniotic fluid, respectively
life–in the UK, any that occur above 24 weeks;
in Australia and other places, 20 weeks and
above
abdominal skin
pregnancy appear white and those from any
previous pregnancy are more silvery
11.11 Examples of single-gene disorders that
can be detected antenatally
Autosomal dominant
• Huntington’s chorea • Myotonic dystrophy
Autosomal recessive
• Cystic fibrosis
• Sickle cell disease
X-linked
• Duchenne muscular dystrophy • Haemophilia
• Thalassaemia
11.12 Age-related risk of Down’s
syndrome (trisomy 21)
Maternal age Risk
20 1 in 1500
30 1 in 900
35 1 in 400
40 1 in 100
45 1 in 30
and liver (high vitamin A content). Domestic violence can start or
escalate in pregnancy and is associated with an increased risk of
maternal death. All patients must be seen alone (without their
partner) on at least one antenatal visit to allow this to be explored.
Occupational history
Ask the patient about their occupation and whether they plan to
continue it. Occupations involving exposure to ionising radiation
pose specific risks to the foetus or mother, so their job plan may
require modification for safety reasons. There is no definitive
evidence of a link between heavy work and preterm labour or
pre-eclampsia.
Examination sequence
• Calculate BMI (weight/height2).
• Obtain a midstream specimen of urine for microscopy, cul-
ture and sensitivities.
• Measure blood pressure.
• Do not perform a routine full physical examination (including
breast and vaginal examination) in healthy pregnant patients.
It is unnecessarily intrusive and has a low sensitivity for disease identification. However, you should perform a full examination, including cardiac auscultation, of any patient with
poor general health.
Investigations
Routine investigations are required at the booking visit
(Box 11.13).
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11.13 Antenatal investigations
Investigation Timing Indication/comment
Mid-stream specimen urine (MSU) for culture Booking; always sent Detects asymptomatic bacteriuria (and group B streptococcus)
Urinalysis Every visit Trace or þ proteinuria: send MSU, ask about symptoms of
Full blood count Booking, 28 weeks, 36 weeks If haemoglobin is <105 g/L, treat; consider checking
Haemoglobin electrophoresis Booking To check for sickle cell disease and thalassaemias
Blood group and antibody screen Booking, 28 weeks More often if advised by laboratory
Hepatitis B Booking If the patient is a previous intravenous drug abuser or is known to
HIV Booking Unless the patient opts out
Syphilis Booking
Plasma glucose Booking
Carbon monoxide level Every visit for smokers Advice and referral for cessation, growth scans
Combined biochemical screening and nuchal
translucency measurement for trisomy 21
First-trimester ultrasound scan 6–13 weeks Viability, gestational age Æ7 days, fetal number, some major
Detailed ultrasound scan 18–22 weeks Detects 90% of major congenital abnormalities and placental site
Placental site If low at 20 weeks, recheck
Growth scan After 24 weeks; can be as
Presentation scan After 36 weeks If there is concern that presentation is not cephalic
Amniocentesis 15 weeks onwards For fetal karyotype; 0.5–1% risk of miscarriage
Chorionic villus biopsy 10 weeks onwards For fetal karyotype, single-gene disorder; 2% risk of miscarriage
Free foetal DNA maternal test (non-National Health
Service)
DNA, Deoxyribonucleic acid; HIV, human immunodeficiency virus.
11–14 weeks Detects 80–90% of affected pregnancies
later at about 34 weeks
often as 2–4 weekly
End of first trimester To detect trisomy: current guidance advocates use as a
urinary tract infection
þþ Proteinuria: consider pre-eclampsia or, rarely, underlying
renal disorder
Glycosuria: consider random blood glucose or glucose tolerance
test
haematinics
be HIV- or hepatitis B-positive, also carry out hepatitis C
screening
anomalies (e.g. anencephaly)
If there is an anterior placenta in a woman who has had a
previous Caesarean section, recheck the scan at 28 weeks to
consider the risk of placenta acreta
Previous growth-restricted baby, other risk factors, measurement
of a small-for-dates baby, reduced foetal movements
screening test only
11
ROUTINE ANTENATAL CHECK IN LATER PREGNANCY
The history
Ask about:
• any new symptoms
• symptoms relevant to ongoing conditions unrelated to
pregnancy
• the mother’s perception of foetal movements.
Fetal movements are initially felt at 16–20 weeks’ gestation.
Their frequency increases until about 32 weeks to an average of
30 movements per hour, and this level remains unchanged until
delivery. The ‘classic’ fetal movement is a kick, but any perceived
fetal activity counts as movement. Movements may decrease if
the mother is given sedative drugs and may be felt less if the
placenta is anterior. They also may decrease with intrauterine
compromise, which may precede stillbirth.
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Common presenting symptom s
Physiological symptoms
• Breast tenderness: often the earliest symptom of pregnancy
and may occur even before a missed period.
• Mild dyspnoea: may be due to increased respiratory drive
early in pregnancy or diaphragmatic compression by the
growing uterus late in pregnancy.
• Heartburn: gradually increases in prevalence, affecting up to
three-quarters of patients by the third trimester. It results from
relaxation of the gastro-oesophageal sphincter and acid
reflux.
• Constipation, urinary frequency, nausea and vomiting (which
usually resolve by 16–20 weeks).
• Aches and pains, especially backache, carpal tunnel syndrome and pubic symphyseal discomfort.
These physiological symptoms affect patients to different degrees and will occasionally merit examination and investigation to
exclude other problems. Secondary amenorrhoea is the most
obvious symptom of early pregnancy.
Reduced fetal movements
This is a common emergency presentation or reason for referral
to a hospital by a midwife, and merits a full history, examination
and fetal monitoring. It can be a sign of fetal compromise.
tract infection; less common causes include appendicitis, ovarian
cyst accidents, sickle cell crisis or inflammatory bowel disease. It
is critical to take a complete history of a pregnant patient with
abdominal pain and to perform a full obstetric and abdominal
examination, including renal angle palpation. This becomes more
difficult as pregnancy progresses, and the expanding uterus
makes palpation of other organs and masses difficult. Ultrasound
or MRI scanning may aid diagnosis.
Pre-eclampsia
Pre-eclampsia is a multifactorial syndrome comprised of high
blood pressure, proteinuria and placental compromise, and is a
significant cause of maternal and foetal morbidity. It is often
asymptomatic and detected by blood pressure monitoring and
urinalysis, although some patients develop generalised headaches and rapidly worsening peripheral oedema. A history
focused on headaches, worsening oedema and upper abdominal pain should be taken. The examination is that of a routine
antenatal assessment but should also include a check for
hyperreflexia and ankle clonus.
Pruritus
Pruritus (itching) affects one-quarter of pregnant patients. Rarely,
it is associated with liver cholestasis, in which case it is generalised, and there is no rash.
Vaginal bleeding in pregnancy
Vaginal bleeding in pregnancy before viability may herald a
miscarriage; after 24 weeks, it is called an antepartum haemorrhage. It can be a sign of a placental abruption, where the placenta
prematurely separates, or of a low-lying placenta. At term, light
vaginal bleeding can also be a sign of labour. Vaginal bleeding is
never considered normal in pregnancy and always merits hospital
review with a full history and examination. Painless bleeding is
more typical of local causes, such as a cervical polyp, or a lowlying placenta, whereas painful bleeding is more in keeping with
placental abruption. It is imperative to always consider venous
access and send blood for blood count and cross-matching in
any pregnant woman presenting with vaginal bleeding.
Abdominal pain
Abdominal pain is common in pregnancy. It can be caused by
benign physiological issues such as constipation and is also a
common presenting feature of labour when patients are contracting in established labour or tightening in early labour. It can
also be caused by polyhydramnios or placental abruption.
Any condition causing abdominal pain can present coincidentally in pregnancy, however. A common example is urinary
Breathlessness
Mild breathlessness is physiological in pregnancy. In rare circumstances, increased breathlessness is due to pulmonary
oedema in pre-eclampsia or exacerbation of heart disease. If
breathlessness is associated with chest pain, a pulmonary embolism (p. 85) should be considered. The chest should be
examined, and oxygen saturation and respiratory rate measured.
An electrocardiogram is helpful, and the risks/ benefits of
radiological imaging should be assessed. Consideration should
be given to an echocardiogram to exclude unknown congenital
or acquired heart disease (e.g. cardiomyopathy).
The physical examination
Examination sequence (Videos 23
and 23A)
• Before examining the patient, ask them to empty their
bladder (perform urinalysis). They should lie with their head on
a low pillow, with their abdomen exposed from the symphysis
pubis to the xiphisternum.
• Examine patients in late pregnancy in the left lateral position
or semirecumbent, 15 degrees to the horizontal, to avoid
A
The physical examination • 259
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B
C
Fig. 11.35 Abdominal examination. A Palpate the fundal area to identify which pole of the fetus (breech or head) is occupying the fundus. B Slip your
hands gently down the sides of the uterus to identify which side the firm back and knobbly limbs of the fetus are positioned on.
and slide your hands gently on the lower part of the uterus.
vena cava compression, which can cause hypotension for the
mother and hypoxia for the foetus.
• Measure blood pressure.
• Note their general demeanour. Are they at ease or distressed
by physical pain?
• On inspection, look for signs of pregnancy, such as the linea
nigra (a dark discoloration of the midline of the abdominal
skin) and striae gravidarum (stretch marks).
• Look for any scars, particularly from a previous Caesarean
section. Note the swelling of the uterus arising from the pelvis
and any other swellings. You may also see fetal movements.
Uterine examination (Video 23B)
• Ask the patient to report any tenderness and observe their
facial and verbal responses constantly.
• Place the flat of your hand on the uterine swelling. Gently flex
your fingers to palpate the upper and lateral edges of its firm
mass. Note any tenderness, rebound or guarding outside the
uterus. Palpate lightly to avoid triggering myometrial
contraction, which makes fetal parts difficult to feel. Avoid
deep palpation of any tender areas of the uterus. Note any
contractions and any foetal movements.
• Face the patient’s head. Place both your hands on either side
of the fundus and feel the fetal parts. Estimate if the liquor
volume is normal. Assess how far from the surface the fetal
parts are. If you can feel them only on deep palpation, this
implies large amounts of fluid (Fig. 11.35A).
• With your right hand on the patient’s left side, feel down both
sides of the uterus. The fuller side suggests the location of the
fetal back (see Fig. 11.35B).
• Now face the patient’s feet. Place your hands on either side
of the uterus, with your left hand on the left side, and feel the
lower part of the uterus to try to identify the presenting part.
Ballott the head by pushing it gently from one side to the
other and feel its hardness move between your fingers (see
Fig. 11.35C).
• The size of the uterus increases as pregnancy advances
(Fig. 11.36). At 20 weeks, the uterine fundus is at the umbilicus; by 36 weeks, it reaches the xiphisternum. The distance
Fig. 11.36 Approximate fundal height with increasing gestation.
from the pubic symphysis to the top of the uterine fu ndus is
the symphyseal fundal height (SFH). In a singleton pregnancy, if the ba by is growing well, the SFH in c entimet res
approximates the duration of pregnancy i n weeks. In
multiple pregnancies, the fund us will measure larger at
each stage. After 20 weeks, mea sure the SFH in centimetres. With a tape measure, fix the end at the high est
point on the fundus (not always in the midline) and measure
to the top of the symphysis pubis. To avoid bias, place the
blank side of the tape facing you, lift the tape and read the
measurement on the other sid e. The SFH is measured at
every vi sit and recorded on a SFH centile chart in the
maternal handheld record. In tall or thin patients, the SFH
may be smaller than expected; in obese patients, it may be
larger. After 25 weeks gestation, a difference of 3 or m ore
C Turn to face the patient’s feet
Xiphisternum
36 weeks
30 weeks
Umbilicus
20–22 weeks
16–18 weeks
14 weeks
Symphysis pubis
11
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between the number of completed weeks of pr egnancy
and the SFH in centimetres may suggest that the baby is
small or large for dates. If this discrepancy occurs or if the
• Do not perform a vaginal examination routinely in pregnancy
SFH centile is static or falling, the patient should be ref erred
for a growth scan (Fig 11.37).
• In late pregnancy or lab our, you ne ed to a ssess the fe tal lie,
fetal presentation and e ngagement of the head in the
maternal pelvis. The lie describes the longitudinal axis of
the fetus related to the longitudinal axis of the mother’s
uterus. Most fetuses have a longitudinal lie in the third
trimester (Fig. 11.38 ). From 36 weeks, a posi tion other than
longitudinal is abnormal and requires further investigation.
• The presentation is the part of the fetus’s body that is ex-
pected to deliver first. With a longitudinal lie, there is either a
Abdominal organs are displaced during pregnancy. For
example, in the case of ovarian cysts or an inflamed appendix,
the pain and tenderness may not be in the usual sites. The
kidneys and liver cannot normally be palpated and listening for
bowel sounds may be difficult in late pregnancy. Ultrasound
scanning is now used routinely to assess fetal development (Figs
11.40 and 11.41).
cephalic or a breech presentation. Finally, assess whether
more than 50% of the presenting part has entered the bony
pelvis. This is usually the head, which is then said to be
engaged (Fig. 11.39).
Investigations
• Percussion of the pregnant abdomen is unnecessary.
• Listen for the fetal heart if you cannot feel fetal movements. A
hand-held Doppler machine can be used from 14 weeks.
1716 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
Symphysis-fundal height (cm)
22
21
20
19
18
17
16
15
14
13
12
11
10
Routine investigations are required at specific antenatal visits
(see Box 11.13).
Fig. 11.37 International symphysis-fundal height standards. University of Oxford.
From 28 weeks, the Doppler machine is held over the anterior
shoulder of the foetus.
unless there is a specific indication. Never perform a vaginal
examination after 20 weeks unless the placental location is
known, as there is a risk of severe bleeding if it is low.
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
Symphysis-fundal height (cm)
22
21
20
19
18
17
16
15
14
13
12
11
10
Weeks1716 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Investigations • 261
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Fig. 11.40 Ultrasound scan at 12 weeks showing a twin pregnancy.
11
Fig. 11.38 The lie and presentation of the foetus at term.
Perform dipstick urinalysis at each visit, looking for glycosuria
or proteinuria. Protein of 1þ may indicate a urinary tract
infection or pre-eclampsia. Glycosuria requires a formal test for
gestational diabetes.
Completely
above
5/5 4/5 3/5 2/5 1/5 0/5
Level of
pelvic brim
Free, above
the brim
Sinciput +++
Occiput ++ Occiput +
‘Fixing’
Sinciput ++ Sinciput +
Fixed,
not engaged
Fig. 11.41 Ultrasound scan at 13 weeks showing crown–rump
measurement.
Occiput just felt
Just engaged Engaged Deeply engaged
Sinciput +
Occiput not felt
None of head
palpable
Fig. 11.39 Descent of the fetal head.
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MALE REPRODUCTIVE SYSTEM
Anatomy and physiology
The male genitalia include the testes, epididymides and seminal
vesicles, penis, scrotum and prostate gland (Fig. 11.42).
The testes develop intra-abdominally near the kidneys and
migrate through the inguinal canal into the scrotum by birth. They
have their own blood, lymphatic and nerve supply, so testicular
problems may cause abdominal pain and enlargement of the
para-aortic lymph nodes. The scrotum is a pouch with thin,
pigmented, wrinkled skin that helps to regulate the temperature
of the testes (Fig. 11.43), as sperm production is most efficient
below body temperature. The left testis lies lower than the right.
Each testis is oval, 3.5–5 cm long, and covered by the tunica
albuginea, which forms the posterior wall of the tunica vaginalis.
This is a prolongation of the peritoneal tube that forms as the
testis descends during development. If it persists, it may be
associated with an indirect inguinal hernia sac or a congenital
hydrocoele. Along the posterior border of each testis is the
epididymis.
The testes produce sperm and testosterone, starting at puberty (10–15 years of age; see Fig. 15.19). Sperm mature in the
epididymis and pass down the vas deferens to the seminal
vesicles. They are ejaculated from the urethra, together with
prostatic and seminal vesicle fluid, at orgasm.
The penis has two cylinders of endothelium-lined spaces
surrounded by smooth muscle, the corpora cavernosa
(Fig. 11.44). These are bound with the bulbospongiosus surrounding the urethra, which expands into the glans penis. The
penile skin is reflected over the glans, forming the prepuce
(foreskin). Sexual arousal causes a parasympathetically mediated
increased blood flow into the corpora cavernosa with erection to
enable vaginal penetration. Continued stimulation causes
sympathetic-mediated contraction of the seminal vesicles and
prostate, closure of the bladder neck and ejaculation. Following
orgasm, a reduction in blood inflow causes detumescence.
The prostate and seminal vesicles contribute to seminal fluid.
After age 40, the prostate develops a trilobar structure because
Spermatic cord
Vas deferens
Pampiniform plexus
Epididymis
Testis
Scrotum
Fig. 11.43 The scrotum and its contents.
Seminal vesicle
Ejaculatory duct
Levator ani muscle
Bulbocavernosus
Fig. 11.42 Anatomy of the male genitalia. The male genitalia include the external organs, seminal vesicles and prostate gland.
Rectum
Anus
muscle
Bladder
Symphysis pubis
Prostate gland
Urethra
Hydatids of Morgagni
Epididymis
Glans
Testis
Glans penis
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Urethra
Corpus cavernosum
Corpus spongiosum
The history • 263
There may be associated systemic upset or clinical signs
associated with urological disease; a complete history and examination are therefore important.
Common presenting symptom s
Urinary symptoms
Urinary symptoms are a common presentation of genital or lower
urinary tract dysfunction. Dysuria (see below), voiding symptoms
and haematuria are covered in Chapter 12.
Crus penis
Ischial tuberosity
Dorsal vein
Corpus cavernosum
Corpus spongiosum
Urethra
Cross-section
Fig. 11.44 Anatomy of the penis. The shaft and glans penis are formed
from the corpus spongiosum and the corpus cavernosum.
of benign enlargement. Two lateral lobes and a variable median
lobe protrude into the bladder and may cause urethral and
bladder outflow obstruction. Prostate cancer develops in the
peripheral tissue of the lateral lobes and sometimes may be
detected by digital rectal examination. Only the posterior aspect
and the lateral lobes of the prostate can be felt by rectal examination (p. 111).
The history
Disorders of the male genitals may present as urinary symptoms,
genital or pelvic pain, genital swellings, sexual dysfunction or
infertility.
In addition to documenting the patient’s main genital or urinary
problems, be sure to ask about:
• the timescale of their development
• how they affect lifestyle and any sexual activity
• sexual function, if appropriate
• past conceptions or problems with fertility
• general urological symptoms:
• genital swelling
• genital or pelvic pain
• lower urinary tract symptoms
• urethral discharge.
Penile discharge or dysuria
Ask about:
• the duration of discharge or dysuria
• whether these are new or recurrent symptoms
• any other urinary symptoms
• the sexual history
• any systemic upset.
These symptoms usually represent urethritis which is the result
of either an STI or a urinary tract infection. They may precede and
lead to epididymo-orchitis (see later) or prostatitis. Prostatitis is
associated with pelvic, perineal or scrotal pain, fever and systemic upset in acute bacterial prostatitis, or may lead to chronic
pain and urinary symptoms in chronic prostatitis.
Scrotal swelling or pain
Patients often present acutely with scrotal pain and swelling
together; they may also, however, present with either symptom
alone.
Ask about:
• duration of the swelling
• whether it is unilateral or bilateral
• association with pain
• onset of pain: sudden or gradual
• character and duration of the pain
• radiation of the pain
• any history of trauma
• any associated symptoms:
• systemic upset (nausea, vomiting, fever or weight loss)
• urinary symptoms
• urethral discharge
• sexual history (see Box 11.5).
There are many causes of scrotal swelling or pain, but a patient with sudden-onset unilateral scrotal pain should be
considered to have testicular torsion until proven otherwise.
Testicular torsion occurs most commonly between the ages of
10 and 30 years and is very rare over the age of 40. Pain is
usually of acute onset and excruciating; it is not relieved by lying
still. It is often associated with nausea and vomiting but not
usually fever, lower urinary tract symptoms or urethral discharge.
11
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Epidydimal cyst
Fig. 11.45 Swellings of the scrotum.
Epididymo-orchitis is the most common differential diagnosis.
The pain of epididymo-orchitis is often more insidious in onset
compared to testicular torsion, and the patient may report a dull
ache initially. There may be associated fevers, dysuria or urethral
discharge, suggesting underlying STI or urinary tract infection.
The discomfort is often worse when standing or moving around
and may be relieved when lying still. On examination, it is usually
possible to distinguish the tender, inflamed epididymis from the
adjacent testis. If testicular torsion cannot be excluded on history
and examination, urgent testicular exploration is warranted, as
torsion will cause loss of a testis if not relieved within 4–6 hours.
While an ultrasound examination may be used to confirm a
diagnosis of epididymo-orchitis, it should never be requested to
assess for torsion.
Other scrotal swellings include hernias, varicocoele, hydrocoele, epididymal cysts and testicular tumours. These are usually
painless, although vague or constant dull aches may be
described (Fig. 11.45). Examination findings can usually differentiate these diagnoses (Box 11.14).
11.14 Summary of examination findings in common
scrotal pathologies
Inguinoscrotal: unable to ‘get above’
Inguinoscrotal hernia
• May be reducible and have a cough impulse
• Does not transilluminate
• May be associated with bowel sounds on auscultation
Hydrocoele
• Is not reducible
• Transilluminates
• Not associated with bowel sounds
• It is possible to palpate the normal cord above some hydrocoeles
Scrotal mass: able to ‘get above’
Epididymal cyst
• Firm, well circumscribed and separate from testicular body
• Transilluminates
Testicular tumour
• A hard, mass that may be well circumscribed or ill defined, arising
from the testicular body
• Does not transilluminate
Varicocoele
• Described as feeling like a ‘bag of worms’ around the cord
• Present on standing or with a Valsalva manoeuvre but usually resolves
on lying flat
persistent phimosis. This may produce balanitis (recurrent
infection of the glans penis), posthitis (infection of the prepuce) or
both (balanoposthitis).
If a tight foreskin is retracted and is not replaced, swelling and
pain ensue, resulting in paraphimosis due to the tight preputial
band (Fig. 11.46).
Dermatological conditions and drug reactions may affect the
genital skin. Painful genital ulcers are usually caused by herpes
simplex; painless ulcers occur in reactive arthritis (p. 293), lichen
simplex and (rarely) syphilis. Genital warts may also be present,
as well as penile carcinoma.
Penile skin lesions
Ask about:
• location, duration and progression of the lesion
• any pain
• any problem retracting the prepuce
• any associated systemic upset
• any urinary symptoms
• any history of dermatological disease
• sexual history.
The inability to retract the foreskin (phimosis) is a common
symptom in the urology clinic. Phimosis may be normal, 95% of
babies are born with a non-retractile prepuce, but this usually
resolves by the age of 16 years, when only 1% of boys have
Erectile dysfunction
Erectile dysfunction (ED) is the consistent or recurrent inability to
attain and/or maintain a penile erection sufficient for penetrative
intercourse.
Clarify from the history:
• Is the problem failure to gain or maintain an erection, painful
erection, penile deformity on erection or a combination of these?
• How long has ED been a problem?
• Has the patient ever been able to gain a rigid erection?
• Do they ever have morning erections on waking?
• Are they able to gain an erection under any circumstances,
such as masturbation?
• Do their problems prevent penetrative intercourse?
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