Saturday, January 11, 2014

The Male Genital and Rectal Exams

Update 3/30/14 - If you've found this page because you are nervous about going to see the doctor, please consider reading a patient's story who contacted me after reading this post. 

Click here to read Nervous About Going to the Doctor - A Patient's Story.

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This week, I learned how to do the male genital and rectal exams. I then performed these exams on live patient volunteers. That's right - real humans. I don't know if they were truly volunteers or if they got paid, but I speak for all medical students when I say I hope they got paid and got paid a LOT. If they didn't get paid, then they have my utmost gratitude for volunteering for the sake of my education.

I went into the experience with significant uncertainty, as you can probably imagine. My emotions could probably be more aptly be described as an odd mixture of curiosity and trepidation. That's probably true of the majority of the new clinical exams that we learn, with this one weighted more heavily on the "trepidation" side of that balance...

If you have no clue why I'm saying this, you probably don't know what the exam entails. I'll help you out with a blunt description of each exam. I'll use common terms, but know that these are not the words that get used in the writeup. Please skip the rest of this if it makes you feel uncomfortable:

The Male Genital Exam:

The examiner first washes his or her hands and puts on gloves. The patient is asked to stand up and pull up his gown to the level of the belly button. The examiner sits in a stool in front of the patient and examines his genitals, noting things like skin lesions, uniformity of hair growth and skin pigmentation, and looking for any big signs of infection. The examiner explains what he's doing the whole time, both as a way to make the patient feel more comfortable and as a way to make sure to not skip any steps.

First, the shaft of the penis is examined for any changes in consistency, skin discoloration, lesions, discharge, and hypospadias (where the meatus exits the penis along the ventral side instead of the tip). If foreskin is present, the examiner must retract it to fully inspect all sides of the penis before replacing the foreskin. If the foreskin is left retracted, it can cause it to swell painfully around the head of the penis, potentially obstructing blood flow. It can be a big deal, apparently. Anyway, after inspecting the shaft, the scrotum must be inspected carefully, again looking for signs of inflammation, color change, or lesions. The testicles must both be felt at the same time to compare consistency and size between the left and right. The same goes for the epididymis on both sides, and the spermatic cords. The vas deferens must also be compared bilaterally, as well as the spermatic veins, looking for specific conditions.

A key part of the genital exam is to check for abdominal hernia. This is done by finding the inguinal canal, a structure just lateral to the pubic symphysis through which the spermatic cord runs on each side. Once it is located and a finger is placed in this canal, the patient is asked to either turn his head in that direction and cough, or to simply bear down. If a hernia were present, the examiner would be able to feel the intestine press against the tip of his or her finger. Once both sides are checked for hernia, the male genital exam is done.

The Male Rectal Exam:

The patient is asked to keep his gown at the level of the umbilicus. The exam can be done with the patient in the fetal position, or standing. We did the exam standing, but apparently it is mostly up to patient and examiner preference. With the patient standing, the patient is instructed to bend over and lean his elbows on the examining table. First, the examiner checks the skin of the buttocks and the perianal region, looking once more for skin color changes and lesions. One of my patients had a minor hemorrhoid, so I had to first check and make sure that it was non-tender before proceeding. The examiner applies some lubricating jelly to the tip of a gloved index finger and notifies the patient to be prepared for some cold pressure. At times, the external sphincter can be too tight, in which case the examiner applies anterior pressure to the inside margin of the external sphincter, causing it to loosen.

With the index finger inserted into the rectal vault, the examiner first checks to see if it is possible to palpate the far margin of the prostate. If the patient has an enlarged prostate, or if the examiner has very short fingers, this is not always possible. The examiner should also locate the central sulcus of the prostate, which is basically a sort of valley between the two lobes of the prostate. Our instructors told us that the prostate's consistency should feel like the tip of someone's nose, but that didn't really fit what I felt with my patient. It seemed more like if you took two miniature clementines and smushed them together, then wrapped them in a thin layer of plastic and ran a lubricated gloved finger over the whole thing. Firm, but not rock-hard.

We were also told that this portion of the exam can make the patient feel as though he needs to urinate. I forgot to mention this to my patient volunteer during the exam, but I'm sure he'd gone through enough exams by the other students that he was plenty used to it. After palpating and mentally comparing both sides of the prostate for consistency, nodularity, and size, the examiner sweeps the entire 360 degrees of the rectal vault, 180 degrees clockwise and counterclockwise, then removes the finger and offers the patient tissue with which to clean himself up. If any fecal matter is stuck to the gloved finger, the examiner uses it to do a hemoccult test, which checks for blood in the stool.

And those are the procedures for the male genital and rectal examinations! It went much smoother than I had anticipated, and I felt like I learned a TON. My patient volunteers were both very helpful and professional, and my physician preceptors both did a great job facilitating the experience. This was probably the best physical exam experience that I've had so far here at MSU CHM, though the female breast exam (which I don't think I wrote about due to being insanely busy at that time last semester) comes in at a close 2nd place in terms of the professionalism of both the patient volunteers and the physician preceptors. I learned a ton in that experience as well.

After the exam, the students have to write up the observation portion of the exam - basically, their clinical findings, described as concisely as possible. I realized later that I had forgotten to estimate the approximate size of his prostate, but oh well - guess that's what learning experiences are for! Below you'll find mine for one of my patient volunteers, with some defining physical characteristics removed:


Genital Exam:
Uncircumcised race male with calm demeanor, good apparent health and general appearance. Penile shaft absent of lesions, discharge, or discoloration. Prepuce retractable, no lesions noted. Light, large (XX cm), benign, specific skin abnormality noted over the left upper medial thigh, fading into the pubic hair. Scrotal pigmentation significantly relative darkness on left than right, but no scrotal swelling/lesions noted. Pubic hair symmetrical and of uniform density and color. Testes absent swelling, both smooth and descended with no masses. Epididymis nontender bilaterally. No varicocele of spermatic cord noted. No inguinal or femoral hernias detected, though the left inguinal ring noted to be larger than right.

Rectal & Prostate Exam:

External sphincter intact. Small (0.5cm), nontender, noninflamed hemorrhoid noted at the extreme anterior margin of the anus, otherwise no perirectal lesions or fissures noted. Rectal space and walls without masses or lesions to palpation. Nontender prostate bilaterally. Left lobe of prostate markedly firmer and more nodular than right, consistent with patient history of prostate reduction surgery. Median sulcus of prostate palpable and nontender. No stool present – Hemoccult test not attempted.


Experiences like this one definitely help make med school feel more real. I'm becoming much more confident in my interaction with patients. I've definitely begun to see how the transition from student doctor into doctor is possible, though it's still a long, looooong way off... All right, back to studying Urinary Tract pathology, the first domain of my 4th semester in medical school! Wish me luck.


Anonymous said...

I'm a nurse practitioner student at MSU, and when we did our male and female genital exams, the people got paid $50/hr (at least that's what we were told). It's good pay, but I wouldn't do it!

Jill Thomas said...

Very interesting blog post for a non-medical person like me to read. Glad you're getting good hands on/in experience.

Alan Ellaway said...

I served as a "patient" for this exam - just once- about 20 years ago. I had been seriously injured in a car wreck some time before and been out of action for three months- IE in bed. and I had done some blood work studies. And this came up- I think in the student newspaper. And as I remember it -it paid $200-$300 , I could be wrong about the amount, and I think now it is standardized and they have a group of regulars. I know the money motivated me but I also felt that I wanted to somehow give sonmething back to the medical community. BUt I have to admit the day I arrived for the session, I almost ran out. I met with the Dr, who was not too friendly- arrogant and verging on rude. The feeling that I got was that if I was doing something like this that I was in some way a sleazy specimen. After a very few words basically just saying that I would be examined, he gave me a robe and told me to strip "completely"- I had some idea from the original phone call I made as well . I anxiously asked “What do I do if I start to get an erection?” He responded with a very unpleasant look and stated firmly “That won’t happen ” handed me a robe and left the room. He came back with all male students- about 7 I think. Ranging from a chubby, short Chinese to a gorgeous athletic blond. ( I should mention that I am gay) . The dr gave a short intro, told me to lift the robe and proceeded to do a not too gentle exam. AS I am uncircumcised he did have a bit of a job rolling back my foreskin( I seemed to shrink and "dry out" with nerves(?) and actually doing the testicles-one part using a finger and prodding up inside my scrotum- something that I have never experienced in any exam) which was very uncomfotable and then turned it over to the class. The Chinese guy was first, and pretty nonedescript but it was almost like I was being examined in reverse order of attractiveness, and about half way through I did notice some arousal sensations, but managed to basically control it, although it must have been noticable to some degree. Well the "gorgeous" blond was last and I did lose my self control. I got fully erect , which he was fairly relaxed and fine with and even laughed a little and made some appropriate comments- he appeared to be reasonably comfortable taking a firmer grasp and rolling my foreskin back and forwards, – I did get a little seepage, which he also pased off, and used a tissue on and then-and he was the only one – he pulled my foreskin back when he finished. The others just left it retracted. So in effect ( after the first one)it was rolled back at the start of each individual exam, the blond has actually started the exam by rolling it back in place and then rolling it back so to speak. The Dr was fairly obviously treating me with little respect which made my embaressment and humiliation even worse. The rectal was again very agressively done by the Dr, and some of the students- due to inexperience I guess- were also pretty rough. I am English ( to explain the uncircumcised look a little)and I had never even had a rectal exam before. One suggestion re: this part, I think when the last one is finsished and you're still bent over, it would be considerate to wipe the excess gel away. I felt embarressed and humiliated standing there wiping my butt in front of this group.

At the end of the session the Dr advised me that I should not have accepted the job if I was unable to control myself and that my behaviour was "completly unacceptable". It was not a pleasant experience, and I never did it again.

Justin said...

@Alan - I am really sorry that you had that experience with the physician overseeing the exam. While I can't say what is normal or abnormal for the preceptors overseeing the students and volunteers (as I've only participated in the experience one time), I can say that the physicians interacting with the two simulated patients seemed to be very professional, and the volunteers seemed fairly comfortable with the physicians and us as students. That could be because they are regulars, as you mentioned.

I would like to apologize on behalf of MSU for the comments made by that physician, and how you felt. Reactions like the one that you had can be completely involuntary. There is no way that you can "control yourself." They explained to us very clearly that this is something that can happen sometimes, and that there is no reason for the patient or the student doctor to be embarrassed by it. That being said, sometimes it can be embarrassing, and the best thing for students to do is to give the patient a moment for things to calm down before proceeding with the examination.

In short, I am sorry that you had such an uncomfortable experience. Thank you for volunteering to be examined by those students. I can tell you that it is a very valuable experience in the formation of a future doctor. What you did was worthwhile, and I think it is a shame that you were made to feel embarrassed or in any way "less" because you had volunteered for it. I am sure that these days, the volunteer patients are not only better prepared for the experience, but are also treated with more respect.

Thanks for reading, and thanks for giving the perspective of a volunteer. I'm just sorry that it went that way for you.

Alan Ellaway said...

Thanks for taking the time to read and respond Justin.
I had a purpose in writing my entry, Firstly to let other potential "models" be aware that this (an erection/ seepage etc) could happen. Obviously some people would be more "at ease' with it than others. But I think potential model patients, should consider this happening and while I would not wish them to be deterred from volounteering but perhaps be a little more prepared than I was- i.e Give it some more thought. Also realize that you might run into these people in "real" life and they might-after all they are students- let their companions know that they had examined your genitals and could describe them- this also happened to me shortly after my session. And also not all practitioners are as considerate as they might be. (The Dr could have been, in fairness, having a bad day ) It's one thing to consider it as either a way of making some extra cash and/or helping the medical community and the Dr's of tomorrow.. But in a way I was lucky that no females students were present(although being gay it might have acted as a detterent- apologies to any females reading this). And probably if I had continued to take part in future sessions the eroticism factor would have worn off. Although I wonder about this being "healthy", I mean if you are suddenly naked in front of a group of strangers and they proceed to handle your 'junk" and do things that normally only a sexual partner would be doing, and one of them turns out to be someone you personally find a turn on, do you really want to not be even slightly aroused? I wonder if this might give problems later in life with ED? I guess for the medical practitioner,it's probaly different, although I kind of think that you are also human, and if a very attractive patient (whatever your sexual preference) has to be intimately examined, it must require some discipline to completely divorce yourself from your humanness and see them 100% completely as just a patient. It was also noteworthy that the blond student, seemed more comfortable handling my erection and "seepage" than the teacher. An amusing side note, when I was undergoing the rectal and the students were being advised how to identify the prostate, I remember one of them at last succeeeding( in finding it) and with apparent enthusiasm happily saying "This is so cool!" ,it was unfortunate that at the time I could not come up with an approprite response... perhaps "happy to oblige!".

Alan Ellaway said...

Oh, one other thing, I am not sure that in my particular situation that giving me a moment to calm down would have worked, I kind of think that standing there waiting for my erection to become flaccid that once it did and someone took a hold of me again that it would have all been too immediate and that I would have got hard again. I think that it might have been a better approach for the Dr to have said something like " As you can see Alan has become aroused and has become erect this is entirely normal and can happen, if it does happen you should let your patient know that it is normal and continue with the exam..."

A. Banterings said...


I hope you did more than just walk in, wash hands and say pull up your gown...

I hope that you at least introduced yourself, explained what you were going to do, and asked permission.

I am 45, never had a genital or rectal exam, and never will. I had been traumatized by healthcare providers when I was very young. I don't remember what happened, but I know that I will never fully or blindly trust healthcare again.

I am not saying that you or all providers are untrustworthy. All I am saying, is don't assume. You never know what your patient has endured. Sexual abuse. maybe?

Most providers assume consent just by a patient coming to see you. I know that you are taught "fiduciary responsibility," but that is only to your abilities. A patient coming to see you is giving you the opportunity to earn their trust.

If you do a good job with that trust, it only guarantees that patient's next healthcare encounter. That means if that trust is betrayed, then that affects ALL subsequent healthcare encounters (if that patient ever receives healthcare again). That also means that another provider can destroy all the trust that you have built with a patient.

If you take what I say to heart, then you can be a great physician.


Cryptoreformer said...

I am a semi-retired R.N. For 40 years I have been in the medical field and have assesses a lot of patients, both male and female. Professional demeanor and good bedside manner is a must. My advice to examining patients is to (1) have confidence and be professional, (2) explain what you are doing and why. (3) learn the art of small talk to put the patient at ease.
Since 2012, when I went of Medicare, I had a list of things which needed testing or fixing on me.
I had to go to a urologist for severe E.D.. The first one was a young doc just out of his residency. He walked in, grabbed my testicles, and said: "There is nothing I can do to help you, as you are a fat baby-boomer." I was insulted and asked for a second opinion. I got a referral to a surgeon at a teaching hospital. The day of the appt., I checked in and was told that the female Fellow of the surgeon would see me. I was a little hesitant, but then thought "Well she is a professional and I need help." I saw her, was instantly put at least. She examined me with confidence and spoke to me at the time. At the end, she said: I can help you." I was very pleased tjat I had found the right doctor. The first urologist was a young guy, and my second was a young female. He failed be as a physician, and the second was successful in treating me as a person.

A. Banterings said...

Many patients (and physicians) perceive a genital exam as a sexual experience. Patients can suffer adverse side effects from genital exams even when they are performed according to guidelines.

Here is an excellant article (with citations) that illustrates this point. Many of the citations are from the Nation Institutes of Health and other credible scientific and medical journals (so I am not making this up).

This article is about as long as this post (The Male Genital and Rectal Exams) and there are 43 citations. It WILL give you a new perspective......

Ponto said...

This is my opinion about genital and rectal exams. It is nothing to do with nudity or a person handling your genitals or fingering your back passage specifically. It is about the necessity to do so. Even if you are over 50, why do these things. Personally speaking I knew I had an enlarged prostate, I didn't have to have a rectal exam or an ultra sound to tell me so, and I do not care if the doctor does not accept my statements without those tests. People know something is wrong and those tests may confirm this, but it is also an intrusion and a violation of one's body. These last years I have had a stable full of strangers, doctors, nurses, medical ancillaries all looking at parts of me I haven't even seen myself. I loathed the process but put up with it in order to get a TURP. How about using less invasive ways of getting the data instead of using hundred years old manipulation techniques.

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