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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: