Scrotal examination

 

Scrotum

Plan for examination of the scrotum
Scrotal neck Junction between corrugated & smooth skin

At root of penis

At the pubic tubercle

Skin
Tunica Normally not felt except there is fluid If Minimal fluid it is felt by benching

If large amount of fluid it is felt as swelling

Testis Testicular sensation

Size

Epididymis
Cord Thickness

Vas felt like tough structure

Inguinal region Inguinal lymph nodes (that drain scrotal skin)
Penis Shaft for Hypospadias

Epispadias

Circumcision
DRE Prostate

Seminal vesicles

Perineum
Abdomen Para-aortic lymph nodes

Maldescended testis

Neck Left  supraclavicular LNs ( Verchow’s sign)

 

Aim of examination in case of scrotal swelling is to answer 4 questions

Can you get above the swelling?

Can you identify the testis and the epididymis?

Is the swelling is translucent?

Is the swelling is tender?

and these are examples for how you can comment on your examination of scrotum.

Hydrocele

  1. “Enlarged right side of the scrotum”
  2. Look to back of the scrotum and penis
  3. “No signs of inflammation (scars, sinuses or dilated veins)”
  4. “No cough impulse and not reducible (بيرجع؟)”
  5. “I can get above the swelling so it is pure scrotal swelling”
  6. Feel the swelling (relation to testis and epidydimis)
  7. Transillumination

Varicocele

  1. Examine in supine position after standing
  2. Inspection normal
  3. Feel bag of worms
  4. May feel cough impulse or thrill
  5. Separate from testis
  6. Can get above it
  7. No transillumination

Continue reading “Scrotal examination”

Clinical Examination of the Hernia

 

Inguinal hernia

Ask the patient to stand up (or can done in supine position first)

Always examine both inguinal regions

Look

at the lump from in front

Is this swelling a hernia?
  • Anatomical site of a hernia (groin)
  • Expansile impulse on cough (except if strangulated) (كح)
  • Reducible (except if irreducible, obstructed or strangulated) (تقدر ترجعها؟)
  • Opaque by transillumination (except in infants)
Which type (femoral or inguinal)?
  • Exact site (palpate ASIS and pubic tubercle ‘inguinal ligament’)   above or below?
Is it recurrent? (Scars)
Scrotum and penis
Feel Feel from in front (same items as inspection +)

Examine the scrotum

If you can “get above it

Feel from the side Stand at the side of the patient on the same side as the hernia. Place one hand in the small of the patient’s back to support him And your examining hand on the lump with your fingers and arm roughly parallel to the inguinal ligament

Examine for (Position – Temperature – Tenderness – Shape – Size – Tension)

Expansile cough impulse (كح)
Is the swelling reducible? Direction of reduction (تقدر ترجعها؟)
Internal ring test (direct or indirect?)
Percuss and auscultate

the lump

Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele) vs. Omentum (omentocele)

Consistency: Soft  vs. Doughy

Gurgling: Occurs during reduction vs.  None

Ease of reduction: First part is more difficult to reduce than the last vs.  Last part is more difficult to reduce

Percussion: May be resonant vs.  Dull

Complete by

Ventral hernias

Ask the patient to stand up (or usually done in supine position first)
Look Is this swelling a hernia?
  • Anatomical site of a hernia
  • Expansile impulse on cough (except if strangulated (هم براسك او كح)
  • Reducible (except if irreducible, obstructed or strangulated) (تقدر ترجعها؟)
Which type ? Umbilical, paraumbilical or epigastric.
Is it recurrent? (Scars)
Feel Examine for (Position – Temperature – Tenderness – Shape – Size – Tension)
Expansile cough impulse (هم براسك او كح)
Is the swelling reducible? Direction of reduction (تقدر ترجعها؟)
Percuss and auscultate the lump Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele) Omentum (omentocele)

Consistency: Soft vs.  Doughy

Gurgling: Occurs during reduction  vs. None

Ease of reduction: First part is more difficult to reduce than the last vs.  Last part is more difficult to reduce

Percussion: May be resonant vs.  Dull

Complete by

TAKING HISTORY FROM A PATIENT WITH A Hernia

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Lump
    • Anatomical site of hernia
    • Expansile impulse on cough (except if strangulated)
    • Reducible (except if irreducible, obstructed or strangulated)
  • Symptoms suggesting complication
    • Symptoms of intestinal obstruction (Pain – Vomiting – Distension – Absolute constipation)
    • Symptoms suggesting sliding hernia
      • Urinary symptoms (urinary bladder in inguinal hernia)
      • Dyspepsia (stomach in epigastric hernia)
  • History of suggesting cause
    • Congenital (sense birth)
    • Acquired
      • Raised intra-abdominal pressure (Chronic cough – Straining at micturation or stools – Heavy work – Obesity – Huge abdominal swelling)
      • Weak abdominal wall (Obesity – Senility – Debility – Pregnancy – Weak scar – Damage nerve supply of the muscles)

Differential diagnosis of hernias

Abdominal herniae
  • Common
    • Inguinal
    • Umbilical
    • Incisional
    • Femoral
    • Epigastric
  • Rare
    • Spigelian
    • Obturator
    • Lumbar
    • Gluteal
The differential diagnosis of a lump in the groin
  • Inguinal hernia
  • Femoral hernia
  • Enlarged lymph glands
  • Sapheno-varix
  • Ectopic testis
  • Femoral aneurysm
  • Hydrocele of the cord or hydrocele of the canal of Nuck
  • Lipoma of the cord
  • Psoas bursa
  • Psoas abscess
The differential diagnosis of inguinal hernia
  • Femoral hernia
  • Vaginal hydrocele
  • Hydrocele of the cord or the canal of Nuck
  • Undescended testis
  • Lipoma of the cord
Differences between indirect (oblique) inguinal hernia and direct inguinal hernia

Indirect inguinal hernia

Direct inguinal hernia

Age Any age Elderly
Side Uni or bilateral Commonly bilateral
Shape Oblong hemispherical
descent into the scrotum Can (and often does) Does not (hardly ever)
Direction of reduction upwards, then laterally and backwards upwards, then straight backwards
Internal ring test Controlled, after reduction ,by pressure over internal inguinal ring Not Controlled, after reduction ,by pressure over internal inguinal ring
The defect not palpable, as it is behind the fibres of the external oblique muscle may be felt in the abdominal wall above the pubic tubercle
Direction of descent After reduction, the bulge reappears in the middle of inguinal region and then flows medially before turning down to the neck of the scrotum After reduction, the bulge reappears exactly where it was before
at operation Neck of the sac is Lateral to the inferior epigastric artery Neck of the sac is Medial to the inferior epigastric artery
Anatomical types of oblique inguinal hernia
  • Congenital type
    • Reaches down to the bottom of the scrotum
    • Testis lies among the content of the sac
  • Infantile type
    • Operative finding
  • Adult type
    • Bubonocele
      • Limited to inguinal canal
    • Funicular hernia
      • Reaches down to the neck of the scrotum
    • Complete (scrotal) hernia
      • Descends to the bottom of the scrotum
      • Testis is behind the hernia and difficult to locate
The differential diagnosis of femoral hernia
  • Inguinal hernia
  • Enlarged lymph gland
  • Sapheno-varix
  • Ectopic testis
  • Psoas abscess
  • Lipoma
Complication of hernia
  • Irreducibility
  • Obstruction
    • Manifestations of intestinal obstruction
    • Locally hernia becomes (Distended – Irreducible – Soft)
  • Strangulation
    • Acute pain
    • Sudden enlargement of the hernia
    • Manifestations of intestinal obstruction
    • Locally hernia becomes (Tense – Tender – Irreducible – No impulse on cough)
  • Inflammation
    • Locally hernia becomes (Tender – Not tense – Overlying skin is red and oedematous)
  • Hydrocele of a hernia sac
  • Torsion of omentum
Causes for raised intra-abdominal pressure or weak abdominal wall?
  • Occupation
  • Multiplicity of hernias
  • Divercation of recti
  • Bulge of lower abdomen on straining
Operative differences between viable and non viable intestine

Viable

Non viable

Luster Normal luster Lusterless
Color Pink Grey or black
Mesenteric arteries pulsation Pulsating Not pulsating
Bleeding Bleeds if injured Does not bleed
Consistency Firm Flabby and thin
Effect of pinching Contract if pinched No response
Contents of spermatic cord

3 arteries

  1. Testicular artery (abdominal aorta)
  2. Artery of vas (inferior vesical)
  3. Cremasteric (inferior epigastric)

3 nerves

  1. Ilioinguinal
  2. Cremasteric
  3. Sympathetic

3 tubes

  1. Vas deferens
  2. Pampiniform plexus of veins
  3. Lymphatic vessels

Jaundice

 

Jaundice

Hemolytic Hepatocellular Obstructive
Cause Destruction of RBCs Liver dysfunction Outflow obstruction
Color Lemon yellow Orange yellow Olive green
Bilirubin Indirect Direct& idirect Direct
Associations Evidence of hemolysis Picture of LCF Pruritus

Other evidence of obstruction

Urine Darken on standing Dark Frothy dark
Stools Dark Pale Clay colored

Peripheral stigmata for abdominal disease

While performing the General Examination for a patient with abdominal complain you should emphasis in searching for these signs.

Peripheral stigmata for abdominal disease

Hand

  1. Clubbing
  2. Koilonychias ‘spoon-shaped nail’ (iron-deficiency anemia)
  3. Leukonychia ‘white nails’ (liver disease – fungal infection)
  4. Liver flap (uncompensated liver disease)
  5. Palmer erthema (liver disease)

Eyes

  1. Pallor (anemia)
  2. Jaundice

Mouth

  1. Hepatic foetor
  2. Pallor (anemia)
  3. Ulcer
  4. Pigmentation (peutz-jeghars)

Neck

Supraclavicular L.N.s

Upper trunk

  1. Gynecomastia
  2. Spider naevi
  3. Scratch marks
  4. Pulse

Lower limb

Edema

Abdominal Examination

 

Abdominal examination

Inspection

General

Contour

Movement with respiration

Visible peristalsis

Skin (Scar – Striae – Scratch marks – Veins – Haemorrhage)

Specific

Breast
Subcostal angle
Epigastric pulsation
Divercation of recti (هم براسك او كح)

Umbilicus

Site

Shape (Inverted – Everted)

Skin (Pigmentation – Nodules – Discharge – Ulcer – Scar)

Impulse on cough (هم براسك او كح)

Suprapubic hair distribution
Hernia orifices (هم براسك او كح)
External genetalia

Palpation

Superficial Tenderness – Rigidity – Superficial swelling
Deep Tenderness – Swelling

Organs

Liver

1st do tidal percussion

Size

Border

Surface

Consistency

Tenderness

Pulsation ‘bimanually’

Spleen Size

Border

Surface

Consistency

Tenderness

Notch

Pitting

Kidney Size

Right and left

Surface

Consistency

Tenderness

Bladder Size

Consistency

Tenderness

Colon
Lymph nodes
Aorta
Gall bladder

Percussion

  • Liver (and Tidal percussion)
  • Spleen (and Truab’s area)
  • For ascites (Transmitted fluid thrill – Shifting dullness – Knee elbow position – Ultrasound)
  • Bladder – Any mass

Auscultation

  • Intestinal sounds – Arterial bruit (Renal – Superior mesenteric – Iliac – Femoral)
  • Venous hum
  • Rub (Perisplinitis – Perihepatitis)
  • Succession splash
  • Scratch test
Never forget to examine

History taking, Symptoms and DDx of abdomen and GIT 

  • Abdominal pain
  • Abdominal swelling
  • Related to esophagus and mouth
    • Halitosis – Salivation – Dysphagia – Heart burn – Reflux – Painful swallowing or odynophagia
  • Related to upper GIT
    • Dyspepsia or indigestion – Eructation – Flatulence – Hiccups – Vomiting – Retching
  • Related to lower GIT
    • Bowel habits – Constipation – Diarrhea – Dysentery – Worms in stool
  • Related to bleeding
    • Haematemesis – Rectal bleeding – Melena
  • Hepatobiliary
    • Jaundice – Itching – Encephalopathy – Bleeding tendency – Weight loss
  • Constitutional manifestations
    • Fever – Headache – Malaise – Sweating – Fatigue

Clinical presentation of some abdominal/GIT disorders of surgical importance