Testes (testicles)

The two oval testes (gonads) are enclosed in the scrotum, a saclike structure that lies suspended from the exterior abdominal wall. This position keeps the temperature in the testes below normal body temperature, which is necessary for viable sperm production and storage. Each testis contains one to three coiled seminiferous tubules that produce the sperm cells. After puberty, millions of sperm cells are produced daily. The testes also produce the hormone testosterone. Testosterone is responsible for the development of male secondary sex characteristics.

Ductal system

Accessory glands

The ductal system transports and stores sperm. The accessory glands, which produce seminal fluid (semen), include the seminal vesicles, the prostate gland, and Cowper’s glands. With each ejaculation (2 to 5 mL of fluid), approximately 200 to 500 million sperm are released.

Urethra and penis

The male urethra has two purposes: conveying urine from the bladder and carrying sperm to the outside. The cylindrical penis is the organ of copulation. The shaft of the penis ends with an enlarged tip called the glans penis. The skin covering the penis, called the prepuce, or foreskin, lies in folds around the glans. This excess tissue is sometimes removed in a surgical procedure called circumcision to prevent phimosis (tightness of the prepuce of the penis that prevents retraction of the foreskin over the glans).

Three masses of erectile tissue, the corpus spongiosum and two copora cavernosa, contain numerous sinuses that fill the shaft of the penis. With sexual stimulation the sinuses fill with blood, causing the penis to become erect. Sexual stimulation concludes with ejaculation, which is brought about by peristalsis of the reproductive ducts and contraction of the prostate gland. After ejaculation, the penis returns to a flaccid state.

Sperm

Colposcopy

Colposcopy (colpo, vagina or vaginal; and scopy, observation) provides direct visualization of the cervix and vagina. Prepare the patient for a pelvic examination and explain the purpose of the procedure. The physician inserts the vaginal speculum, followed by insertion of the colposcope for inspection of the area. The color of the tissue, presence of growths and lesions, and condition of the vascularity are observed and specimens obtained as necessary.

Culdoscopy

Culdoscopy is a diagnostic procedure that provides visualization of the uterus and adnexa (uterine appendages, i.e., the ovaries and fallopian tubes). Explain the purpose and the method of procedure. Prepare the patient for the vaginal operation with preoperative instructions. The patient is given a local, spinal, or general anesthetic. After the anesthetic is administered, the patient is assisted to a knee-chest position. The culdoscope is passed through the vaginal wall in back of the cervix. The area is examined for tumors, cysts, and endometriosis. During the procedure, conization (removal of eroded or infected tissue) may be done. This procedure is generally done on an outpatient basis. After the operation, assess for bleeding, assess vital signs, and monitor voiding.

Laparoscopy

Laparoscopy (examination of the abdominal cavity with a laparoscope through a small incision made beneath the umbilicus) provides direct visualization of the uterus and the adnexa. Preparation of the patient includes insertion of a Foley catheter to maintain bladder decompression for an open view. The procedure is done with a general anesthetic. The physician grasps the cervix with forceps and inserts a lighted laparoscope through the incision. Carbon dioxide may be introduced to distend the abdomen for easier visualization. If a biopsy is to be done or organs are to be manipulated, a second incision may be made in the lower abdomen to allow for instrument insertion. The ovaries and fallopian tubes are observed for masses, ectopic pregnancy, adhesions, and pelvic inflammatory disease (PID). Tubal ligations may be done using this procedure. Instruct the patient of the probability of shoulder pain afterward because of carbon dioxide introduced into abdomen.

Papanicolaou (pap) test (smear)

Papanicolaou (Pap) test (smear) (a simple smear method of examining stained exfoliative peeling and sloughed-off tissue or cells) is most widely known for its use in the early detection of cervical cancer. Scrapings of secretions and cells are taken from the cervix and spread on a glass slide. The slide is sprayed with a fixative and sent to the laboratory for analysis. It is important that slides be properly labeled with the date, time of the last menstrual period, and whether the woman is taking estrogens or birth control pills. Instruct patients not to douche, use tampons, use vaginal medications, or have sexual intercourse for at least 24 hours before the examination. Collect careful menstrual and gynecologic history.

The American Cancer Society (ACS) (2009a) highly recommends that every woman begin annual Pap tests within 3 years after becoming sexually active or no later than 21 years of age. Women should be tested every year (regular Pap test) or every 2 years (thin prep Pap test). Women age 30 years or older who have had three normal Pap tests in a row may choose to be screened every 2 to 3 years instead of annually. Women age 70 years or older who have had three or more normal Pap tests in a row and no abnormal test results in the past 10 years may decide to stop having cervical screenings altogether. Also, women who have had a hysterectomy may stop having cervical cancer screenings (unless their surgery was done as a treatment for cervical cancer or precancerous cells).

Thin prep Pap tests may slightly improve the detection of cancers and greatly improve the detection of cervical precancers. Thin prep Pap tests also reduce the number of tests that need to be repeated.

The physician may recommend more frequent testing for women with a history of multiple sexual partners or sexually transmitted infections (STIs), a family history of cervical cancer, or those whose mothers used diethylstilbestrol (DES) during pregnancy.

Pap tests have long been used to look for cervical cancer and precancerous cells. Cervista 16/18 and Cervista HPV HR are recently introduced tests for detecting the high-risk types of human papillomavirus (HPV) that are most likely to cause cervical cancer by looking for pieces of their deoxyribonucleic acid (DNA) in cervical cells. These DNA-based tests, in conjunction with the Pap test, have been approved by the U.S. Food and Drug Administration (FDA) (2009b) for women ages 30 and over with slightly abnormal Pap test results to find out if more testing or treatment may be needed.

Biopsy

Biopsies are procedures in which samples of tissue are taken for evaluation to confirm or locate a lesion. Tissue is aspirated by special needles or removed by forceps or through an incision.

A breast biopsy is performed to differentiate benign or malignant tumors. Breast biopsy is indicated for patients with palpable masses; suspicious areas appearing on mammography; and persistent, encrusted, purulent, inflamed, or sanguineous discharge from the nipples. The biopsy is performed by fine-needle aspiration (FNA); stereotactic or ultrasound core biopsy, under local anesthetic; or surgical biopsy, with general or local anesthetic. In an FNA, fluid is aspirated from the breast and expelled into a specimen bottle. Pressure is placed on the site to stop bleeding, then an adhesive bandage is applied. In an open surgical biopsy, an excisional biopsy is usually performed in a portion of the breast to expose the lesion and then remove the entire mass (Lewis et al., 2007). Another procedure called stereotactic and ultrasound core biopsy is a reliable diagnostic technique to obtain breast biopsy if an abnormal mass is seen on mammogram. A mammogram is used to find the lesion, the skin is anesthetized, and a small superficial incision is made. A biopsy gun device is fired into the lesion and removes a core sample of the mass. Compared with an open surgical biopsy, this procedure produces less scarring, uses only a local anesthesia, has reduced costs, and is done on an outpatient basis (Cleveland Clinic, 2009). Specimens of selected tissue may be frozen and stained for rapid diagnosis. The wound is sutured and a bandage applied. Observe the incision site for bleeding, tenderness, and erythema.

A cervical biopsy is done to evaluate cervical lesions and to diagnose cervical cancer. The biopsy is generally done without anesthesia. The colposcope is inserted through the vaginal speculum for direct visualization, the cervical site is selected and cleansed, and tissue is removed. The area is then packed with gauze or a tampon to check the blood flow.

An endometrial biopsy is performed to collect tissue for diagnosis of endometrial cancer and analysis for infertility studies. The procedure is generally performed at the time of menstruation when the cervix is dilated and cells are more easily obtained. The cervix is locally anesthetized, a curette is inserted, and tissue is obtained from selected sites of the endometrium.

Other diagnostic studies

Conization of the cervix is used to remove eroded or infected tissue or confirm cervical cancer. A cone-shaped section is removed when the mass is confined to the epithelial tissue. After surgery the area is packed with gauze to control bleeding. The patient is observed for bleeding and generally discharged from the hospital the same day.

Dilation and curettage (D&C) (scraping of material from the wall of a cavity or other surface; performed to remove tumors or other abnormal tissue for microscopic study) is a procedure used to obtain tissue for biopsy, to correct cervical stricture, and to treat dysmenorrhea. The patient is placed under general anesthesia, the cervix is dilated, and the inside of the uterus scraped with a curette. Packing may be inserted for hemostasis, and a perineal pad is applied for absorption of drainage. After vaginal packing is removed, instruct the patient to monitor for excessive vaginal bleeding or malodorous drainage.

Cultures and smears are collected to examine and identify infectious processes, abnormal cells, and hormonal changes of the reproductive tissue. Specimens collected for smears are prepared by spreading the collected smear on a glass slide and covering it with a second slide or spraying it with a fixative. Handle specimens with aseptic techniques and take care to avoid the transfer and spread of organisms. Cultures are taken from exudates of the breast, the vagina, the rectum, and the urethra. STIs and mastitis are diagnosed by isolation of the causative organisms. Treatment is prescribed according to the results of the culture.

Schiller’s iodine test is used for the early detection of cancer cells and to guide the physician in doing a biopsy. An iodine preparation is applied to the cervix, and glycogen, which is present in normal cells, stains brown. Abnormal or immature cells do not absorb the stain. Unstained areas may be biopsied. This method of detection is valuable but not entirely reliable, since normal cells sometimes lack glycogen and malignant tissue sometimes contains glycogen. After the procedure the patient should wear a perineal pad to avoid stains on the clothing.

Radiographic examinations are performed to detect abnormal tissue, locate abnormal structures, and observe patency of ducts.

Hysterograms and hysterosalpingograms are studies for visualizing the uterine cavity to confirm (1) tubal abnormalities (adhesions and occlusions), (2) the presence of foreign bodies, (3) congenital malformations and leiomyomas (fibroids), and (4) traumatic injuries. The patient is placed in the lithotomy position. A speculum is inserted into the vagina, a cannula is inserted through the speculum into the cervical cavity, and a contrast medium is injected through the cannula. As the contrast medium progresses through the cavity, the uterus and fallopian tubes are viewed by a fluoroscope and films are taken.

Mammography is radiography of the soft tissue of the breast to allow identification of various benign and neoplastic processes, especially those not palpable on physical examination. Digital mammography is a newer technique that allows a clear and more accurate image; it involves digitally coding x-ray images into a computer (Lewis et al., 2007). It is believed that the average breast tumor is present for 9 years before it is palpable. Digital mammography is helpful as a screening procedure. The ACS (2009a, b) recommends baseline mammograms for women between ages 35 and 39, with annual mammograms after age 40.

When the mammography procedure is scheduled, advise the patient to refrain from using body powders, deodorants, and ointments on the breast areas, since this could cause false-positive results. Before the procedure give the patient a gown and ask her to remove jewelry and upper garments. The technician asks the patient to sit or stand in an upright position and rest one breast on the radiographic table. A compressor is placed on the breast, and the patient is asked to hold her breath as an anterior view is taken. The machine is rotated, the breast is again compressed, and a lateral view is taken. This procedure is repeated on the other breast. The patient may be asked to remain until the radiographic films are read.

Because of the greater density of breast tissue, mammography is less sensitive in younger women, which may result in more false-negative results. About 10% to 15% of all breast cancers can only be detected by palpation and cannot be seen on mammography. Even if mammogram findings are unremarkable, all suspicious masses should be biopsied.

Ultrasound is a helpful diagnostic tool to differentiate a benign tumor from a malignant tumor. It is useful in women who have dense breasts with fibrocystic changes. Unlike a mammogram, an ultrasound will not detect microcalcifications (Lewis et al., 2007).

The ACS (2007b) recommends, in addition to annual screening with mammography, the use of magnetic resonance imaging (MRI) for women with a 20% to 25% or greater lifetime risk of developing breast cancer. An MRI is not recommended as a routine screening for all eligible women due to its high cost and greater risk of false positives as compared to mammograms.

In pelvic ultrasonography, high-frequency sound waves are passed into the area to be examined, and images are viewed on a screen; this is similar to a radiographic film. Ultrasound is useful in detecting foreign bodies (such as intrauterine contraceptive devices [IUDs]), distinguishing between cystic and solid tumor bodies, evaluating fetal growth and viability, detecting fetal abnormalities, and detecting ectopic pregnancy. Generally it is noninvasive, safe, and painless. Encourage the patient to drink fluids beforehand. Explain that a full bladder is essential to the accuracy of the test.

Tubal insufflation (Rubin’s test) involves transuterine insufflation of the fallopian tubes with carbon dioxide. The procedure enables evaluation of the patency of the fallopian tubes and may be part of a fertility study. Tubal insufflation takes approximately 30 minutes and is usually performed on an outpatient basis. If the tubes are open, the gas enters the abdominal cavity. A high-pitched bubbling is heard through the abdominal wall with a stethoscope as the gas escapes from the tubes. The patient may complain of shoulder pain from diaphragmatic irritation. In this case a radiographic film shows free gas under the diaphragm. If the tubes are occluded, gas cannot pass from the tubes, and the patient will not report pain.

All pregnancy tests, regardless of method, are based on detection of human chorionic gonadotropin (hCG), which is secreted in the urine after the fertilization of the ovum. Regardless of method, it is important to know that the tests do not indicate whether the pregnancy is normal. False-positive results may occur.

Serum CA-125 is a tumor antigen associated with ovarian cancer, since it is positive in 80% of such cases. CA-125 antigen levels in the blood decrease as the cancer cells decrease. CA-125 has been touted as a way to detect primary ovarian cancer, but unfortunately it does not do so. CA-125 is useful mainly to signal a recurrence of ovarian cancer and to follow the response to chemotherapy treatment. If chemotherapy causes a progressive decline in CA-125, it is an accurate indicator of a good response and is a good prognostic sign. Other conditions—such as endometriosis, PID, pregnancy, gynecologic cancers, and cancer of the pancreas—may result in an elevation of serum CA-125.

Testicular biopsy

Testicular biopsy is a means to detect abnormal cells and the presence of sperm. The testing can be done by aspiration or through an incision. The anesthetic used depends on the technique. Postbiopsy care measures consist of scrotal support, ice pack, and analgesic medications. Warm sitz baths for edema may also be helpful. Instruct the patient to call the physician if bleeding or elevated temperature occurs.

Semen analysis

Semen analysis can be performed to substantiate the effectiveness of a vasectomy, to detect semen on the body or clothing of a suspected rape victim, and to rule out or determine paternity. The procedure is generally one of the first tests performed on men to evaluate fertility. Semen can be collected for testing by manual stimulation, coitus interruptus, or the use of a condom.

Prostatic smears

Prostatic smears are obtained to detect and identify microorganisms, tumor cells, and even tuberculosis in the prostate. The physician massages the prostate by way of the rectum, and the patient voids into a sterile container prepared with additive preservative. The specimen is collected and a smear is prepared in the laboratory.

Cystoscopy

In cystoscopy a man’s prostate and bladder can be examined by passing a lighted cystoscope through the urethra to the bladder. Before the procedure, obtain a signed consent form and educate the patient concerning the procedure. The procedure is usually performed without anesthesia, but a local anesthetic may be instilled into the bladder. After the cystoscopy the patient may have pink-tinged urine and frequency and burning on urination. Provide comfort by warm sitz baths, heat, and a mild analgesic (Lewis et al., 2007). Cystoscopy can be done for both men and women to detect bladder infections and tumors.

Other diagnostic studies