The reproductive system

Oliver Young

Colin Duncan

Kirsty Dundas

Alexander Laird

Breast 212

Anatomy and physiology 212

The history 212

Common presenting symptoms 212

The physical examination 214

Investigations 216

Female reproductive system 216

Anatomy and physiology 216

The history 217

Common presenting symptoms 217

Drug history 219

Family and social history 220

Sexual history 220

The physical examination 220

Passing a speculum 220

Taking a cervical smear 222

Bimanual examination 222

Investigations 223

Obstetric history and examination: the booking visit 225

The history 225

Past medical history 225

Drug, alcohol and smoking history 225

Family history 225

Social history 225

Investigations 226

Routine antenatal check in later pregnancy 226

The history 226

Common presenting symptoms 226

The physical examination 228

Investigations 230

Male reproductive system 230

Anatomy and physiology 230

The history 230

Common presenting symptoms 231

Past medical history 233

Drug history 233

Social history 233

The physical examination 233

Skin 233

Penis 233

Scrotum 234

Prostate 235

Investigations 235

OSCE example 1: Breast examination 236

OSCE example 2: Scrotal pain history 236

212 • The reproductive system

BREAST

Anatomy and physiology

The breasts are modified sweat glands. The openings of

the lactiferous ducts are on the apex of the nipple, which is

erectile tissue. The nipple is in the fourth intercostal space in

the mid-clavicular line, but accessory breast/nipple tissue may

develop anywhere down the nipple line (axilla to groin) (Figs 11.1

and 11.2). The adult breast is divided into the nipple, the areola

and four quadrants (upper outer to lower inner), with an axillary tail

(of Spence) projecting from the upper outer quadrant (Fig. 11.3).

The size and shape of the breasts are influenced by age,

hereditary factors, sexual maturity, phase of the menstrual cycle,

parity, pregnancy, lactation and nutritional state. Fat and stroma

surrounding the glandular tissue determine the size of the breast,

except during lactation, when enlargement is mostly glandular. The

breast responds to fluctuations in oestrogen and progesterone

levels. Swelling and tenderness are common in the premenstrual

phase. The glandular tissue reduces and fat increases with age,

making the breasts softer and more pendulous. Lactating breasts

are swollen and engorged with milk, and are best examined

after breastfeeding.

The history

Benign and malignant conditions of the breast cause similar

symptoms but benign changes are much more common. The

most common presenting symptoms are a breast lump, breast

pain, and skin and nipple changes. Men may present with

gynaecomastia (breast swelling). Women are often worried that

they have breast cancer, whatever breast symptom they have,

and it is important to explore these concerns.

The history of the presenting symptoms is crucial. Find out

the nature and duration of symptoms, any changes over time

and any relationship to the menstrual cycle.

Ask about risk factors for breast cancer, in particular:

• previous personal history of breast cancer

• family history of breast or ovarian cancer and the age of

those affected

• use of hormone replacement therapy

• previous mantle radiotherapy for Hodgkin’s lymphoma.

Common presenting symptoms

Breast lump

Not all patients have symptoms. Women may present with an

abnormality on screening mammography or concerns about

their family history.

Ask:

• Is it a single lump or multiple lumps?

• Where is it?

Fig. 11.1 Accessory breast tissue in the axilla.

)DW

/REXOHV

'XFWV

'LODWHGVHFWLRQ

RIGXFWWR

KROGPLON

1LSSOH

1RUPDOGXFWFHOOV

%DVHPHQWPHPEUDQH

/XPHQFHQWUHRIGXFW

&KHVWZDOO

ULEFDJH

3HFWRUDOLV

PDMRU

PXVFOH

Fig. 11.2 Cross-section of the female breast.

Tail of Spence

Upper outer

Lower inner

Upper inner

Lower outer

Fig. 11.3 Adult right breast.