ASSESSING FEMALE GENITOURINARY SYSTEM B.

PREGNANT FEMALE (tikang la po ini ha notes kay wa

hiya han pics)
EXTERNAL GENITALIA: 3 Signs:
. MONS PUBIS Presumptive – signs felt by the pregnant woman only
 rounded mound of fatty subcutaneous tissue Nausea
 highly sensitive to Estrogen Vomiting
 also called Mons Veneres in Latin which means Early morning sickness
“Mound of Venus”
Amenorrhea- absence of menstruation
 contains sebaceous glands which secretes secretions
Probable – signs and symptoms felt by the examiner
that facilitates sexual attraction to males.
Pheromones – substantial during sexual intercourse  Goodell’s Sign – softening of the cervix at 4 to 6 weeks
2. PREPUCE OF THE CLITORIS of pregnancy
 “clitoral hood”  Chadwick’s Sign – bluish or purplish discoloration of
 protects the clitoris the vaginal mucosa and cervix at 8 to 12 weeks
 covers the shaft of the clitoris - normal in pregnant women (bluish)
3. CLITORIS  Hegar’s sign – softening of the lower uterine segment
 highly sensitive tissue or glands at 6 to 8 weeks
 has an abundance of nerve endings - influenced by hormones (estrogen)
 not synonymous to the glans of the penis because it Positive – confirmation tests that confirms the pregnancy
does not contain erectile tissue or nerve cells
Ex. Ultrasound or auscultating the fetal heart sounds
 most common site of syphilitic infection
Cunnilingus – oral stimulation of the female organ
4. LABIA MINORA Mucus Plug – clot of thick tenacious mucus forms in the spaces
 inner lips of the cervical canal. It protects the fetus from invading
 serve or protect from mechanical irritation, dryness pathogens.
and infection Bloody Show – true sign of labor
 protects the urethral meatus
5. LABIA MAJORA  The uterus increases its capacity by 500 to 1000 times
 enclose or protect the inner organs of the female its non-pregnant state
genitourinary systems  Non-pregnant uterus has a flat and pear-shaped and
 contain sebaceous glands that secretes oil to prevent by 10 to 12 weeks gestation the uterus becomes
dryness
globular shaped and it’s too large to stay in the pelvis
6. PERINEUM
 the space between the anus and vulva in females  By 20 to 24 weeks, the uterus has an oval shaped
 space between scrotum and rectum in males
7. ANUS C. THE AGING FEMALE
 control the expulsion of feces  Menopause – cessation of the menses, usually occurs
8. VAGINAL ORIFICE around 48 to 51 years old.
 allows for the delivery of the fetus during childbirth  Uterus shrinks in size.
 channels menstrual flow or menses  Ovaries atrophy to 1 to 2 cm and are not palpable
 The sacral ligaments relax and pelvic musculature weakens
DEVELOPMENTAL CARE:
 Cervix shrinks and looks paler with a thick glistening
A. INFANTS AND ADOLESCENTS
epithelium
 At birth, the external genitalia are engorged
 The vaginal epithelium is atrophies
 The ovaries are located in the abdomen during childhood
 Decreased vaginal secretion
 The uterus is small with a straight axis an no anteflexion
 Increased risk for vaginitis
 At puberty, development of secondary sex characteristics
 Impaired female sexual response
occur
 Vaginitis – it is caused by decrease acidity in the vagina.
 The first signs of puberty are breast and pubic hair
 Dyspareunia – it is pain during intercourse. The natural
development
lubricant is gone
 Ovaries are now at pelvic cavity
CROSS-CULTURAL CARE:
TANNER’S 5 STAGES OF PUBIC HAIR
 Mexican-Americans (Women do not show their body to
DEVELOPMENT/SMR:
men)
Stage I – No pubic hair, mons and labia covered with fine vellus
 Chinese-Americans (Examination of the genitalia is
hair as on abdomen
offensive)
Stage II – Growth sparse and mostly on labia. Long downy hair,
slightly pigmented. Straight or only slightly curly. Occurs at 11  Muslim women (Female modesty)
and 12.  Infibulation (invasive procedure to remove the clitoris to
Stage III – Growth sparse and spreading over mons pubis. Hair inhibit sexual pleasure) or female genitalia mutilation is
is darker, coarser, curlier. Occurs at 12 and 13. common in Africa
Stage IV – Hair is adult in type but over smaller area; none on With all the Cultural Considerations, maintain a calm
medial thigh. Occurs at 13 and 14. and business-like manner and explain to the client the
procedure carefully
Stage V – Adult in type and pattern; inverse triangle. Hair is
present on medial thigh surface.
SUBJECTIVE DATA COLLECTION - Osteoporosis – one of the function of
1. Menstrual History the estrogen is bone development. If
2. Obstetric History there is a decrease or diminished
3. Menopause number of estrogen there will be bone
4. Self-Care Behaviors resorption or bone loss.
5. Urinary Symptoms Associated Symptoms:
6. Vaginal History  Hot flashes (vasomotor symptom)
7. Past History  Headache
8. Sexual Activity  Mood Swings
9. Contraceptive Use  Vaginal Dryness
10. STD  Itching

SUBJECTIVE DATA: ASSESSMENT 4. Self-care Behaviors

1. Menstrual History a) How often do you have gynecologic check-up?
a. Date of last menstrual period b) Last Papanicolau smear?
b. Age at first period Pap Smear – it cleans the cervical cancer (19 years
c. How often the periods occur and above and sexually active females)
d. Hoe many days does the period last
e. Usual amount of flow: light, medium, heavy 5. Urinary Symptoms
f. Amount of pads or tampons being used each day or a) Any burning or pain in urinating
hour Dysuria – painful during urination
2. Obstetric History b) Awaken during night to urinate
a. How many times Nocturia- excessive urination at night
b. How many babies have you had c) Blood in the urine
c. Any miscarriages or abortion Hematuria – Is the presence of blood in the urine
d. Do you think you may be pregnant now? What d) Any difficulty in controlling urine
symptoms have you noticed? e) Urinate with a sneeze, laugh, cough, bearing down
 G (Gravida) the total number of pregnancy dead or Urinary Incontinence (d and e ) FORUMS
alive 6. Vaginal History
 T (Term) indicates the full term of pregnancy (37-40
a) Any unusual vaginal discharge? Note the character,
weeks AOG)
smell and color
 P (Pre-term) no. of deliveries at the age of 20-36
weeks AOG
 A (Abortion) before 20 weeks AOG 7. Past History
Viability: Ability of the fetus to survive a) Any problems in the genital area? Sores or lesions
Fetus should be 24 weeks for the fetus to survive b) Any abdominal pain
 L (Living) no. of baby alive c) Any past surgery on uterus, ovaries, vagina?
 M (Multiple Pregnancy or Deliveries) d) Sexual Acitivity

GTPALM OBJECTIVE DATA ASSESSMENT:

 A 20 years old female is currently 8 weeks pregnant. She Preparation
had a miscarriage at 12 weeks gestation 2 years ago. She 1. No douching for 48 hours
has no living children 2. Urinate before examination
G – 2 (currently pregnant at 8 weeks; had a miscarriage 2 years 3. Dorsal lithotomy position
ago 4. No hands over the head
T–0 5. Elevate client’s head and shoulders
P–0
A – 1 (miscarriage 12 weeks) Equipment
M–0 1. Stool
2. Light
3. Menopause 3. Vaginal speculum
a. Have you periods slowed down or stopped? a. Grave’s Speculum – used for elderly woman
o Perimenopause – can begin 8 to 10 years before the b. Pederson Speculum – used for adolescents
menopause. Ovaries gradually produce less estrogen. 4. Water soluble lubricant
Usually starts in a woman’s 40 but can start in the 30s * in some books use of lubricants are avoided
as well. Women are still having menstrual cycle and Rationale: Lubricants provide bacteriostatic effect which
can get pregnant will alter the result of analysis
o Menopause – is the point when a woman no longer * Use warm water instead
has menstrual periods. Diagnosed when menstruation 5. Large swabs for vaginal examination
does not occur in one year or 12 consecutive months. 6. Specimen container
Ovaries have stopped releasing eggs and producing 7. Gloves (non-sterile)
estrogen 8. Ayre spatula
o Post menopause – years after the menopause. 9. Endocervical broom
10. pH paper
11. Mirror c. Endocervical Speimen (performed last because it can
Rationale: The use of mirror helps you teach the patient about cause injury)
the anatomy of Female Reproductive System thereby promoting - insert the cytobrush into the oust. Rotate the brush
calm manner and cooperation from the patient 720 degrees in one end direction.
* the woman may feel a slight pinch of the brush
INSPECTION:
1. Skin color
2. Hair distribution
NECESSARY DATA FOR LABORATORY REQUEST:
3. Labia Majora
 Name
4. Clitoris
5. Labia Minora  Age and Date of birth
6. Labia Majora (an nakadto ppt kay minora la ghap idk  Date of specimen
HAHA)  Date of LMP (first day of menstrual cycle- ask the patient
7. Urethral opening the first day of her menstrual period)
8. Introitus  Any hormone medication
9. Perineum  If pregnant, EDD/EDC (Expected Date of Delivery)
 Known Infections
PALPATION:  Abnº findings on physical examination
1. Skene’s gland
2. Bartholin’s gland SCREENING FOR STD
3. Posterios part of the labia majora  Gonorrhea & Chlamydia GC Culture
4. Palpate the perineum
ABNORMALITIES OF THE EXTERNAL GENITALIA:
SPECULUM EXAMINATION: 1. Pediculosis Pubis (Crab Lice)
1. Select the proper-sized speculum S: Severe perineal itching
2. Do not use lubricant GEL O: Exoriations and erythematous areas
 Visible little dark spots and adherent to pubis hair
INSPECTION OF THE CERVIX AND OS: 2. Syphilitic Chancre (Trepoutoma Pallidum)
NOTE: O: Begins as a small, solitary silvery papule that erodes to a red,
Color – cervical mucosa is pink and even round or oval, superficial ulcer with a yellowish serous discharge
(+) Chadwick’s sign for pregnant Tx: Penicillin G
Pale for elderly 3. Herpes Genitals
Position – midline, either anterior or posterior (Projects 1-3cm S: Episodes of local pain, dysuria (painful urination), fever
into the vagina) O: Clusters of small, shallow vesicles with surrounding
Size – diameter is 1 inch erythema
OS – small and round  Erupt on genital areas and inner thigh
Horizontal and irregular slit  (+) inguinal adenopathy, edema
 Vesicles on labia rupture in 1 to 3 days, leaving painful
ulcers
NORMAL VARIATIONS OF THE CERVIX:  Initial infection lasts 7 to 10 days
 Round  Virus remains dormant indefinitely
 Horizontal Parous (after childbirth)  Recurrent infections last 3 to 10 days with milder symptoms
Tx: Antiviral
LACERATIONS: 4. Genital Warts (Condyloma Acuminatum)
 Unilateral Transverse CA: Human Papilloma Virus
 Bilateral Transverse S: Painless wart growths, may be unnoticed by woman
 Stellate O: Pink or flesh colored, soft, pointed, moist, warts papules
 Cervical Eversion  Single or multiple in cauliflower-like patch. Occur around
 Nabothian cysts (benign) – fluid like vesicle vulva, introitus, anus, vagina, cervix
Tx: Prophylactic (Gardasil Vaccine)
CERVICAL SMEARS AND CULTURES: 5. Abscess of Bartholin’s Gland
S: Severe, local pain
a. Vaginal Pool O: Overlying skin & hot
- you insert or gently rub the blunt end or ayre spatula  Posterior part of labia swollen; palpable fluctuant mass and
over the vaginal wall and under and lateral to the cervix. Wipe tenderness
the specimen on the slide and spray with fixative immediately.  Mucosa shows red spot at site of duct opening
Rationale: To prevent drying and to preserve the specimen.  Secondary to gonococcal infection
6. Urethral Caruncle
b. Cervical Scrape
-insert the bifed end of the ayre spatula into the S: Tender, painful with urination, urinary frequency, hematuria,
vaginal wall. Rotate the spatula 360-720 degrees using firm dyspareunia
pressure. O: Small, deep red meatus; usually secondary to urethritis or
skenitis; lesion may bleed on contact
7. Urethritis S: Variable: Vaginal discharge, dysuria, abnormal uterine
S: Dysuria bleeding, abscess in Bartholin’s or Skene’s glands;
O: Palpation of anterior vaginal wall shows erythema, O: Purulent vaginal discharge. Diagnose by positive culture of
tenderness, induration along urethra, purulent discharge from organism. It may progress to acute salpingitis, PID
meatus. Caused by N. Gonorrea, Chlamydia, Staphylococcus
infection EXTRA FROM MY NOTES:
Nulliparous – waray pa kaburod
ABNORMALITIES OF THE PELVIC MUSCULATURE:
1. Cystocele Pheromones – stimulates sexual desire or sexual attraction
S: Feeling of pressure in vagina, stress incontinence
O: Introitus widening and the presence of soft, round anterior Vaginitis – due to decreased acidity of the vagina
bulge (bladder)
2. Rectocele G- gravida (total number of pregnancy, dead or alive)
S: Feeling of pressure in vagina, possibly constipation T- term (number of pregnancy that reached 37-40 weeks AOG)
O: Introitus widening and presence of a soft, round bulge from P- preterm (number of pregnancy that reached 20-36 weeks
posterior (part of the rectum covered by vaginal mucosa, AOG)
prolapses into vagina) A- abortion (number of delivery less than 20 weeks AOG)
3. Uterine Prolapse L- living (number of babies that are alive)
O: Uterus protrudes into vagina M- multiple gestation (number of babies e.g. twins)
First degree – cervix appears at introitus with straining Age of viability – 24 weeks (age should be of the baby to be
Second Degree – cervix bulges outside introitus with straining alive inside a pregnant woman’s womb
Third Degree – whole uterus protrudes into vagina even without
straining Hematuria – presence of blood in urine

VULVOVAGINAL INFLAMMATIONS: Types of Urinary Incontinence:

1. Atrophic Vaginitis F- functional (urinary tract is functional but with the presence of
S: Postmenopausal vaginal itching, dryness, burning sensation, disability the individual prevents himself from staying dry)
dyspareunia, mucoid discharge O- overflow (incomplete bladder emptying; there is blockage of
O: Pale mucosa with abraded areas that bleed easily; may have the urine from flowing normally out of the bladder)
bloody discharge Ex. Prostate Cancer – there is hyperplasia of your prostate
2. Candidiasis (Moniliasis) gland
S: Intense pruritus, thick whitish discharge R- reflex (bladder muscle contracts and urine leaks without any
O: Vulva and vagina are erythematous and edematous. warning or urge)
Discharge is usually thick, white, curdy, “like cottage cheese” U- urge (feeling of strong urge to urinate)
Predisposing Factors: M- mix (combination of overflow and stress incontinence)
 Use of oral contraceptives S- stress (leaks when you jump, cough and laugh)
 Use of antibiotics
 Alkaline vaginal pH
 Diabetes
 Pregnancy
3. Trichomoniasis (Trich)
S: Pruritus, watery and often malodorous vaginal discharge,
urinary frequency, terminal dysuria
o Symptoms are worse during menstruation
O: Vulva may be erythematous. Vagina diffusely red, granular,
with red raised papules and petechiae (strawberry appearance)
 Frothy, yellow-green, foul-smelling discharge
 Microscopic examination of saline wet mount specimen
shows characteristics flagellated cells
4. Bacterial Vaginosis (Gardnerella Vaginalis/
Haemophilus Vaginalis, Nonspecific Vaginitis)
S: Profuse discharge, “constant wetness” with foul-fishy rotten
odor
O: Thin, creamy, gray-white, malodorous discharge. No
inflammation on vaginal wall or cervix
 Microscopic view of saline wet amount of specimen shows
typical “clue cells”
5. Chlamydia
S: Urinary frequency, dysuria or vaginal discharge
O: May have yellow or green mucopurulent discharge, friable
cervix, cervical motion tenderness
6. Gonorrhea
Anatomy and physiology of the male genitalia:  Cultural reasons.
 Prevention of phimosis
PENIS-external male reproductive organ that serves as urinal
 Inflammation of Glans penis
duct.
 Prevent UTI during infancy
The penis has 3 column erectile tissue:
SUBJECTIVE DTA COLLECTION
1. Corpora carvernosa
2. Corpus Spongiosum- extends to the distal ends of the 1. Review Normal urinary elimination pattern.
glans penis- which is the most sensitive part of the a. If there is a history of nocturia (excessive urination at
penis. night.
b. Note the character and volume of urine.
SCROTUM- protective function and act as a climate control c. If there is dysuria (pain in urination).
system of the testes. d. If there is presence of hematuria (presence of blood in
urine.)
Cremaster Muscle- controls the size of the scrotum by e. Note the urgency and the frequency
responding to ambient temperatures. To keep the testes at 3°C f. Note the different types of urinary incontinent
below the abdominal temperature.
Normally in the cold temperature, it is the cremaster muscle to RATIONALE: Urinary problems are associated with GU
hold up or constrict and extend to the abdomen the scrotum to problems.
preserve the temperature adequate for sperm viability.
2. Assess patient’s sexual history and use of safe sex habits.
DEVELOPMENTAL CARE
a. Identify the multiple partners
Infant- the testes develop in the abdominal cavity. Before birth b. Infection import risk and failure to use condom
the testes descend along the inguinal canal into the scrotum.
RATIONALE: Sexual History reveals risk for and
Adolescence- puberty begins between 9.5- 13.5 years old. understanding of STD and HIV
Occurs the enlargement of the testes 3. Determine if the patient has had previous surgery or illness
involving urinary or reproductive organs.
TANNERS STAGE OF MALE GENITAL DEVELOPMENT RATIONALE: Alterations resulting from disease or surgery
STAGE 1 – prepubertal genital. No pubic hair. are sometimes responsible for symptoms or changes in
STAGE 2- few straight hair. Slightly dark hair. No enlargement organs structures or function.
of the penis. Testes and scrotum begins to enlarge. Scrotum
becomes reddens and changes in texture. 4. Ask if the patient has noted penile pain or swelling, genital
STAGE 3- spares of growth of pubic hair over the entire pubis. lesions, or urethral discharge.
Hair darker and curly. Penis becomes longer.
STAGE 4- there is a thick of pubic hair over the pubic area but RATIONALE: These signs and symptoms may indicate STI
not on the thighs. Enlargement of the penis in length and 5. Determine if patient has noticed heaviness or painless
diameter increases. enlargement of testis or irregular lumps.
STAGE 5- Hair growth spread over the midthighs. Penis and
scrotum is now on the adult size and shape. RATIONALE: These signs and symptoms are early warning
signs for testicular cancer.
Adults and Aging Adults
6. If the patient report an enlargement in inguinal area assess if
A. Sexual development remains constant. No further
it is intermittent or constant, associated with straining or lifting,
genital growth and no further circulating hormones. The
and painful and whether pain is affected by coughing, lifting, or
male does not experience tandilent end to fetility as female.
straining at stool.
At the age of 40 years old- reproduction of sperm
begins to decrease RATIONALE: These signs and symptoms reflect potential
By the age 0f 55-60 years old- testosterone production inguinal hernia.
declines.
B. Aging changes due to: 7. Ask if the patient if has inguinal pain when achieving erection
1. Decreased muscle tone or ejaculation.
2. Decreased subcutaneous fats 8. Review if the patient is diuretic, sedative or hypotensive or
3. Decreased cellular metabolism tranquilizer
C. Amount of Pubic hair decreases and hair turns gray.
D. Penis size decreases. Due to decrease of dartos muscle RATIONALE: This medication influence sexual
(a fascia, a connective tissue and a subcutaneous fat). It is performance and impotence.
decrease subcutaneous fats brought about the aging
process. OBJECTTIVE ASSESSMENT
E. Slower and less intense sexual response. It is due by PREPARATION
declining testosterone production. 1. Have the patient void. Position the male in a supine position
F. Erection takes longer to develop and then to assess for hernia have the patient standing,
G. Ejaculation is shorter and less forceful. undershorts down.
H. Rapid detumescence 2. Do not discuss genitourinary history or sexual practices
I. Refactory state lasts longer. while performing the examination.
CROSS CULTURAL CARE 3. Use a firm touch, not a soft stroking one
4. If an erection does occur. Do not stop the examination.
CIRCUMCISION RATIONALE: To avoid embarrassment and ensure the patient
Indication: that it is normal physiological response to touch.
GENITAL HERPES
PUBIC HAIR
 Inspect the distribution, amount and characteristics of  Cluster of small vesicle with surrounding erythema,
pubic hair which are often painful, erupt on the glans or foreskin.
RATIONALE: Abnormal production of pubic hair indicates of ABNOMALITIES OF THE PENIS
thyroid problems or endocrine problems.
PHIMOSIS
PENIS
 Inspect the penile shaft and glans penis for lesions,  Foreskin is advance and fixed so tight it is impossible
nodules, swellings of inflammation. to retract over glans.
 Inspect the urethral meatus for swelling, inflammation  May be congenital or acquired from adhesions.
and discharge.  Poor hygiene leads to retained dirt and smegma, which
*Compress the glans slightly to open the urethral meatus. increases risk of inflammation or calculus formation.
Normal color of meatus is color PINK. HYPOSPADIAS
 Palpate the penis for tenderness, thickening and
nodules  Congenital defect
 Urethral meatus opens on the ventral side of the glans,
shaft, or at the penoscrotal junction.
SCROTUM
 Inspect the scrotum for appearance, general size and EPISPADIAS
symmetry.
 Palpate the scrotum to assess status of underlying  Meatus opens on the dorsal side of the glans or shaft
testes, epididymis, and spermatic cord. above a broad spadelike penis.
 Palpate both testes simultaneously for comparative
PRIAPISM
purposes.
 Prolonged painful erection without sexual desire.
Normal: asymmetry scrotum
PEYRONIE’S DISEASE
*If note swelling, perform Trans illumination. Darken the room
and put a light behind the scrotum.  Hard, nonlender, subcutaneous plaques palpated on
Normal: Do not illuminate. dorsal or lateral surface of the penis.
 Associated with painful bending of the penis during
INGUINAL AREA erection.
 Inspect both inguinal area for bulges while the client is ABNORMALITIES OF THE SCROTUM
standing and is straining down
ABSENT TESTIS CRYPTOCHIDISM
To check the patient if there is hernia:
S: Empty scrotal half
1. Instruct the patient to tilt the head O: Inspection- in true maldescent, atrophic scrotum on affected
2. Insert your index finger in the inguinal area side
3. Instruct the patient to cough. Palpation : No testis palpable.
Normal: No movement changes of the finger when examining TESTICULAR TORSION
the inguinal area.
S: Sudden of excruciating in testicle.
TESTICULAR SELF EXAMINATIN (TSE)
Lower abdominal pain
 At least once a month
Nausea and vomiting
 Check in the shower.
No fever
MALE GENITAL LESIONS
O: Inspection- Red, swollen scrotum
SYPHILITIC CHANCRE
Palpation- cord feel thick, swollen and tender cremasteric
 Begins 2-4 weeks of infection
reflex is absent on side of torsion.
 Small, solitary, silvery papule that erodes red, round
and oval. Superficial ulcer with a yellowish serous EPIDIDYMITIS
discharge.
 Severe pain in the epididymis portion. Relived by
CONDYLOMA ACUMINATUM elevation.
 Also known as genital warts. Prehn's sign- to help determine whether the presenting
 Caused by human papillomavirus (HPV) testicular pain is caused by acute epididymitis or from testicular
 Soft, pointed, moist, fleshy, painless or multiple in a torsion.
cauliflower like patch.
To determine if it is epididymitis. You let the patient lie flat on the
 Correlated with early onset of sexual activity,
bed. Observe if the pain subside.
infrequent use of contraception and multiple sexual
partners. HYDROCELE
 A circumcised collection of serous fluids around
the testis.
S: Painless, swelling weight and bulk in scrotum
O: Inspection- enlarged, mass does transilluminate with a pink
or red glow.
Palpation: Non tender mass
SCROTAL HERNIA
 Due pinky red inguinal hernia
S: Swelling may have pain with straining
O: Inspection- enlarge and may reduce when supine does not
transilluminate
Palpation: Soft mushy mass
ORCHITIS
S: Acute or moderate pain of sudden onset. Swollen testis,
feeling of weight fever.
O: Inspection- enlarged edematous reddened does not
transilluminate.
Palpation- swollen, congested, tense and tender testis
SCROTAL EDEMA
 Occurs in total inflammation due to epididymitis,
obstruction of inguinal lymphatic.
S: Tenderness
O: Inspection- enlarged, may be reddened (with local irritation)
Palpation: probably unable to feel scrotal contents.

HERNIAS
1. INDIRECT HERNIA
 Most common form of hernia
 Sac herniates through internal inguinal ring. Can
remain in canal or pass into scrotum.
 Common in infants and in male 16 to24 years old
s/s: pain with straining. Soft swelling that increases
intraabdominal pressure may decrease when lying down.
2. DIRECT HERNIA
 Brought on by heavy lifting, muscle atrophy, obesity,
chronic cough or ascites. Common in body builders.
 Directly behind through external inguinal ring above
inguinal ligament, rarely enters scrotum. Common in
men in 40 years old and above.
s/s: Painless. Round swelling close to the pubis area of internal
inguinal ring: Easily reduced when supine.
3. FEMORAL HERNIA
 Through femoral ring and canal below inguinal
ligament, more often on right side.
 Due to increased abdominal pressure muscle eakness
or frequent stooping
s/s: Severe pain. May become strangulated. (Common in
women)