Learning Intimate Exams

llg, PhD, RN · Dec 8, 2016

Many years ago, while getting my MSN, I learned to do pelvic exams with the help of such a teaching associate. It was a very effective teaching method. At first, the instructor demonstrated a basic exam with me as the only student in the room with the teaching associate. Then the instructor left the room and the associate talked me through the exam.

To answer the original question ... for me as a student, the time together with the teaching associate before doing the exam myself was important. Talking with her while the instructor demonstrated a few skills gave me a chance to get comfortable with her and let me see that she was comfortable being examined. So by the time I began to actually touch her, we had established a relationship and I was more comfortable because I knew she was OK with the situation.

Julius Seizure · Dec 9, 2016

I recently had this learning experience in school, so I'll try to give you some feedback on what made it a positive experience for me and my classmates:

My instructor was pretty good. It was a group of three students (all female), and him in the room - he was mid-20s (younger than us), which was a little odd at first, but he was very professional while also being personable, so things were okay. One thing that made it more chill was that he sat in a chair and kept himself clothed/covered when talking with us, rather than standing in front of us awkwardly.

He didn't just right into "okay, take turns checking me for hernias!". He had brought some teaching tools, like a model of various prostates, some normal and some with various abnormalities. He talked a lot at first, briefly about how he ended up with such a crazy job and then describing the entire assessment that we were about to do while he was still clothed. Then he disrobed from the waist down and demonstrated the assessment of the genitals and hernia checks on himself. He gave some tips like, to assess the underside of the member it might be best to flip it over (it can bend that way?!) rather than lifting it up because then you are an attractive chick with her face behind your junk and the poor guy is already trying to focus on mentally reviewing baseball statistics rather than thinking about what is going on. He kind of let us know how things would feel, both from the patient and the provider side.

THEN we actually practiced the assessment on him. So there was a good amount of time of learning and getting used to the weirdness of being in a room with a naked guy first. (One thing that we found kind of humorous was that all eye contact from him disappeared as soon as his pants came off, and once we started assessing, he stared at the ceiling the whole time :laugh: )

So after that was all out of the way, he wrapped himself in a bath towel and talked about the prostate exam - how much guys dread it, how important it is, and how to do it. All while covered. Then disrobed and demonstrated the positioning. Then, he stood up and had us all practice telling our patient how to position themselves (football stance, rather than "bend over!") and we all practiced.

I was dreading the whole experience, but it turned out that it wasn't so bad after all.

Specifically regarding your questions:

What can I do to make a student's first intimate exam of a male to be less stressful?

- Keep your pants on to talk at first. Don't be awkwardly formal, but also don't be too informal. (Was that clear enough? :up: )

Should there be a lecture or a video demonstration prior to the actual exam?

- We already had video demonstrations assigned to us in class. Seeing the teaching assistant demonstrate on himself before we practiced was helpful and made us feel more comfortable. We knew what he was expecting us to do and then we did it.

Would it be helpful to have the urogenital teaching associate meet with the class prior to the session to discuss crossing social and religious taboos, ethics and modesty?

- I think that this would have been really interesting and insightful.

Does being in a session with students of the same gender or mixed gender matter?

-Nah. Well maybe for the one guy in our class but not for the girls. The guy felt uncomfortable regardless, I think.

As far as awkward things to avoid.....one group said that their teaching tried to shake hands with everybody. Nobody wants to shake hands after that!

ethics&modesty · Dec 9, 2016

Thank you. That was very helpful.

I find that most nursing students going for a certification already have practical patient experience so are less intimidated with the sight and touch of a patient. One of the best questions from a bolder student is "What can I do to lessen the patient's embarrassment?" and "What can I do to lessen the likelihood of causing an erection?"

In my sessions I am already in a gown with my pants and underwear removed and I remain seated on the exam table with the back at 45 degrees with a drape over my legs. I can keep eye contact at all times with the students and encourage them to do so even during the exam. We talk for about 1/2 hour before I uncover anything and I first teach how to fold the gown just enough to uncover the part of the patient to do that portion of the exam. So when they palpate for lymph nodes on my thighs or suprapubic region for instance my genitals remain covered.

After I demonstrate upon myself and I have the first student begin an exam, the others typically hang back so I stop and ask the others to gather around the table to watch more closely so they can see what is being done and hear any advise I may give I find that they all step up eagerly which seems to make the student doing the exam a bit less "alone". My first piece of advice is to use a firmer touch when palpating anything as it is much more effective at finding tumors or swollen nodes and much less likely to cause any arousal. And yes, the male organ is very flexible when flaccid so it can be twisted and stretched without any pain.

The most difficult thing to impart is that I feel no embarrassment and that they are not going to hurt me. Even when trying to find the epididymus or palpating the testes. I teach them to teach men how to do a self exam and the reasons why it is important if we are going to catch testicular cancer early enough. Something that helps my students is that I am in my 60's so I usually look more like a father or uncle figure than a peer in age

Again thank you

**NICU Guy, BSN, RN** · Dec 9, 2016

We only had mannequins and a professionally made video using a nurse and actor/patient for the genital exams. It would have been far more beneficial if we had live "patients" to practice on, especially opposite sex "patients".

twinmommy+2, ADN, BSN, MSN · Dec 9, 2016

I was fortunate to have done sessions with a female and male GU instructor and it was a really great experience. I have done several pelvic exams as a SANE nurse and still learned quite a bit during the session, and being I had never done a male exam I learned a lot. I would recommend this to any nurse or NP upcoming.

I work as a male urological teaching associate. I use my body to teach students to find all of the physical landmarks to do a complete exam including inguinal lymph nodes, hernia, testicular cancer, STD's, locate the epididymus, vas deferns, femoral pulse and a DRE. The sessions usually have 4 students at a time.
What can I do to make a student's first intimate exam of a male to be less stressful? Your professional attitude will help many to feel more comfortable.
What information would be most helpful to have prior to the exam? I think going over the procedures that you will be performing and just going over that a response may be elicited from performing a male exam and is normal. Another thing that would have been helpful to me would have been telling me that I would have to palpate deep to find the inguinal canal opening.
Should there be a lecture or a video demonstration prior to the actual exam? I don't know if that would have been helpful to me. When it came to the female exam I had prior experience being a SANE nurse so I took the first turn at the pelvic exam to help show the others how it was done.
Would it be helpful to have the urogenital teaching associate meet with the class prior to the session to discuss crossing social and religious taboos, ethics and modesty? That would be a good discussion to have with the professors prior to the exam.
Does being in a session with students of the same gender or mixed gender matter? For me it doesn't matter. We are all there to learn.
What questions you would like answered that you might feel embarrassed to ask in public? None

blackribbon · Dec 9, 2016

OK...I don't know that the "patient" should be the teacher...I think that takes away from the professional separation that allows us to do these kind of exams. I would be more comfortable with a person being the patient and a separate person being the teacher because in real life situations, the nurse often is the one who has to make the patient feel comfortable in a potentially embarrassing situation.

As a gyn nurse who also worked general med/surg for a while, I don't think school can prepare us for the real world...and considering how different real human bodies are when it comes to sexual organs, I don't know that examining a single one would really prepare us for that much at all. I personally believe real patients with real problems and a good bedside mentor is a better learning environment. That is how you learn to treat the patient with respect and learn how to put them at ease ... not the other way around. I personally still have played enough real "which hole is the winner" when placing a female foley/straight cath ... the last one being an 83 year old woman with a broken hip whose ureter was actually in the lady parts. Ironically my first real patient as a solo RN was a woman with a labial abscess. Followed a few weeks later by a gentleman who had a scrotal abscess that was huge enough it had to be surgical lanced and drained and I was the lucky nurse who got to do the dressing changes.

Honestly, if you really want to prepare them for "real life", you would make several inappropriate comments and attempt to make them uncomfortable so they learn to stay professional when their real patients act like real patients.

ethics&modesty · Dec 9, 2016

Interesting perspective especially on real life and real patients. You then advocate the sink or swim method of learning. But if I were teaching music I would not start with Beethoven's fifth. I would teach the student the scales.

Real patients can present real difficulties in physiology and demeanor. Nursing is hard. A nurse can have just finished tending to a woman who has had a miscarriage with all of the emotional upheaval to go to the next patient who is whining about being served cold soup. Every patient is selfish and is constantly demanding attention for their own needs. That is part of the job. When I have been a patient I always try to make a double effort to be grateful for any kindness the nurses have shown to me, but sometimes, especially when I have been in pain, I forget.

So you would make the student's first experience doing an intimate exam as emotionally uncomfortable as possible with inappropriate comments from the patient? Not sure they would learn how to do a proper exam under that additional stress. Yes, they will face those situations in clinical rotation eventually, but on day one in school? I am not sure about that. Would like to hear from others on this point.

Hmmmm ... I am a pretty big fellow, I suppose I could pretend to be a combative homicidal patient just brought in by the police and be handcuffed to the table so they can forcibly insert a catheter to draw urine for evidence but I am not sure that would be a good first experience. Certainly would not be for me as a standardized patient!!!

WanderingWilder, ASN · Dec 9, 2016

My sister has told me about using paid "patients" at her medical school, but I don't believe they do the instructing but act as a patient would and then one of my sister's instructors does the teaching. I'll have to ask her about it now. This is an interesting thread.

kbrn2002, ADN, RN · Dec 19, 2016

This is a fascinating discussion and I must thank you for what you do to help students. Unfortunately not many nursing programs hire live "patients" for exams. Most are lucky to have decent mannequins. I would imagine your skills are utilized in a medical school, NP or PA program much more often than in a nursing program. That being said I wish we would have had the opportunity to work with a somebody as skilled and thoughtful as you seem to be.

I am trying to remember back to the day we covered this in school and I am not coming up with anything more than seeing some pictures in the text, maybe watching a video or two and practicing on a mannequin that was pretty creepy because it was only the torso and pelvic region. It was also only a female mannequin, for the male anatomy we relied on only a plastic model of genitalia for the hands on experience. Also about the only thing we really even practiced on the plastic patients was placing a catheter and finding testicular lumps in the male. Which was even more creepy because the male model looked like nothing more than a high end sex toy adding to the general discomfort in the room. It would have been so much more helpful to have a live patient there to give instruction and feedback during an actual exam.

All these years later the one thing I remember being worried about when I actually had to perform a genital exam and place a catheter the first time was whether I was causing the real patient any pain or physical discomfort. I sadly don't remember being in the least bit concerned with the patients feelings as I was too darn worried about doing the actual procedure right. Some practice and real insight in this from the patient perspective would have been immensely helpful.

ethics&modesty · Dec 22, 2016

Thank you.

Yes, most are 2nd year med students who are usually totally inexperienced. They all look like they are going to their doom when they enter the exam room for the first time. My job is to first address their feelings of embarrassment, fear of injuring me, getting over the idea that this is somehow sexual, breaking normal social taboos, etc. After all for the past 20 years or so they have been taught that nice people do not look at or touch other people's "private parts".

Unfortunately in the USA our culture teaches body shame and that nudity always equals sexuality. If you are an experienced nurse you know that this is definitely not true, but try to explain that to a non-medical person. I can not think of anything less sexy that sitting in an exam room wearing a hospital gown with my bare legs and black socks sticking out and having my genitals examined by a group of 20-something med students.

Also med students tend to be far more academic and tend to lack social confidence. They were all good kids and got top grades in elementary and high school and when they went to college they hit the books, not the party circuit. So there was a lot less sex, drugs, Rock & Roll in their lives. They also tend to put off personal relationships so as a group are a bit more on the introverted side and far less likely to be sexually experienced then many of their peers. A few have volunteered that they have intentionally delayed getting into any relationships and I assure them that there is nothing wrong with that at all. I was a science nerd myself, but a math and computer geek as opposed to a biology / chemistry geek so I understand completely.

I think it is hardest on the male students in that they have never touched another male's body much less in any intimate way so are a bit creeped out by the image of homosexuality. I have to keep reassuring them that 1. I am heterosexual, 2. even if I were a homosexual I am still a patient and this is about learning how to treat patients and how to sensitively teach males self-examination. I have yet to meet a male med student who has ever been taught how to do a self-exam for testicular cancer. All of the females have been taught about breast self-exam but the guys are neglected. Also males are always fearful of being accused as sexual predators in some manner especially when examining female patients.

The female students are less fearful but no matter what personal experience they may have had with males, I doubt they ever tried to find the epididymus or palpated the vas deferens on their partners. Their fear in most about hurting me and bashfully asking what to do if a patient becomes erect. Once they get past the embarrassment the nerdy scientist comes out from within and they get a kick when they can find the landmarks inside my body just by touch. The session usually ends with big grins and grateful thanks. One young woman thanked me because I was more like a favorite uncle and not a creepy pervert. I took that as a compliment.

The nursing students are the easiest as they usually have had a good deal of patient experience and most have placed catheters, drawn blood, started IV, etc. and are therefore much less squeamish. Their only problem is that they do not take their time examining carefully. It is more of a quick touch and go to get it over with. I understand this. They normally try to spare patients extended pain or embarrassment so try to get whatever procedure they are doing over with as quickly as possible. Not good during an examination, especially while palpating for tumors. One nurse palpated the lymph nodes in my leg so fast that it felt like a 100 rpm Swedish massage. No way she would have felt a tumor at that speed. Even when I have been a patient in the hospital or at the blood donation center (I go 4 times a year) I tell them to "SLOW DOWN, don't rush, take your time, do a good and careful job, you are not really hurting me, I do not have any modesty issues" and I always make sure I tell them how grateful I am for their care.

As for making a patient who is conscious feel more comfortable, communication as a human is the key. Look them in the eye. Tell the patient what you need to do and why. Ask if this is the first time the patient has had this procedure, even if it is simple like drawing blood or starting an IV. If they have then tell them that they are a pro just like you. If not assure them how long it will take (10 seconds), it may pinch or they may feel a bit of discomfort (never say pain) but it will be only for a few seconds. Explain that taking a deep breath and exhaling slowly for a ten count will help a great deal, then ask "OKAY?" They will always say yes but will feel like they have control and you will have permission and a more cooperative patient. Well, usually. Then "congratulate" them with "good job" or "well done", anything positive. In the end they will feel better.

Even with my knowledge and experience, when I was going into surgery last year I was feeling anxious even though I did not expect to be and the O.R. nurses were terrific. They let me get in position and comfortable on the OR table and allowed me to get my legs into the lithotomy supports, protected my sense of modesty with drapes, asked if I needed warmed blankets as the room was cool, explained everything they were doing, what machines they were hooking up, were willing to answer my questions and asked me what else I would like to know, and the CRNA even waited and asked me if I was ready before she administered the propofol. She gave me a sense of control, respect and showed a great deal of empathy. I woke up on the table and they waited about 3 minutes before they asked me to slide over onto the gurney. While waiting for me to get my bearings and gather myself they asked me how I felt, what I last remembered, any discomfort, introduced me to the recovery nurse who explained how I would be taken to recovery and what would happen there, answered whatever questions I had. I never felt that I was a piece of meat in a processing plant. Never once did they ignore me as a human even though they do a dozen patients each week.

Rocknurse, MSN, APRN, NP · Dec 23, 2016

I recently did this at my graduate school and it was held in the affiliated hospital to make things more professional. The two "patients" were actually professional patients who do in fact earn their living this way and two medical student GAs oversaw the event. The male and female were extremely knowledgeable and taught us in small groups. They made us feel at ease and talked us through the whole procedure. They were very comfortable which made all of us very comfortable, and their experience shone through their teaching. They also had teaching tools with them, like a prostate model, and were able to demonstrate to us normal vs abnormal. I was dreading this class also but it turned out to be a fantastic experience and I think they're very brave and do a great service. I learned a lot that day. I don't know how you do it but thank you! The poor female model had about 10 PAP smears done that day. I would have been in bits!

ethics&modesty · Dec 23, 2016

Dear Rocknurse,

Curious as to which medical facility hosted your nursing students. I assume that you and the others were going for physician's assistant or nurse practitioner.

Yes, we get a stipend for the day but it is not a full time job even if you work at several facilities.

I do this because I have lost too many friends to cancer and the one common element of survival is early detection. I know that doctors are reluctant to giving men, especially teens and young adults, full and thorough exams because their patients dread it. So if I can educate medical students and nursing students that the exam does not need to be embarrassing if the examiner adopts the right interpersonal skills then maybe they will go from being a good medical provider to being a great medical provider. The difference is the ability to connect with the patient and communicate respect and care for their well-being.

When the students come into a session with that look of dread on their faces not knowing where to look or what to do it is my job to normalize the exam and model good communication skills for them to follow. I acknowledge their discomfort. I reassure them that I am not embarrassed. I reassure them that they will not hurt me. I reassure them that while some nudity will occur and some touching has to happen that it will not be sexual at all for either of us. The more they relax the easier it is for them to learn how to find the landmarks on my body and palpate various areas. As for the DRE I know that it is falling out of favor because there are better diagnostic tools available but those tools are more expensive and are used on even fewer men than a DRE. At least there is a chance that a DRE might uncover a problem before there is pain. A DRE is a bit awkward, yes, I always feel a bit vulnerable each time I lean over, but the students all have been gentle and all do well and are thrilled when they can feel my prostate. The students have all been respectful, even when they are nervous, but feel elated once they finish because it is never as "bad" as they thought AND they have learned something interesting.

Ultimately I would hope that doctors doing their residency or nurse practitioners would one day be visiting high school health classes teaching the girls about breast self exams and the boys about testicular self exams with proper parental authorization and proper supervision. Teach the kids that their health matters, their bodies are not shameful, and maybe save a few lives in the bargain.

Learning Intimate Exams

Were you comfortable doing your first intimate exam?