Examination of the male genitalia - Qpercom

Indications for assessing the genitalia vary considerably. If symptoms are localised in the genital region, the need for examination is clear. Other symptoms, however, can be caused by disorders in the genitals. For example, pain in the lumbar or abdominal regions (inguinal region) may be caused by testicular disorders, such as testicular torsion. Physicians should also realise that patients (regardless of age) may have difficulty spontaneously reporting symptoms that occur in the genital region. This feeling of discomfort will be exacerbated if the physician also has difficulty asking about and discussing genital or sexually-related topics.

Before the examination

Explain to the patient what will be examined and, if necessary, why.
Perform the examination in the presence of a third person.
This can be someone who is accompanying the patient. If the patient is alone, ask an assistant to be present for the examination. This protects both the patient and the physician from ‘undesired intimacy’.
Have the patient undress the lower half of the body.
The examination can be performed while the patient is lying down or standing.
If the examination is performed immediately after the abdominal examination, it may be more convenient to perform the examination while the patient remains lying on their back. The lying position is also preferred for immobile and very ill patients. If hernia is suspected and the inguinal canal must be examined, the standing position is preferred.
Many patients will find it uncomfortable to stand in the middle of a room. Leaning with the back against the examination table which has been placed against a wall, is often considered more comfortable and also provides stability. The physician can then sit on a low stool in front of the patient so that the groin and genitalia are at eye level [66]. Shorter patients (children) may be asked to stand on a small but stable bench.
Examination can be performed with or without gloves.
Although sensitivity is better without gloves, the use of well-fitting, non-sterile gloves is preferred for hygienic and professional reasons.

Examination of the penis

Procedure

Inspect the pubic region [Figure 67].

Figure 67

Palpate this region only if abnormalities are visible.
Inspect the dorsal side of the penis.
Ask the patient to retract the foreskin (prepuce) completely.
The physician can also do this.
Inspect the glans penis, urethral meatus and coronal sulcus [68].
Ask the patient to turn the penis, so that the frenulum and the ventral side of the penis can be inspected.
Have the patient retract the foreskin.
Palpate the penis, if indicated, from the base (proximal) to the coronal sulcus.
Palpation of the penis should only be performed in the rare case of visible penile abnormalities or if the patient experiences twisting of the penis while erect.
Do not palpate too gently: gentle palpation increases the chance of inducing an erection. Avoid touching or applying pressure to the coronal sulcus as this may cause too much erotic stimulation.

Focus points

When inspecting the pubic region, note the pattern of hair growth, skin disorders (e.g. folliculitis, papilloma), and parasites (pubic lice).
Determine whether the foreskin can be retracted easily.
This is not relevant for circumcised patients. If retraction is difficult, the patient may have phimosis / paraphimosis.
Check for signs of tumours, scarring and inflammation of the glans and coronary sulcus.
Blisters suggest genital herpes, and ulcers are consistent with syphilis.
Assess the urethral meatus and note any discharge from the urethra.
Note the position of the meatus: hypospadia = ventral displacement; epispadia (rare) = dorsal displacement.
To confirm or rule out urethral stricture, the glans can be pinched lightly in the dorsoventral direction with the thumb and index finger [Figure 69a]. Normally, this causes the urethra to open.
Pus leakage from the urethra indicates gonorrhoea.

Figure 69a

During inspection of the penis, check for scars, ulcers (STDs) and tumours. During palpation, check for pain upon pressure and scleroses (indurations).

Examination of the scrotum

Procedure

Inspect the scrotum [Figure 69b].
To inspect the skin, hold the penis to one side. Remember to inspect the back of the scrotum (this requires lifting up the scrotum). The dorsal side of the scrotum can also be examined as part of inspection of the anus, if rectal examination is also performed.

Figure 69b

Palpate the contents of the scrotum [Figure 70]:
With fingers together, place the right hand on the back of the left side of the scrotum and place the thumb on the scrotum. (Use the left hand to palpate the right side of the scrotum.)
Hold the testis between the thumb and fingers and move it laterally slightly so that the skin of the scrotum is pulled slightly tighter.
Palpate the testis through the skin of the scrotum by sliding the thumb and fingers over the testis until its entire surface has been examined systematically.

Figure 70

Move the hand upward to palpate the epididymis [Figure 71]. The epididymis is often difficult to feel.
The epididymis is usually an irregular, grainy-feeling structure lying next to the testis, usually found cranially on the anterior side. Palpation of the epididymis may cause a nauseating, painful sensation.

Figure 71

Palpate higher to find the spermatic cord (funiculus spermaticus). Hold the skin of the scrotum firmly between thumb and index finger at the median just above the testis [Figure 72]. Move the fingers laterally without relieving the pressure. The spermatic cord will then slip away between the fingers. It is often difficult to feel.
The spermatic cord feels like a small bundle of thin elastic bands. The spermatic cord also behaves like an elastic band and easily shoots away during palpation.

Figure 72

Focus points

When examining the scrotum, note the following:
- scrotal skin:
  scars, colouration (local / diffuse), dermatologic abnormalities;
- symmetry:
  the left side of the scrotum usually hangs lower than the right;
- swellings:
  causes of swelling include hydrocele, varicocele, haematoma, hernia, carcinoma and testicular torsion;
- axial status of the testes:
  the testis normally lies at an angle to the vertical axis, whereby the upper pole is tilted forward and the lower pole tilts to the back. A wider angle from the vertical axis provides greater mobility of the testis. This leads to a greater risk of testicular torsion.
Determine by palpation whether both testes are present in the scrotum and whether they feel normal.
The average normal testis is 4 × 3 × 2.5 cm, firm but rubbery in consistency, smooth, egg-shaped, and painless during a properly executed examination.
Palpation is painful in cases of testicular torsion, torsion of the testicular appendix (hydatid of Morgagni), or orchitis.
If an irregular structure is found on the testis next to the epididymis, the chance of malignancy is high.
Determine whether the epididymis is enlarged (epididymal cyst, spermatocele) or painful (epididymitis).
During palpation of the spermatic cord, check for the absence of the vas deferens (agenesia), pain, and swelling.
The spermatic cord consists of multiple tube-shaped structures, including the vas deferens and blood vessels.
A painful swelling is consistent with inflammation (e.g. tuberculosis), a painless swelling suggests hydrocele (smooth swelling) or spermatocele (worm-like surface).