Examination of the male genitalia is typically performed when a patient presents with a specific concern, as part of the newborn examination, or as part of an overall child or adult health visit. In adults, examination of the anus, rectum, and prostate (see Chapter 21 ) is often performed at the same time.
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Inspect the pubic hair characteristics and distribution
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Retract the foreskin if the patient is uncircumcised
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Inspect the glans of the penis with foreskin retracted, noting:
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Color
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Smegma
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External meatus of urethra
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Urethral discharge
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Lesions
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Palpate the penis for tenderness and induration
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Strip the urethra for discharge
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Inspect the scrotum and ventral surface of the penis for:
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Color
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Texture
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Asymmetry
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Lesions
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Unusual thickening
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Presence of hernia
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- 7.
Palpate the inguinal canal for a direct or indirect hernia
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Palpate the testes, epididymides, and vasa deferentia for:
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Consistency
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Size
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Tenderness
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Bleeding, masses, lumpiness, or nodules
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- 9.
Transilluminate masses in the scrotum
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Palpate for inguinal lymph nodes
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Elicit the cremasteric reflex bilaterally
Anatomy and Physiology
The penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles constitute the male genitalia ( Fig. 20.1 ).
The penis serves as the final excretory organ for urine and, when erect, as the means of introducing semen into the vagina. The penis consists of the corpora cavernosa, which form the dorsum and sides, and the corpus spongiosum, which contains the urethra. The corpus spongiosum expands at its distal end to form the glans penis. The urethral orifice is a slitlike opening located approximately 2 mm ventral to the tip of the glans ( Figs. 20.2 and 20.3 ). The skin of the penis is thin, redundant to permit erection, and free of subcutaneous fat. It is generally more darkly pigmented than body skin. Unless the patient has been circumcised, the prepuce (foreskin) covers the glans. In the uncircumcised penis, smegma is formed by the secretion of sebaceous material by the glans and the desquamation of epithelial cells from the prepuce. It appears as a cheesy white material on the glans and in the fornix of the foreskin.
The scrotum, like the penis, is generally more darkly pigmented than body skin. A septum divides the scrotum into two pendulous sacs, each containing a testis, epididymis, spermatic cord, and a muscle layer termed the cremasteric muscle that allows the scrotum to relax or contract ( Fig. 20.4 ). Testicular temperature is controlled by altering the distance of the testes from the body through muscular action. Spermatogenesis requires maintenance of temperatures lower than 37° C.
The testicles are responsible for the production of both spermatozoa and testosterone. The adult testis is ovoid and measures approximately 4 × 3 × 2 cm. The epididymis is a soft, comma-shaped structure located on the posterolateral and upper aspect of the testis. It provides for storage, maturation, and transit of sperm. The vas deferens begins at the tail of the epididymis, ascends the spermatic cord, travels through the inguinal canal, and unites with the seminal vesicle to form the ejaculatory duct.
The prostate gland, which resembles a large chestnut and is approximately the size of a testis, surrounds the urethra at the bladder neck. It produces the major volume of ejaculatory fluid, which contains fibrinolysin. This enzyme liquefies the coagulated semen, a process that may be important for satisfactory sperm motility. The seminal vesicles extend from the prostate onto the posterior surface of the bladder.
Erection of the penis occurs when the two corpora cavernosa become engorged with blood, generally 20 to 50 mL. Arterial dilation and decreased venous outflow produce the increased blood supply; both processes are under the control of the autonomic nervous system and occur because of the local synthesis of nitric oxide. Ejaculation during orgasm consists of the emission of secretions from the vas deferens, epididymides, prostate, and seminal vesicles. Orgasm is followed by constriction of the vessels supplying blood to the corpora cavernosa and gradual detumescence (subsidence of the erection).
Infants and Children
The external genitalia are identical for males and females at 8 weeks of gestation, but by 12 weeks of gestation, sexual differentiation has occurred. Any fetal insult during 8 or 9 weeks of gestation may lead to major anomalies of the external genitalia. Minor morphologic abnormalities arise during later stages of gestation.
During the third trimester, the testes descend from the retroperitoneal space through the inguinal canal to the scrotum. At full term, one or both testes may still lie within the inguinal canal, with the final descent into the scrotum occurring in the early postnatal period. Descent of the testicles may be arrested at any point, however, or they may follow an abnormal path.
Small separations between the glans and the inner preputial epithelium begin during the third trimester. Separation of the prepuce from the glans is usually incomplete at birth and often remains so until the age of 3 to 4 years in uncircumcised children.
Adolescents
With the onset of puberty, testicular growth begins and the scrotal skin reddens, thins, and becomes increasingly pendulous. Sparse, downy, straight hair appears at the base of the penis. The penis enlarges in length and breadth. As maturation continues, the pubic hair darkens and extends over the entire pubic area, and the prostate gland enlarges. By the completion of puberty, the pubic hair is curly, dense, and coarse and forms a diamond-shaped pattern from the umbilicus to the anus. The growth and development of the testes and scrotum are complete (see Chapter 8 for stages of genital developmental and sexual maturation).
Older Adults
Pubic hair becomes finer and less abundant with aging, and pubic alopecia may occur. The scrotum becomes more pendulous. An erection may develop more slowly, and orgasm may be less intense.
Review of Related History
For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examination and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations) as well as complementary and alternative therapies are relevant for each.
History of Present Illness
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Discharge or lesion on the penis
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Character of lumps, sores, rash
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Discharge: color, consistency, odor, tendency to stain underwear
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Symptoms: itching, burning, stinging
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Exposure to sexually transmitted infection (STI): multiple partners, infection in partners, failure to use or incorrect condom use, history of prior STI
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Swelling in inguinal area
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Intermittent or constant, association with straining or lifting, duration, presence of pain
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Change in size or character of swelling
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Pain in the groin: character (tearing, sudden, searing, or cutting pain), associated activity (lifting heavy object, coughing, or straining at stool)
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Use of truss or other treatment
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Frequent heavy lifting
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Medications: analgesics
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Testicular pain or mass
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Change in testicular size
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Events surrounding onset: noted while bathing, after trauma, during a sporting event; sudden onset
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Irregular lumps, soreness, or heaviness of testes
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Practice of tucking: manually displacing the testes upward into the inguinal canal, and positioning the penis and scrotal skin between the legs and rearward toward the anus. Commonly practiced by transgender women. Tight underwear, tape, or a special garment known as a gaff may be used to maintain this positioning.
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Medications: analgesics, antibiotics
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Curvature of penis in any direction with erection
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Associated pain
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Injury to penis
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Personal history diabetes, contracture of fourth and fifth fingers of the hand (Dupuytren contracture)
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Family history of condition
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Medications: propranolol
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Persistent erections unrelated to sexual stimulation
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Current history of sickle cell disease, leukemia, multiple sclerosis, diabetes, spinal cord injury
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Trauma to genitals or groin
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Associated with alcohol ingestion or medication
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Medications: erectile dysfunction agents, antidepressants, antipsychotics, anticoagulants, anxiolytics, recreational drugs
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Difficulty with ejaculation
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Painful or premature, efforts to treat the problem
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Ejaculate color, consistency, odor, and amount
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Medications: alpha blockers, antidepressants, antipsychotics, clonidine, methyldopa
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Difficulty achieving or maintaining erection
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Pain with erection, prolonged painful erection
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Constant or intermittent, with one or more sexual partners
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Associated with alcohol ingestion or medication
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Medications: diuretics, sedatives, antihypertensive agents, anxiolytics, estrogens, inhibitors of androgen synthesis, antidepressants, carbamazepine, erectile dysfunction agents
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Infertility
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Lifestyle factors that may increase temperature of scrotum: tight clothing, briefs, hot baths, employment in high-temperature environment (e.g., a steel mill) or requiring prolonged sitting (e.g., truck driving)
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Length of time attempting pregnancy, sexual activity pattern, knowledge of fertile period of woman’s reproductive cycle
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History of varicocele, hydrocele, or undescended testes
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Diagnostic evaluation to date: semen analysis, physical examination, sperm antibody titers
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Medications: testosterone, glucocorticoids, hypothalamic releasing hormone, marijuana
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Past Medical History
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Gender identity: male, female, transgender woman, transgender man; sex assignment at birth
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Congenital anomaly and/or surgery of genitourinary tract: undescended testes, hypospadias, epispadias, hydrocele, varicocele, hernia, prostate; vasectomy
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STIs: single or multiple infections, specific organism (gonorrhea, syphilis, herpes, human papillomavirus [HPV]), chlamydia), treatment, effectiveness, residual problems; vaccination for HPV (see Patient Safety Box; HPV Immunization )
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Chronic illness: testicular or prostatic cancer, neurologic or vascular impairment, diabetes mellitus, cardiac disease
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Recent and past genitourinary/gynecologic procedures: masculinizing phalloplasty, scrotoplasty, erectile implants, vaginectomy, metoidioplasty (clitoral release/enlargement that may include urethral lengthening), hysterectomy, oophorectomy, orchiectomy, feminizing vaginoplasty
HPV infection can cause cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers as well as genital warts. Vaccination against HPV before exposure to the virus through sexual activity is recommended for all preadolescents and adolescents.. The vaccine is also recommended for any man who has sex with men, and those with compromised immune systems (including human immunodeficiency virus [HIV]) through age 26 if they did not get fully vaccinated when they were younger. The genital examination presents an opportunity to educate about the vaccine and to discuss it in terms of disease prevention.
Family History
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Infertility in siblings
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History of prostate, testicular, penile or breast cancer
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Hernias
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Peyronie disease (contracture of penis)
Personal and Social History
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Occupational risk of trauma to suprapubic region or genitalia, exposure to radiation or toxins
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Exercise: use of a protective device with contact sports or bicycle riding
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Concerns about genitalia: size, shape, surface characteristics, texture
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Testicular/genital self-examination practices (see Patient Safety, “Self-Examination for STIs” )
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Concerns about sexual practices: sexual partners (single or multiple), sexual lifestyle (heterosexual, homosexual, bisexual)
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Reproductive function: number of children, form of contraception used, frequency of ejaculation
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Alcohol, marijuana use: quantity and frequency
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Use of drugs
Genital self-examination (GSE) is recommended for anyone who is at risk for contracting a sexually transmitted infection (STI). This includes sexually active persons who have had more than one sexual partner or whose partner has had other partners. The purpose of GSE is to detect any signs or symptoms that might indicate the presence of an STI. Many people who have an STI do not know they have one, and some STIs can remain undetected for years. GSE should become a part of routine self-examination healthcare practices. Explain and demonstrate the following procedure to your patients, and give them the opportunity to perform a GSE with your guidance.
Instruct the patient to hold the penis in the hand and examine the head. If not circumcised, the patient should gently pull back the foreskin to expose the glans. Inspection and palpation of the entire head of the penis should be performed in a clockwise motion while the patient carefully looks for any bumps, sores, or blisters on the skin. Bumps and blisters may be red or light-colored or may resemble pimples. Have the patient also look for genital warts, which may look similar to warts on other parts of the body. The urethral meatus should also be examined for any discharge.
Next, the patient will examine the entire shaft and look for the same signs. Instruct him to separate the pubic hair at the base of the penis and carefully examine the skin underneath. Make sure he includes the underside of the shaft in the examination; a mirror may be helpful.
Instruct the patient to examine the scrotal skin and contents. Instruct the patient to hold each testicle gently and inspect and palpate the skin, including the underneath of the scrotum, looking for any lesions, lump, swelling, or soreness. Educate the patient about other symptoms associated with STIs, specifically pain or burning on urination or discharge from the penis. The discharge may vary in color, consistency, and amount.
If the patient has any of the preceding signs or symptoms, he should see a healthcare provider.
Infants and Children
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Maternal use of sex hormones or birth control pills during pregnancy
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Circumcised: complications from procedure
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Uncircumcised: hygiene measures, retractability of foreskin, interference with urinary stream
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Scrotal swelling with crying or bowel movement
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Congenital anomalies: hypospadias, epispadias, undescended testes, ambiguous genitalia
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Parental concerns with masturbation, sexual exploration
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Swelling, discoloration, or sores on the penis or scrotum, pain in the genitalia
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Concern for sexual abuse
Adolescents
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Knowledge of reproductive function, source of information about sexual activity and function
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Presence of nocturnal emissions, pubic hair, enlargement of genitalia, age at time of each occurrence and of first nocturnal emissions
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Concern of sexual abuse
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Sexual activity, protection used for contraception and STI prevention
Older Adults
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Change in frequency of sexual activity or desire: related to loss of spouse or other sexual partner; no sexual partner; sexually restrictive environment; depression; physical illness resulting in fatigue, weakness, or pain
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Change in sexual response: longer time required or inability to achieve full erection, less forceful ejaculation, more rapid detumescence, longer interval between erections, prostate surgery
Penile
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Infection with high-risk types of HPV
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Lack of circumcision with failure to maintain good hygiene
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Phimosis
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Age: risk increases with age
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Smoking (smoking alone increases risk; smokers with HPV infection at even higher risk)
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HIV infection
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UV light treatment of psoriasis if genitalia exposed
Testicular
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Undescended testicle (cryptorchidism): risk elevated for both testicles
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Personal history of testicular cancer (the opposite testicle is at increased risk)
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Family history of testicular cancer
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HIV infection
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Age: 20 to 34 years
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Race: white; five times that of blacks and more than three times that of Asian Americans and Native Americans
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Androgen suppression: likely decreases the risk in transgender women
Examination and Findings
Equipment
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Gloves
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Drapes
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Penlight for transillumination
Examination of the genitalia involves inspection, palpation, and transillumination of any mass found. The patient may be anxious about examination of the genitalia, so it is important to examine the genitalia carefully and completely but also expeditiously ( Box 20.1 ). Patients who have undergone gender-affirming surgeries may have varying physical examination findings depending on the procedures performed. The patient may be lying or standing for this part of the examination. A chaperone protects both the examiner and patient and one is often required by policy. Some patients may be reluctant to reveal confidential and sensitive information in the presence of a chaperone .
The physical examination is laden with anxiety-provoking elements for most people, but examination of the genitals is particularly likely to arouse anxiety. Patients are often fearful of having an erection during the examination. Patientsmay worry about whether their genitals are “normal,” and misinformation on sexual matters (such as “the evils of masturbation”) can add to their concerns. For transgender patients, the use of a gender-affirming approach during the examination (e.g., use of correct name and pronouns and acceptance of gender-affirming treatments and procedures) can help reduce anxiety. Your attitude and ability to communicate can reassure the apprehensive patient. Some important elements to remember:
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Know the language. It is inappropriate to talk down to anyone, but you and the patient must understand each other. You may not be entirely comfortable with some of the common words and phrases you hear from the patients, but the common language may be appropriate in certain circumstances. Know the language and use it effectively, without apology, and in a nondemeaning fashion.
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Never make jokes. Light, casual talk or jokes about the genitalia or sexual function are always inappropriate, no matter how well you know the patient. Feelings about one’s own sexuality run deep and are often well masked. Do not pull at the edges of a mask you may not suspect is there.
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Remember that your face is easily seen by the patient when you are examining the genitalia. An unexpected finding may cause a sudden change in your expression. You must guard against what you reveal by nonverbal communication.
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Remember that you are a professional, fulfilling the responsibility of a professional.
Inspection and Palpation
Genital Hair Distribution
First inspect the genital hair distribution. Genital hair is coarser than scalp hair. It should be abundant in the pubic region and may continue in a narrowing midline pattern to the umbilicus (the biologic male escutcheon pattern). Depending on how the patient is positioned, it may be possible to note that the distribution continues around the scrotum to the anal orifice. The penis itself is not covered with hair, and the scrotum generally has a scant amount.
Penis
Examine the penis. The dorsal vein should be apparent on inspection. Note whether the patient is circumcised or uncircumcised ( Fig. 20.5 ). If the patient is uncircumcised, retract the foreskin or ask the patient to do so. It should retract easily, and a bit of smegma (white cheesy sebaceous matter that collects between the glans penis and the foreskin) may be seen over the glans. Occasionally the foreskin is tight and cannot be retracted. This condition is called phimosis ( Fig. 20.6 ) and may occur during the first 6 years of life or as a result of recurrent balanitis (inflammation of the glans) ( Fig. 20.7 ) or balanoposthitis (inflammation of the glans penis and prepuce), which occur in uncircumcised individuals and may be caused by either bacterial or fungal infections. It is most commonly seen in patients with poorly controlled diabetes mellitus. Phimosis may also be caused by previous unsuccessful efforts to retract the foreskin that have caused radial tearing of the preputial ring, resulting in adhesions of the foreskin to the glans.
If the patient is circumcised, the glans is exposed and appears erythematous and dry. No smegma will be present.
Urethral Meatus
Examine the external meatus of the urethra. The orifice should appear slitlike and be located on the ventral surface just millimeters from the tip of the glans. Press the glans between your thumb and forefinger to open the urethral orifice ( Fig. 20.8 ). You can ask the patient to perform this procedure. The opening should be glistening and pink. Bright erythema or a discharge indicates inflammatory disease, whereas a pinpoint or round opening may result from meatal stenosis.
