Chapter 16

Male Genitalia

Equipment

• Gloves

• Penlight

Examination

Have patient lying or standing to start examination.

Technique	Findings
Wear gloves on both hands
Inspect pubic hair
• Characteristics	EXPECTED: Coarser than scalp hair.
• Distribution	EXPECTED: Male hair pattern distribution. Abundant in pubic region, continuing around scrotum to anal orifice, possibly continuing in narrowing midline to umbilicus. Penis without hair, scrotum with scant hair.
	UNEXPECTED: Alopecia.
Inspect glans penis
• Uncircumcised patient Retract foreskin or ask patient to do so.	EXPECTED: Dorsal vein apparent. Foreskin easily retracted. White, cheesy smegma visible over glans.
	UNEXPECTED: Tight foreskin (phimosis). Lesions or discharge.
• Circumcised patient	EXPECTED: Dorsal vein apparent. Exposed glans erythematous and dry.
	UNEXPECTED: Lesions or discharge.
Examine external meatus of urethra (foreskin retracted in uncircumcised patient)
• Shape	EXPECTED: Slit-like opening.
	UNEXPECTED: Pinpoint or round opening.
• Location	EXPECTED: On ventral surface and only millimeters from tip of glans.
	UNEXPECTED: Anyplace other than tip of glans or along shaft of penis.
• Urethral orifice Press glans between thumb and forefinger	EXPECTED: Opening glistening and pink.
	UNEXPECTED: Bright erythema or discharge.
Palpate penis
Palpate the shaft of the penis.	EXPECTED: Soft (flaccid penis).
	UNEXPECTED: Tenderness, induration, or nodularity. Prolonged erection (priapism).
Strip urethra
Firmly compress base of penis with thumb and forefinger; move toward glans.	EXPECTYED: No discharge
	UNEXPECTED: Discharge.
Inspect scrotum and ventral surface of penis
• Color	EXPECTED: Darker than body skin and often reddened in red-haired patients.
• Texture	EXPECTED: Surface possibly coarse. Small lumps on scrotal skin (sebaceous or epidermoid cysts) that sometimes discharge oily material.
• Shape	EXPECTED: Asymmetry. Thickness varying with temperature, age, emotional state.
	UNEXPECTED: Unusual thickening, often with pitting.
Palpate inguinal canal for direct or indirect hernia
With patient standing, ask him to bear down as if for bowel movement. While he strains, inspect area of inguinal canal and region of fossa ovalis. Ask patient to relax, and insert examining finger into lower part of scrotum and carry upward along vas deferens into inguinal canal, as shown in figure on p. 182. Ask patient to cough. Repeat examination on opposite side.	EXPECTED: Presence of oval external ring.
	UNEXPECTED: Feeling a viscus against examining finger with coughing. If hernia felt, note as indirect (felt within inguinal canal or even into scrotum) or direct (felt medial to external canal).
Palpate testes
Use thumb and first two fingers. Compress gently.
• Descent	EXPECTED: Both testes are present in scrotal sac
	UNEXPECTED: Cryptorchidism.
• Consistency	EXPECTED: Smooth and rubbery. Sensitive to gentle compression.
	UNEXPECTED: Tenderness or nodules. Total insensitivity to painful stimuli.
• Texture	UNEXPECTED: Irregular texture.
• Size	UNEXPECTED: Irregular size; asymmetry in size, <1 cm or >5 cm.
Palpate epididymides
	EXPECTED: Smooth and discrete, with larger part cephalad.
	UNEXPECTED: Tenderness.
Palpate vas deferens
Palpate from testicle to inguinal ring. Repeat with other testicle.	EXPECTED: Smooth and discrete.
	UNEXPECTED: Beaded or lumpy.
Palpate for inguinal lymph nodes
Ask patient to lie supine, with knee slightly flexed on side of palpation.	EXPECTED: No palpable nodes.
	UNEXPECTED: Enlarged, tender, red or discolored, fixed, matted, inflamed, or warm nodes and increased vascularity.
Elicit cremasteric reflex bilaterally
Stroke inner thigh with blunt instrument. Repeat with other thigh.	EXPECTED: The testicle and scrotum s rise on the stroked side
	UNEXPECTED: Absent reflex

AIDS TO DIFFERENTIAL DIAGNOSIS

Subjective Data	Objective Data
Hernia
See table on pp. 184-185.
Genital Herpes
Painful lesions on penis; sexually active; may report burning or pain with urination.	Superficial vesicles—located on glans, penile shaft, or base of penis; often associated with inguinal lymphadenopathy.
Condylomata Acuminata (genital warts)
Soft, painless, warty-like lesions on penis. Sexually active.	Single or multiple papular lesions; may be pearly, filiform, fungating (ulcerating and necrotic) cauliflower, or plaque-like.
Hydrocele
Painless enlargement or swelling of the scrotum.	Nontender, smooth, firm mass superior and anterior to the testis. Transilluminates.
Varicocele
Usually asymptomatic (and found during evaluation for infertility); may report scrotal pain or heaviness.	Abnormal tortuosity and dilated veins of pampiniform plexus within spermatic cord; described as “bag of worms.”
Epididymitis
Painful scrotum, urethral discharge, fever, pyuria, recent sexual activity.	Possible erythema of overlying scrotum, epididymis feels firm and lumpy, and may be slightly tender, and vasa deferentia may be beaded.
Testicular Torsion
Acute onset of scrotal pain, often accompanied by nausea and vomiting; absence of systemic symptoms such as fever and myalgia.	Testicle is exquisitely tender; scrotal discoloration often present.
Testicular Cancer
Painless mass in testicle, scrotal enlargement or swelling; sensation of heaviness in the scrotum, dull ache in the lower abdomen, back, or groin.	Irregular, nontender mass fixed on the testis; does not transilluminate.
Paraphimosis
Retraction of the foreskin during penile examination, cleaning, urethral catheterization, or cystoscopy; penile pain and swelling.	Glans penis congested and enlarged; foreskin edematous; constricting band of tissue directly behind the head of the penis.

Distinguishing Characteristics of Hernias

	Indirect Inguinal	Direct Inguinal	Femoral
Incidence	Most common type of hernia; both sexes are affected; often patients are children and young males	Less common than indirect inguinal; occurs more in male than female individuals; more common in those older than 40 years	Least common type of hernia; occurs more often in female than male individuals; rare in children
Pathway	Through internal inguinal ring; can remain in canal, exit external ring, or pass into scrotum; may be bilateral	Through femoral external inguinal ring; located in region of Hesselbach triangle; rarely enters scrotum	Through femoral ring, femoral canal, fossa ovalis
Presentation	Soft swelling in area of internal ring; pain on straining; hernia comes down canal and touches fingertip on examination	Bulge in area of Hesselbach triangle; usually painless; easily reduced; hernia bulges anteriorly, pushes against side of finger on examination	Right side presentation more common than left; pain may be severe; inguinal canal empty on examination

PEDIATRIC VARIATIONS
EXAMINATION

Technique	Findings
Inspect glans penis
• Uncircumcised patient Retract foreskin.	EXPECTED: In children, foreskin is fully retractable by age 3–4 years. Before that age, forced retraction of foreskin may result in injury.
Palpate scrotum
• Descent Palpate testes in children to determine whether testes have descended. If any mass other than testicles or spermatic cord is palpated in scrotum, determine whether it is filled with fluid, gas, or solid material.	EXPECTED: Bilaterally palpable; 1 cm. Considered descended if testis can be pushed into scrotum. UNEXPECTED: If penlight transilluminates, most likely contains fluid (hydrocele). If no light transillumination, most likely a hernia.
Evaluate maturation in adolescence
Assess stage of pubertal development
In boys, assess the stage of genital and pubic hair development.	EXPECTED: Tanner stages of male pubic hair and external genital development progress in the sequence shown on pp. 186-187.
	UNEXPECTED: Failure to mature and premature maturation.

Five stages of penis and testes/scrotum development in males. (From Frisch RE, 1971. Reproduced with permission from Pediatrics, Vol. 49, p. 68. Copyright 1972, by the AAP.)

Six stages of pubic hair development in males.(From Frisch RE, 1971. Reproduced with permision from Pediatrics, Vol. 49, p. 68. Copyright 1972, by the AAP.)

Sample Documentation

Subjective

Thirty-seven-year-old man reports painful burning lesions on his penis. Present past few days. Is sexually active. No burning on urination.

Objective

Hair in male pattern distribution. Circumcised glans without lesions or discharge. Urethral meatus patent on ventral surface at tip of glans. No urethral discharges. Penile shaft with vesicles present. Testes descended bilaterally; smooth without nodularity. Scrotal contents smooth without tenderness. Inguinal areas without bulges or hernias. Inguinal nodes palpable bilaterally. Cremasteric reflex elicited.