Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 15. Male Genitalia

EQUIPMENT

image Gloves

image Penlight

EXAMINATION

Have patient lying or standing to start examination.

image

TECHNIQUE

FINDINGS

Wear gloves on both hands

Inspect pubic hair

imageCharacteristics

EXPECTED:Coarser than scalp hair.

imageDistribution

EXPECTED:Male hair 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

image 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.

imageCircumcised patient

EXPECTED:Dorsal vein apparent. Exposed glans erythematous and dry.

UNEXPECTED:Lesions or discharge.

Examine external meatus of urethra (foreskin retracted in uncircumcised patient)

imageShape

EXPECTED:Slitlike opening.

UNEXPECTED:Pinpoint or round opening.

imageLocation

EXPECTED:On ventral surface and only millimeters from tip of glans.

UNEXPECTED:Any place other than tip of glans or along shaft of penis.

image Urethral orifice

Press glans between thumb and forefinger

EXPECTED:Opening glistening and pink.

UNEXPECTED:Bright erythema or discharge.

Palpate 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.

UNEXPECTED:Discharge.

Inspect scrotum and ventral surface of penis

imageColor

EXPECTED:Darker than body skin and often reddened in red-haired patients.

imageTexture

EXPECTED:Surface possibly coarse. Small lumps on scrotal skin (sebaceous or epidermoid cysts) that sometimes discharge oily material.

imageShape

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. 202.

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).

image

Palpate testes

Use thumb and first two fingers.

 

imageConsistency

EXPECTED:Smooth and rubbery. Sensitive to gentle compression.

UNEXPECTED:Tenderness or nodules. Total insensitivity to painful stimuli.

imageTexture

UNEXPECTED:Irregular texture.

imageSize

UNEXPECTED:Irregular size; asymmetry in size, less than 1 cm or greater than 5 cm.

imageDescension

UNEXPECTED:Cryptorchidism.

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:Nodes unable to be palpated.

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.

 

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Hernia

See table on p. 205.

Genital herpes

Subjective Data:Painful lesions on penis; sexually active; may report burning or pain with urination.

Objective Data:Superficial vesicles—located on glans, penile shaft, or base of penis; often associated with inguinal lymphadenopathy.

Condylomata acuminata (genital warts)

Subjective Data:Soft painless warty-like lesions on penis. Sexually active.

Objective Data:Single or multiple papular lesions; may be pearly, filiform, fungating (ulcerating and necrotic) cauliflower, or plaquelike.

Hydrocele

Subjective Data:Painless enlargement or swelling of the scrotum.

Objective Data:Nontender, smooth, firm mass superior and anterior to the testis. Transilluminates.

Varicocele

Subjective Data:Usually asymptomatic (and found during evaluation for infertility); may report scrotal pain or heaviness

Objective Data:Abnormal tortuosity and dilated veins of pampiniform plexus within spermatic cord; described as “bag of worms.”

Epididymitis

Subjective Data:Painful scrotum, urethral discharge, fever, pyuria, recent sexual activity.

Objective Data:Possible erythema of overlying scrotum, epididymis feels firm and lumpy and may be slightly tender, and vasa deferentia may be beaded.

Testicular torsion

Subjective Data:Acute onset of scrotal pain, often accompanied by nausea and vomiting; absence of systemic symptoms such as fever and myalgia.

Objective Data:Testicle is exquisitely tender; scrotal discoloration often present.

Testicular cancer

Subjective Data:Painless mass in testicle, scrotal enlargement or swelling; sensation of heaviness in the scrotum, dull ache in the lower abdomen, back, or groin.

Objective Data:Irregular, nontender mass fixed on the testis; does not transilluminate.

Paraphimosis

Subjective Data:Retraction of the foreskin during penile examination, cleaning, urethral catheterization, or cystoscopy; penile pain and swelling.

 

Objective Data:Glans penis congested and enlarged; foreskin edematous; constricting band of tissue directly behind the head of the penis.

Distinguishing Characteristics of Hernias

image

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

Inspect glans penis

image Uncircumcised patient

Retract foreskin.

EXPECTED:In children, foreskin is fully retractable by age 3 to 4 years. Before that age, forced retraction of foreskin may result in injury.

Palpate scrotum

image Descension

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 males, 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 p. 207.

UNEXPECTED:Failure to mature and premature maturation.

image

Five stages of penis and testes/scrotum development in males. From Van Wieringen et al, 1971.

SAMPLE DOCUMENTATION

Genitalia.Circumcised. Glans, penile shaft, contents of scrotal sac are intact without lesions or areas of induration. Urethral meatus patent on ventral surface at tip of glans. No discharge evident. Scrotal contents smooth without swelling, masses, or tenderness. Testes size equal. Inguinal areas are smooth; no masses or nodes palpable. Inguinal canals are free of masses, bulges. Cremasteric reflex elicited.