Male Genitalia Physical Exam

What are the indications for an exam of the male genitalia?

- specific genital complaint

- newborn examination

- well-child or well-person examination

- sexual assault

What does an adult examination include?

Exam of the anus, rectum, and prostate

What is it important to always do before performing any sensitive examinations?

obtain consent

What anatomical structures make up the penis?

- corpora cavernosa (2)

- corpus spongiosum

- glans

- prepuce (foreskin)

What does the corpus spongiosum contain?

urethra

What is smegma?

secretions of the glans that may collect in uncircumcised men

What anatomical structures make up/are contained in the scrotum?

- scrotal septum

- testis

- epididymis

- spermatic cord

- vas deferens

- muscle layer

What is the size of the testis before puberty?

1.5-2 cm

What is the size of the testis post-puberty?

4-5 cm

What muscle is contained in the scrotum?

cremasteric muscle

Describe the size of the prostate gland.

approximately the size of a testicle

What does the prostate surround?

The urethra at the bladder neck

What does the prostate contribute to?

The production of ejaculatory fluid

Anatomically, what must happen to achieve erection of the penis?

The two corpora cavernosa become engorged with blood

What causes increased blood supply to the penis during erection?

increased arterial dilation and decreased venous outflow

What anatomical structures make up the groin?

- inguinal canal

- internal inguinal ring

- external inguinal ring

Where does the inguinal canal lie in relation to the inguinal ligament?

Medial and parallel to the inguinal ligament

What does the inguinal canal form?

a tunnel for the vas deferens as it passes through the abdominal muscles

What details in the HPI are important to obtain for an exam of male genitalia?

- penile discharge/lesions

- testicular pain/lesions/swelling

- STI

What questions should you ask about penile discharge/lesions in the HPI?

Discharge? Staining of underwear?

Color? Amount?

Associated fevers/rash/sores?

What questions should you ask about STI in the HPI?

Hx or prior

When examining the male genitalia, what should you inspect?

genital hair distribution & penis

What is important to note about genital hair distribution?

coarseness & abundance/lack

What parts of the penis should you inspect?

- skin (ventral and dorsal aspect)

- prepuce (assess for foreskin retraction)

- glans (assess for inflammation/discharge)

- shaft (palpate for induration, necessary only if symptomatic)

What is important to remember when inspecting the prepuce?

always replace the foreskin before proceding to the next step

When examining the male genitalia, what should you inspect and palpate?

urethral meatus & scrotum

What should you note about the urethral meatus?

- orifice size and location

- color and moisture/discharge

What should you note about the scrotum?

- skin (assess posterior surface as well)

- scrotal contours

- inguinal areas

What is the suggested sequence for palpation?

- palpate each testicle and epididymis between the thumb and the first two fingers

- palpate the epididymis on the posterior surface of the testicle

- palpate the spermatic cord

*perform exam on one testicle then the other*

When palpating the testicle, what should you look for?

- firm but not hard

- descended

- symmetric

- nontender

- without masses

*testicular prosthesis vs pump*

How does the epididymis feel?

- nodular and cord-like

- typically, non-tender

Where does the spermatic cord run?

from epididymis to external inguinal ring

How does the vas deferens feel?

slightly stiff and tubular, different from surrounding vessels

What would be an indication to trans-illuminate?

swelling of the scrotum

What information does transillumination provide?

- hydroceles light up

- large testes/masses would not light up

How do you assess for a hernia?

insert a gloved finger thorugh the inguinal canal

What is the typical Hx and PE for an indirect inguinal hernia?

Hx = commonly congenital

PE = bulge near the internal inguinal ring (touches the tip of the examining finger)

What is the typical Hx and PE for a direct inguinal hernia?

Hx = mid-elderly age men; heavy lifting

PE = bulge near the external ring (touches the side of the examining finger)

Where would you palpate for a femoral hernia?

anterior thigh in the region of the femoral canal

Hernia Exam: Inspect

evaluate for a bulge while standing

Hernia Exam: Palpate

with valsalva/cough

Hernia Exam: Auscultate

presence or absence of bowel sounds

What important thing should you evaluate during a hernia exam?

incarceration or strangulated hernia

What is an incarcerated or strangulated hernia?

Nonreducible hernia in which the blood supply to the protruded tissue is compromised

What does an incarcerated or strangulated hernia require?

prompt surgical intervention

How should we assess the cremasteric reflex, and what should occur?

Stroke the inner thigh with a blunt instrument. The testicle and scrotum should rise on the stroked side.

True or False: According to the 2012 American Academy of Pediatrics, evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it.

True

True or False: There is no sufficient evidence to recommend routine circumcision for all.

True

Who should make the decision about circumcision?

Parents in consultation with a pediatrician with consideration for medical, religious, cultural, and ethnic traditions.

What are the benefits of circumcision?

Prevention of:

- UTIs

- acquisition of HIV

- transmission of some STIs

- penile cancer

True or False: Circumcision adversely affects penile sexual function/sensitivity or sexual satisfaction.

FALSE

What is Tanner Staging?

sexual maturity rating scale - objective classification system to document and track the development and sequence of sexual characteristics of children

What is the range of Tanner Staging?

puberty (stage 1) to adult (stage 5)

What might atypical progression through the Tanner Staging be related to?

precocious puberty or delayed puberty possibly indicating underlying conditions

When is the typical male puberty onset?

9-14 years old

Tanner Stage 1

Pubic Hair: no pubic hair

Penis: prepubertal size and proportion

Testes and Scrotum: prepubertal size and proportion

Tanner Stage 2

Pubic Hair: few straight, darker hairs at base on penis

Penis: little or no enlargement

Testes and Scrotum: begins to enlarge, scrotal skin reddens and changes in texture

Tanner Stage 3

Pubic Hair: sparse growth over pubis, darker, coarse and curly

Penis: enlargement, especially in length

Testes and Scrotum: further enlarged

Tanner Stage 4

Pubic Hair: coarse and curly as an adult, growth over the pubis, not on thighs

Penis: growth in length and diameter, development of the glans

Testes and Scrotum: testes almost fully grown, scrotum darkens

Tanner Stage 5

Pubic Hair: growth spreads over the medial thighs

Penis: adult size and shape

Testes and Scrotum: adult size and shape

What is paraphimosis?

Inability to replace the foreskin to its usual position after it has been retracted behind the glans

Hx consistent with paraphimosis.

Uncircumcised, c/o pain and swelling, can cause obstructive urinary symptoms

PE consistent with paraphimosis.

- edema and tenderness of the glans

- painful swelling of distal retracted foreskin

- constrictive band over time

- glans ischemia (blue or black, firm to palpation)

What is phimosis?

inability to retract the foreskin from natural position

What patient population is physiologic phimosis present in and why?

Present in almost all newborn males due to adhesions that break down over time

What is pathological phimosis?

Nonretractable due to scarring of the prepuce (trauma, infection, inflammation)

Hx consistent with pathologic phimosis.

Previously able to retract foreskin and can no longer, dysuria, painful erection

PE consistent with pathologic phimosis.

Fibrotic preputial ring around the preputial orifice

What is hypospadias?

Congenital defect in which the urethral meatus is located on the ventral surface of the glans penile shaft or the base of the penis

What is a syphilitic chancre?

Skin lesion associated with primary syphilis

True or False: A syphilitic chancre is typically painful.

FALSE, it is typically painless

What is genital herpes?

an STI caused by herpes simplex virus 2 (HSV-2)

How does genital herpes present?

clustered vesicles on an erythematous base, painful/burning, +/- dysuria, +/- flu like illness

What are condyloma acuminata?

"genital warts" caused by HPV

What is Peyronie disease?

fibrous band in the corpus cavernosum causing bending and/or indentation of the erection

What is typical penile cancer?

squamous cell carcinoma, usually originating in the gland or foreskin

Hx consistent with penile cancer.

typically older males, present with skin abnormality or palpable lesion

PE consistent with penile cancer.

- painless lump, ulceration

- inguinal adenopathy present in some cases

What is a hydrocele?

fluid accumulation in the scrotum between the parietal and visceral layers of the tunica vaginalis

Hx consistent with hydrocele.

painless scrotal swelling

What patient population is hydrocele common in?

Newborns, the majority resolve spontaneously by age 2

What might a hydrocele be associated with?

epididymitis, orchitis, torsion, trauma, tumor in older patients

PE consistent with hydrocele

- cystic scrotal mass

- can be trans illuminated

What is a spermatocele?

Benign cystic accumulation occurring on the epididymis; can be made up of dead sperm

PE consistent with spermatocele.

Painless, cystic mass occurring separate from the testicle, freely mobile, transilluminates

What is a varicocele?

abnormal tortuosity and dilation of veins of the pampiniform plexus within the spermatic cord

Hx consistent with varicocele.

asymptomatic or c/o dull ache/fullness of scrotum upon standing

What is the most common surgically correctable cause of male infertility?

varicocele

PE consistent with varicocele.

"bag of worms" superior to testicle

Describe a primary varicocele.

more prominent in upright position and disappears when supine

Describe a secondary varicocele.

no change in position

What is orchitis?

acute inflammation of the testis secondary to infection

What is epididymitis?

inflammaiton of the epididymis often seen in assocaition with a UTI

What is testicular torsion?

twisting of testis on spermatic cord (SURGICAL EMERGENCY)

How might the testicle appear during testicular torsion?

"high-riding" testicle, usually shortened with horizontal lie

How might the epididymis appear during testicular torsion?

epididymis laying anterior rather than posterior aspect of testicle

Hx and PE consistent with testicular torsion.

- significant pain

- absence of cremasteric reflex

What is Klinefelter syndrome?

congenital anomaly, XXY

Hx consistent with Klinefelter syndrome.

lower IQ, infertility

PE consistent with Klinefelter syndrome.

tall stature, poor muscle tone, gynecomastia, small testes/genitalia