Male reproduction
Focused Assessment - Male Reproductive System
Important Points
Anatomy: Understanding the anatomy is crucial for comprehending the male reproductive system.
Hx & PE: Inspection and palpation are essential components of history and physical examination.
CC (Chief Complaint): Symptoms assessment should include:
Establishing the onset of puberty, typically in early to middle teens.
Documenting past reproductive complaints.
Recent systemic illnesses in the past 6 months.
Notes on recent unintentional weight gain or loss.
New onset of pain in any reproductive organs.
PMH (Past Medical History)
Document any conditions affecting:
Penis, testes, or hormones.
Testicular or GU (Genitourinary) malignancies and treatments.
Consider:
Cryptorchidism, hypothyroidism, pituitary malfunction.
Previous surgeries such as GU surgeries, including:
Orchidopexy
YV plasty to the bladder neck
Inguinal hernia repair (and age)
Epididymis or hypospadias repair
Prostate surgery
Bladder reconstruction and other bladder surgeries
Testicular surgery
Vasectomy
FH (Family History)
Check for:
Testicular or other GU malignancies.
Prostate or bladder conditions in family members.
Any history of similar complaints among family members.
Maternal medication or drug use history during pregnancy.
Social History
Review recent changes such as:
Changes in sexual partner, orientation, and overall sexual activity pattern.
History of fathering children, libido, and erectile function.
Any partner treatment prior to the patient's chief complaint.
Assess activities risk factors for groin area:
Contact sports, cycling, motocross.
Consider exposure to environmental toxins.
Objective Examination - Focused
Environment Consideration: Keep room warm to prevent exaggeration of the cremaster reflex.
I - Inspection: Inspect for:
Development of male secondary sex characteristics.
Lesions, scarring, or discoloration of the penis, scrotum, and groin.
Asymmetry of the testicles.
Signs of gynecomastia and hirsutism.
Location and size of meatal opening.
Scars on the abdomen, groin, or inguinal area.
A - Auscultation: Rarely indicated in male reproductive complaints but may be used if bowel herniation is suspected.
P - Palpation: This step is critically important. Palpate for:
Masses that may arise on the surface of the testicles or nearby.
P - Percussion: Rarely indicated in male reproductive complaints.
Common or Concerning Symptoms
Male Genitalia: Symptoms related to sexual health such as:
Penile discharge or lesions.
Scrotal pain, swelling, or lesions.
Sexually transmitted infections (STIs).
Red Flags
Sudden onset of:
Acute testicular pain.
Cellulitis with necrotic skin changes.
Erection persisting for 60 minutes post sexual activity (Priapism).
Trauma, illness indications (cancer, tumors, cauda equina issues, sickle cell disease).
Inability to urinate or the presence of new masses.
Male Genital Abnormalities
Penis - Normal Findings:
Soft and pliable along the length of the shaft.
Meatus should be midline and central to glans.
Foreskin should retract easily.
Abnormal Findings:
Fibrous plaque along the shaft indicating Peyronie’s disease.
Tenderness suggesting a urethral stricture.
Difficulty with foreskin retraction may suggest:
Phimosis (inflammation or swelling).
Balanitis or balanoposthitis.
Difficulty moving foreskin forward indicative of paraphimosis.
Fibrous texture indicating previous priapism.
Misplacement of meatus indicating hypospadias or epispadias.
Scrotum - Normal Findings
Chiefly, a loose sac of skin partially covered with hair.
Abnormal Findings
Areas of erythema or nodularity may indicate:
Infected sebaceous glands or hair follicles.
Unilateral uncomfortable swelling pointing towards:
Hydrocele, hematoma, or varicocele.
Testes - Normal Findings
Typically two, freely movable testes, each:
Palpated between thumb and first two fingers.
Should have firm, smooth, rubbery consistency.
Average size is , symmetrical; right testicle may be slightly anterior to left.
Abnormal Findings
Possible masses associated with the testicle indicating:
Tumor, hydrocele, or spermatocele.
Solitary testis may indicate non-descent or prior surgical removal.
Small or soft testicles may be suggestive of Klinefelter disease or history of infection.
Epididymis - Normal Findings
Soft ridge of tissue located longitudinally posterior to the testicle, clearly separate from it.
Abnormal Findings
Cystic or nodular growths indicating:
Spermatocele or previous/current infection.
Large, fluctuant masses could be spermatocele.
Localized pain could suggest epididymitis or post-vasectomy pain syndrome.
Vas Deferens and Spermatic Cord - Normal Findings
Typically exhibits a soft, rubbery consistency and is smooth along its length.
Tracing the vas deferens is possible from epididymis to inguinal canal.
Abnormal Findings
Absence of vas deferens either unilaterally or bilaterally could suggest:
Cystic fibrosis or variants thereof.
Sperm granuloma post-vasectomy.
Congested veins (varicocele).
Beading or nodularity indicating obstruction or infection.
Differential Diagnosis Case Study
Case: 21-year-old male presents with a "nodule" on his left testicle found during self-examination.
On examination, both testicles appear normal in size, shape, and consistency.
A soft, nodular tube-like structure is located at the back of the left testicle, without tenderness.
Likely Diagnosis: Normal epididymis; the epididymis is a normal anatomical feature that can sometimes be mistaken for a pathological lump during self-examination.
Special Maneuvers
Cremasteric Reflex:
Brushing or touching the scrotal skin results in elevation of the testicle on the same side. Aggravated by a cool room.
Digital Rectal Examination (DRE):
Involves inserting a gloved, lubricated finger into the anus to sweep across the surface of the prostate.
Prostate should be symmetrical, non-tender, about the size of a walnut (approximately 2.5 cm), and smooth.
Estimation of anal sphincter tone also occurs during this examination.
Neurological Examination:
Testing superficial anal reflex (perianal sensation) by stroking the anus with a cotton swab should yield reflexive contraction of the external anal sphincter.
Bulbocavernosus reflex testing involves squeezing the glans penis when a gloved finger is inserted into the anus, resulting in contraction of anal sphincter and bulbocavernosus muscles. Useful for evaluating complaints of erectile and ejaculatory dysfunction.
Hernia Examination
Inspection and Palpation:
Patient standing and straining down to assess for hernia.
Palpation Technique:
Required palpation of inguinal lymph nodes.
Teach Testicular Self-Examination (TSE):
Timing, Shower, and Examination points (TSE).
Paraphimosis
Definition: Urologic emergency involving the inability to return the foreskin over the glans penis.
Causes:
Chronic balanitis.
Diabetes Mellitus (DM).
Signs/Symptoms:
Swelling and pain in the area.
Scrotal Abnormalities
Epididymitis
Testicular torsion
Varicocele
Tumors
Special Maneuvers in Diagnosis
Transillumination of Hydrocele
Shining a light source through the mass will show a reddish glow; may feel as if it surrounds the testicle, feeling turbid or tense.
Transillumination of Spermatocele
Similarly, a light source shines through this mass, allowing palpation of testicle separately from the spermatocele.
Note that the epididymis may not be distinctly palpated apart from the spermatocele.
Prostate Cancer Screening
Prostate-Specific Antigen (PSA) Testing:
Elevated levels could indicate:
Benign Prostatic Hyperplasia (BPH), prostate cancer, prostatitis.
Precautions:
Avoid ejaculation 48 hours prior to the test, and avoid GU instrumentation.
Medications such as Avodart and Finasteride can cause a 50% decrease in PSA values.
PSA rising more than per year increases the risk of prostate cancer.
Digital Rectal Exam (DRE) – an important adjunct to screening.
Prostate Abnormalities
Normal Prostate: Rounded, heart-shaped structure approximately 2.5 cm long.
Prostatitis: The prostate feels tender, swollen, "boggy," and warm.
Benign Prostatic Hyperplasia (BPH):
May be normal size or symmetrically enlarged, smooth, and firm but slightly elastic. May have obliteration of median sulcus protruding into the rectal lumen.
Prostate Cancer:
Presents as a hardness or distinct nodule in the prostate; may not always be palpable.
Benign Prostatic Hyperplasia (BPH)
Risk Factors:
Advancing age with normal androgen status.
Symptoms:
Lower urinary tract symptoms associated with bladder outlet obstruction such as:
Urgency, frequency, hesitation in average starting stream, decreased caliber of force of stream, nocturnal frequency of urination.
Prostate Characteristics:
Smooth, firm, non-tender, and with elevated PSA relative to age-specific reference.
Prostatitis
Acute or Chronic Infection of the Prostate:
Acute Symptoms Include:
Fever, low back or perineal pain, urinary urgency and frequency, nocturia, dysuria, muscle and joint aches.
Prostate Findings: Tender, boggy, and swollen upon examination.
Erectile Dysfunction (ED)
Categories:
Arteriogenic:
Causes include:
Atherosclerosis, hypertension, hyperlipidemia, smoking, pelvic trauma, diabetes mellitus.
Cavernosal (venogenic):
Involves vascular disease, diabetes mellitus, Peyronie’s disease, insufficient trabecular smooth muscle contraction, aging.
Endocrinologic:
Hypogonadism, hyperprolactinemia, thyroid disorders, orchiectomy.
Neurological:
Conditions like diabetes mellitus, spinal cord injury, multiple sclerosis, pelvic trauma.
Psychological:
Performance anxiety, depression, psychological stress, relationship issues, misinformation.
Systemic Disease-induce:
Chronic renal failure (CRF), coronary heart disease, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hepatic failure, recent myocardial infarction (MI), cirrhosis.
Medications Contributing to Erectile Dysfunction
Categories:
Antiandrogenic agents:
Anticholinergics:
Antihypertensives:
Benzodiazepines:
Lipid-lowering agents:
Miscellaneous medications:
Cimetidine, lithium, baclofen, narcotics.
Monoamine oxidase:
Recreational Drugs:
Tranquilizers:
Tricyclic Antidepressants:
Polypharmacy:
Chemotherapy:
Alcohol Abuse:
Marijuana Use:
Selected Causes of Priapism
Idiopathic (Primary) Priapism: 60% of cases.
Medication-induced Priapism: Caused by a range of pharmacological agents.
Other Medical Conditions or Trauma:
Selected Causes of Hypogonadism
Primary:
Aging
Chemotherapy/Irradiation
Cryptorchidism
Chromosome abnormalities (e.g., Klinefelter syndrome)
Myotonic dystrophy
Orchitis (e.g., due to mumps)
Loss from trauma or tumors
Combined:
Aging
Hemochromatosis
Peripheral causes due to malignancy medications (antiestrogens for prostate cancer).
Psychological stress
Obesity
Pituitary mass lesions
Prolactinoma
Uremia
Cirrhosis
Sickle cell disease
Ejaculatory Dysfunction Causes
Anatomic:
Congenital bilateral absence of the vas deferens, obstruction of seminal vesicles, bladder neck abnormalities, retrograde ejaculation.
Functional:
Premature ejaculation.
Medical:
Affected by SSRIs, MAOIs, alpha-blockers, antipsychotics, benzodiazepines, alcohol, methadone.
Neurological:
Diabetes mellitus, spinal cord injury, multiple sclerosis, and surgical procedures such as bladder reconstruction.
STIs Clinical Presentation in Males
Chancroid:
Presents as a tender ulcer with deep, undermined borders, possibly soft or indurated; may have painful lymphadenopathy.
Chlamydia:
Scant mucoid or mucopurulent urethral discharge with mild dysuria and itching.
Genital Herpes:
First episode involves fluid-filled painful vesicles that coalesce, followed by rupture and development of ulcerative lesions; adenopathy and dysuria may accompany.
Genital Warts:
Recurrences may feature prodromal pain/burning, with lesions resolving in 7-10 days.
Gonorrhea:
Fleshy lesions on the glans or skin; mostly subclinical, detectable with acetic acid.
Nongonococcal Urethritis:
Yellowish or purulent discharge with itching; epididymal or testicular pain can occur; 5-10% of cases may be asymptomatic.
Pediculosis Pubis:
Mild to moderate urethral discharge with itching;
Scabies: Severe pruritus with observation of ectoparasites in the genital area.
Syphilis:
Primary stage shows solitary, painless ulcer (chancre); secondary stage presents with a rash.
Trichomoniasis:
Usually asymptomatic but may cause urethritis.
Lesions
Condyloma Acuminatum (Genital warts): Common STD lesions.
Primary Syphilis: Characterized by the presence of a chancre.
Other Lesions
Genital Herpes Simplex: Fluid-filled vesicles, ulcerative lesions.
Candida Albicans & Balanitis: Fungal infection presenting with itchy lesions.