Male Genitalia Health Assessment Notes

Anatomy and Physiology

  • Key structures:
    • Vas deferens
    • Penis
    • Testicles
    • Epididymides
    • Scrotum
    • Seminal vesicles
    • Prostate gland
    • Blood vessels
    • Corpus cavernosum
    • Corpus spongiosum
    • Urethra
    • Corona
    • Glans
    • Prepuce
    • Urethral meatus
    • Tunica vaginalis
    • Spermatic cord
    • Ejaculatory duct
    • Bulb of the penis

Landmarks of the Groin (Inguinal Area)

  • Location: Junction between the lower abdomen and thigh.
  • Inguinal canal: Tunnel for the vas deferens.
  • Key Structures:
    • Inguinal ligament
    • Internal inguinal ring: Internal opening of the canal (not palpable through the abdomen).
    • External inguinal ring: Exterior opening of the tunnel, palpable just above and lateral to the pubic tubercle.
    • Femoral canal: Femoral hernias protrude here.
  • Lymphatics: Lymph drainage from the penis goes primarily to the deep inguinal and external inguinal nodes; always assess when concerned about a lesion on the penis.

Hernias in the Groin

  • Types:
    • Indirect Inguinal Hernia
      • Frequency, Age, and Sex: Most common, all ages and sexes, often in children, may occur in adults.
      • Point of Origin: Above the inguinal ligament, near its midpoint (the internal inguinal ring).
      • Course: Often into the scrotum. During examination, the hernia comes down the inguinal canal and touches the fingertip.
    • Direct Inguinal Hernia
      • Frequency, Age, and Sex: Less common, usually in men older than 40, rare in women.
      • Point of Origin: Above the inguinal ligament, close to the pubic tubercle (near the external inguinal ring).
      • Course: Rarely into the scrotum. The hernia bulges anteriorly and pushes the side of the finger forward during examination.
    • Femoral Hernia
      • Frequency, Age, and Sex: Least common, more common in women than in men.
      • Point of Origin: Below the inguinal ligament; appears more lateral than an inguinal hernia, can be hard to differentiate from lymph nodes.
      • Course: Never into the scrotum. The inguinal canal is empty during examination.

Male Sexual Development

  • Hypothalamus releases Gonadotropin-Releasing Hormone (GnRH), stimulating the pituitary to secrete Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH).
  • LH acts on interstitial Leydig cells to promote testosterone synthesis.
  • Testosterone is converted in target tissues to 5$\alpha$-dihydrotestosterone (5$\alpha$-DHT).
  • 5$\alpha$-DHT triggers pubertal growth of male genitalia, prostate, seminal vesicles, and secondary sex characteristics.
  • FSH regulates sperm production.
  • Male sexual function depends on normal levels of testosterone, blood flow, and intact innervation.
  • Erection stimuli:
    • Tactile
    • Visual, auditory, and erotic cues
    • These increase levels of nitric oxide and cyclic guanosine monophosphate, resulting in local vasodilation.

Health History: Common Symptoms

  • Penile lesions, penile discharge
  • Scrotal pain, testicular pain, swelling, lesions
  • Sexual transmitted infections (STIs)
    • Discharge: Ask about discharge from the penis, dripping, or staining of underwear. Clarify the amount, color, and any associated symptoms like fever, chills, or rash.
    • Associated symptoms: Sore throat, diarrhea, rectal bleeding, anal itching, pain.
    • Systemic symptoms: Fever, dysuria, skin rashes, joint pain, conjunctivitis.
    • Review previous genital symptoms and past STIs.
    • Review sexual practices.
    • Yellow penile discharge suggests gonorrhea.
    • White discharge suggests nongonococcal urethritis from Chlamydia.
    • Definitive diagnosis requires Gram stain and culture.
    • Ulcer in syphilitic chancre and herpes.
    • Genital warts from human papillomavirus (HPV).
    • Scrotal swelling in mumps orchitis, scrotal edema, and testicular cancer.
    • Pain in testicular torsion, epididymitis, and orchitis.
    • Symptomatic or asymptomatic proctitis may follow anal intercourse.
    • Ask about concerns regarding HIV infection.

Infectious Agents and Symptoms

  • Fever, dysuria (in males):
    • Acute prostatitis
    • Acute pyelonephritis
    • Disseminated gonococcal infection
    • Syphilis
    • Postobstructive UTI
  • Rash:
    • Reactive arthritis
    • Gonococcemia
    • Secondary syphilis
  • Joint pain: Systemic disseminated gonococcal infection
  • Conjunctivitis: Reactive arthritis

Specific Genital Infections

  • Genital Warts (Condylomata Acuminata): HPV Subtypes 6 and 11
  • Primary syphilis: Treponema pallidum
  • Genital Herpes Simplex: Herpes Simplex Virus 2
  • Chancroid: Haemophilus ducreyi

Health Promotion and Counseling

  • Testicular Cancer
    • Rare, most commonly diagnosed cancer in white males age 20-34.
    • Risk factor: cryptorchidism (undescended testicle) increases cancer risk by 3 to 17-fold.
    • Other risk factors: family history, Klinefelter syndrome (XXY), and HIV infection.
    • USPSTF, American Cancer Society recommendations.
  • Testicular Self-Examination (TSE)
    • High-risk patients: cryptorchidism, history of carcinoma in the contralateral testicle; mumps orchitis; inguinal hernia; hydrocele in childhood; and positive family history.

Testicular Self-Examination Instructions

  • Best performed after a warm bath or shower when the scrotal skin is warm and relaxed.
  • Perform while standing.
  • Check for any swelling on the skin of the scrotum in front of a mirror.
  • With the penis out of the way, locate a testicle by gently feeling your scrotal sac. Examine each testicle separately.
  • Stabilize the testicle with one hand. Use the fingers and thumb of your other hand to firmly but gently feel or roll the testicle between your fingers. Feel the entire surface.
  • Find the epididymis, a soft, tube-like structure at the back of the testicle that collects and carries sperm. Note that this is not an abnormal lump.
  • Check the other testicle and epididymis the same way.
  • If you find a hard lump, an absent or enlarged testicle, a painful swollen scrotum, or any other differences that do not seem normal, see your health care provider immediately.
  • Normal findings: one testicle may be slightly larger or hang lower than the other. Each normal testicle has a small, coiled tube (epididymis) that can feel like a small bump on the upper or middle outer side of the testicle.
  • Normal testicles also have blood vessels, supporting tissues, and tubes that carry sperm. Some men may confuse these with abnormal lumps at first. If you have any concerns, ask your doctor or clinician.

Physical Examination: Scrotum and Testes

  • Inspect the skin, prepuce, and glans for ulcers, scars, nodules, inflammation, and excoriations.
  • Retract prepuce if present; essential for detection of chancres and carcinomas.
  • Smegma, phimosis, paraphimosis assessment.
  • Inspect the urethral meatus (discharge).
  • Compress glans gently to inspect for spontaneous discharge; if there is reported urethral discharge, have patient strip or “milk” the penile shaft; culture.
  • Assess for hypospadias, epispadias.
  • Palpate the shaft of the penis between thumb and first two fingers for induration, tenderness.
  • If you retract the foreskin, replace it before proceeding to examine the scrotum.
  • Plaques of Peyronie disease can be palpated on the dorsal side of the penis.
  • Induration or firmness along the ventral surface suggests a urethral stricture or carcinoma.

Physical Examination: Scrotum and Testes

  • Inspect the scrotum including skin, hair, and contour for lesions, swelling, lumps, veins, bulging masses, asymmetry.
  • Lift the scrotum to inspect the posterior surface.
  • Normal for one testicle to be slightly larger than the other, and for one to hang lower than the other.
  • Cryptorchidism - poorly developed scrotum on one or both sides.
  • Common scrotal swellings: indirect inguinal hernias, hydroceles, scrotal edema, and, rarely, testicular carcinoma.
  • Scrotal epidermoid cysts: dome-shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium; benign, common.
  • Evaluating a Possible Scrotal Mass
    • To assess a possible groin hernia presenting as a mass in the scrotum, ask the patient to lie down.
    • If the mass disappears by returning to the abdomen by itself (reducible), it's likely to be an indirect inguinal hernia.
    • The patient can often tell you what happens to his swelling when lying down and may be able to demonstrate how he reduces it himself.

Physical Examination: Scrotum and Testes

  • Palpate each testis to assess size, shape, consistency, and tenderness; feel for any nodules, including the epididymis and spermatic cord, check for presence, size, shape, consistency, symmetry, tenderness, masses, and nodules.
  • Techniques:
    • One-handed technique: thumb and first two fingers.
    • Two-handed technique: cradle testis at both poles in the thumb and fingertips of both hands, slide them back and forth from fingertips of one hand to the other, cupping scrotum.
  • Pressure on the testis normally produces a deep visceral pain.
  • Testes should be firm but not hard, descended, symmetric, nontender, and without masses.
  • Epididymis feels nodular and cord-like and should not be confused with an abnormal lump. Epididymis should not be tender.
  • Palpate each spermatic cord, including the vas deferens, between your thumb and fingers, from the epididymis to the external inguinal ring.
  • Vas deferens feels slightly stiff and tubular.
  • Tender painful scrotal swelling is present in acute epididymitis, acute orchitis, testicular torsion, and strangulated inguinal hernias.
  • Painless nodule on the testis raises the possibility of testicular cancer.

Special Techniques - Groin Hernias

  • Best done with patient standing; can also be supine.
  • Inspect inguinal regions and genitalia for bulging areas and asymmetry.
  • Retract prepuce if present; essential for detection of chancres and carcinomas.
  • A bulge suggests a groin hernia. Groin hernias in women often do not have a visible bulge. Femoral hernias most commonly present in the femoral space.
  • Palpate for an inguinal hernia (direct or indirect) using the tip of the dominant index finger at the inferior margin of the scrotum; advance finger toward the external inguinal ring, invaginating the scrotal skin.
  • Have the patient cough; palpate for a distinct bulge or mass that moves against the finger.
  • A bulge near the external inguinal ring suggests a direct inguinal hernia.
  • A bulge near the internal inguinal ring suggests an indirect inguinal hernia.
  • Hydrocele: abdominal fluid fills sac in scrotum. Transillumination of the scrotal mass may help distinguish a hydrocele from an intestine-containing hernia.
  • Varicocele: abnormal dilation and enlargement of scrotal spermatic veins, which drains blood from each testicle. Palpate spermatic cord; have patient bear down; temporary increase of spermatic cord suggests varicocele.
  • Palpate for femoral hernia by placing fingers on the anterior thigh in the region medial to the femoral canal; locate pulse and move medially; have the patient cough/strain and note any swelling/tenderness.