Male GU Examination

Jong M. Choe, MD
Director of Continence Program
Division of Urology
University of Cincinnati College of Medicine
Veterans Administration Medical Center
 Urology
What do Urologists do?

They are surgeons who treat and operate on

diseases of genitourinary organs in men:
• Kidney • Penis
• Ureter • Urethra
• Bladder • Vas deferens
• Prostate • Testes
 Urology
What do Urologists do?

They are surgeons who treat and operate on

diseases of genitourinary organs in women:
• Kidney
• Ureter
• Bladder
• Urethra
 Initial Evaluation

Urologic patient
Begins with focused history and physical examination
of pertinent genitourinary organs
 Initial Evaluation

FEMALE MALE

Kidneys

Ureters

Bladder

Urinary sphincter

Prostate

Urethra
 Initial Evaluation

Urologic patient
Begins with focused history and physical examination of
pertinent genitourinary organs

• Kidney • Penis
• Ureter • Urethra
• Bladder • Vas deferens
• Prostate • Testes
 Medical History

Chief complaint (CC):

History of present illness (HPI):
Past medical history (PMH):
Past surgical history (PSH):
Family history (FH):
Social history (SH):
Medications:
Allergies:
Review of systems (ROS):
 35 yo white female with history of hematuria. She
needs an intravenous pyelogram (IVP) to evaluate
the source of bleeding
CC: Hematuria
HPI: Began 2 days ago. Has stopped now. History of
smoking x 8 years. Does not think she is
pregnant.
PMH: None
PSH: None
FH: None
SH: (+) smoke or (-) ETOH
Medications: OCP
Allergies: None; no reaction to IVP dye
ROS: Non contributory
45 yo male with benign prostatic hyperplasia
(BPH) has difficulty urinating
CC: Difficult urination
HPI: Weak stream; sense of incomplete emptying,
straining to urinate; AUA symptom score 30/35;
most recent PSA 2.5 ng/ml
PMH: Enlarged prostate (BPH)
PSH: None - specifically no TURP
FH: (-) Prostate cancer
SH: (-) smoke or drink ETOH
Medications: Flomax
Allergies: None
ROS: Non contributory
 Generalized Physical Examination

HEENT
Cor
Lungs
ABD
Flank
GU Penis Pelvic
Testicles
Rectal Prostate
Ext
Neuro
 Generalized Physical Examination

HEENT Benign
Cor RRR
Lungs CTA
ABD soft, NT/ND, NABS
Flank (-) CVAT
GU Penis normal phallus, adequate meatus
Testicles descended bilaterally; WNL
Prostate smooth and benign, (-) nodules
Ext (-) CCE
Neuro No focal neurologic deficits
 Physical Examination

Focused Urologic examination

• Inspection - general observation

• Palpation - gently touch and feel
• Percussion - lightly tap over a finger
• Auscultation - listen with stethescope
 Inspection

Cushing’s syndrome
Excess cortisol production
Clinical signs:
Buffloe hump
Truncal obesity
Moon face
 Inspection

Phimosis
Inability to retract the foreskin
Phimosis
Paraphimosis
Inability to pull down the foreskin

Paraphimosis
 Inspection

Pelvic organ prolapse

Condition where one of the pelvic
organs has herniated out of the vagina
Cystocele - bladder
Rectocele - rectum
Enterocele - bowel
Pelvic organ prolapse
Procidentia - uterus
 Palpation

Kidney examination Prostate examination

Male - Bimanual Female - Bimanual

Hernia examination examination examination
 Kidney Examination

Method of palpation of the kidney

The patient lying supine
Posterior hand tilts the kidney upward
Anterior hand feels for the kidney
Have patient take a deep breath. This causes the
kidney to descend
As the patient inhales, push the anterior hand at
the costoverterbral margin
If the kidney is mobile or enlarged, it can be felt
between 2 hands
 Kidney Examination

Kidneys
Lie under the diaphragm and ribs
Well protected from injury
Right kidney lower than left due to liver
Left kidney usually not palpable
Normal kidneys difficult to palpate especially in men due to ABD muscle tone
Sometimes normal kidneys may be palpable in thin patients and in children
Palpable kidneys are usually displaced or enlarged
 Renal Masses

Hydronephrotic kidney

Renal mass: may be fluid-filled or may

be solid
Solid renal tumor
 Kidney Examination

Renal tumor
Clinically asymptomatic
May present with hematuria
Not palpable unless enlarged
Firm, non-tender, often immobile

Pyelonephritis
Infection of the kidneys
Patient septic (fever, toxic)
Costovertebral angle tenderness (CVAT)
 Kidney Examination

Renal abscess
Infection of the kidneys
Patient septic (fever, toxic)
Costovertebral angle tenderness (CVAT)
Anterior abdominal wall tenderness

Perinephric abscess
Infection of the kidneys
Patient septic (fever, toxic)
Costovertebral angle tenderness (CVAT)
Anterior abdominal wall tenderness
 Kidney Examination

Kidney stone
Complain of flank pain
Renal colic - cannot get comfortable
Costovertebral angle tenderness (CVAT) kidney

Ureteral stone ureter

Complain of flank pain
Renal colic - cannot get comfortable
Costovertebral angle tenderness (CVAT)
Referred pain to groin area
Urinary frequency and urgency
 Prostate Examination

Method of palpation of the prostate

The patient is in left lateral decubitus position or
bent forward at the waist with feet shoulder-
width apart
A well-lubricated gloved index finger is inserted
gently into the rectum
Have the patient Valsalva or bear down as you
are inserting the gloved finger
Palpate the prostate in systematic fashion: right,
middle, left; apex to base
 Prostate Examination

Normal prostate
Normal prostate is size of a chest nut
Has consistency of nose or contracted thenar
eminence

Benign prostatic hyperplasia (BPH)

BPH is enlarged prostate
Has consistency of nose or contracted hyperthenar
eminence
May be as big as an orange
 Prostate Examination

Acute prostatitis
Patient appears septic (fever, toxic appearing)
Prostate is enlarged, fluctuant, warm, and painful
Do not be aggressive with prostate exam!

Chronic prostatitis
May complain of LUTS or hematospermia
Prostate feels boggy and is tender to touch
May see expressed prostatic secretions: white
discharge
 Prostate Examination

Prostate cancer
Clinically asymptomatic - silent cancer
One area of the prostate may feel firm, nodular, or
stony hard.
Need to get PSA and perform prostate biopsy
 Hernia Examination

Technique of examining inguinal

hernia
Inguinal hernia: extrusion of bowel into the inguinal
canal
Gently insert a gloved index finger into the inguinal
canal by invaginating the scrotal skin
Palpate the external inguinal ring - feels like a small
round opening
Have the patient turn his head to one side and cough
Protrusion of bowel against the index finger
signifies hernia
 Bimanual Examination

Male bimanual examination

Performed in a setting of bladder tumor
Insert a lubricated gloved finger into the rectum
Apply fingers of the anterior hand on the suprapubic
area
Attempt to palpate the bladder between 2 hands
Is the bladder palpable? Is it mobile or fixed?
Gives clinical information regarding local invasion
and extent of the tumor
 Bimanual Examination

Female bimanual examination

Performed in a setting of bladder tumor
Insert lubricated 2 gloved fingers into the vagina
Apply fingers of the anterior hand on the suprapubic
area
Attempt to palpate the bladder between 2 hands
Is the bladder palpable? Is it mobile or fixed?
Gives clinical information regarding local invasion
and extent of the tumor
 Bladder Examination

Technique of bladder examination

Apply fingers of the anterior hand on the suprapubic
area
Apply gentle pressure to the suprapubic area
Attempt to palpate the bladder
Is the bladder palpable or not?
 Bladder Examination

Normal bladder
Normally holds 400-500 ml of urine
Is not clinically palpable

Urinary retention
Bladder may hold as much as 2000-3000ml
Complain of difficulty urination, urinary dribbling,
and straining to urinate Normal bladder
Suprapubic fullness
Bladder is palpable and may be tender to touch
Bladder may be palpable up to umbilicus
Urinary retention
 Bladder Masses

Urinary retention Solid bladder tumor

 Percussion

Percussion
Used to assess kidneys
Used to assess bladder
 Kidney Examination

Gentle tapping over the kidney area

- costovertebral angle - normally
should elicit no response.
Presence of costovertebral angle
tenderness (CVAT) upon percussion
suggests:
• stones
• infections
• obstruction
 Bladder Examination

Gentle tapping over the bladder area

- suprapubic area - normally should
elicit no response.
Bladder in retention sounds hollow
like a drum.

Normal Bladder: Urinary Retention:

sounds “flat” to sounds like a drum
percussion to percussion
 Penile Examination

Inspection
If the patient has not been circumcised, the
foreskin should be retracted
This may reveal a tumor or balanitis

Erythroplasia of Queyrat

Penile cancer
 Penile Examination

Inspection
If retraction is not possible as in the case of
phimosis, circumcision is indicated.
 Penile Lesions

Paraphimosis

Penile condyloma

Reduction of Paraphimosis
 Penile Examination

Inspection
The position of the meatus should be noted
Normally the meatus should be located at
the tip of the penis
It may be located proximal to the tip of the
glans on either the dorsum (epispadius) or
the ventral surface (hypospadius)
 Penile Examination

Palpation
Palpation of the dorsal surface of the shaft
may reveal a fibrous plaque involving the
fascial covering of the corpora cavernosa
This is typical of Peyronie’s disease
Tender areas of induration felt along the
urethra may signify urethritis -
inflammaiton of the urethra.
 Penile Examination

Peyronie’s disease
Calcified plaque on the dorsum of penis
Often associated with abnormal penile
curvature, erectile dysfunction, and pain
with intercourse
Peyronie’s disease: calcification
of tunica albuginea
 Testicular Examination

Technique of testicular exam

The testes should be carefully palpated
with the fingers of both hands
Should look for location, size, texture,
consistency, and tenderness
Normal testis has a soft rubbery
consistency with a smooth surface
 Testicular Examination

Cryptorchid testis
This means undescended testis
Testis may lie anywhere along the course
of inguinal canal - ectopic if lies outside
canal
Most common site is the external inguinal
ring

Retractile testis
This means testis is present but it has
tendency to retract upward into the inguinal
canal due to overactive cremasteric
muscles
 Testicular Examination

Kliefelter’s syndrome
47, XXY
Clinical features:
male phenotype
gynecomastia
small, firm testes < 3 cm in length
azospermia (no sperm production)
tall and lanky
 Testicular Examination

Hydrocele
Fluid within tunica vaginalis
Asymptomatic but may cause
scrotal pain. Feels firm, non-tender
Transillumination in a dark room
helpful. Shine a flashlight behind
the scrotum. It glows red.
When in doubt, obtain scrotal
ultrasound

Spermatocele
Epididymal cyst filled with sperm.
Glows green with transillumination.
 Testicular Examination

Testicular cancer
A firm area in the testis proper must be regarded
as a malignant tumor unless proven otherwise
Typically asymptomatic and painless. Brought to
the attention to the patient after infection or
trauma
If transillumination is performed, light will not
transmit through a solid tumor
Tumors are often smooth but may be nodular
Need to obtain scrotal ultrasound
 Testicular Examination

Torsion
Abnormal twisting of the spermatic cord
Patient in severe pain, nausea, vomiting
Testicle high riding - retracted upward
Abnormal horizontal lie
Tender to palpation
May not be able to examine due to patient
distress
Urologic emergency
Need to obtain scrotal US with Doppler studies
 Epididymal Examination

Epididymis
Small cap-like structure located posterior to the
testicle
Should be carefully palpated
for size and induration
Induration means infection -
epididymitis
Epididymis
 Epididymal Examination

Epididymitis
In acute stage of epididymitis, the testis and
epididymis are indistinguishable by palpation Epididymis

The testis and epididymis may be adherent to the

scrotum

The scrotal wall is erythematous and tender

 Spermatic Cord Examination

Varicocele
Varicose veins of pampiniform plexus
Left side more commonly affected
Present with scrotal discomfort, heavy dragging
sensation of the scrotum esp end of the day
Can cause secondary infertility

See mass of dilated tortuous veins lying superior

Pampiniform plexus
to and above the testis - “bag of worms”
Degree of dilation accentuated by Valsalva
maneuver. Feels like “bag of worms”
Confirmed by scrotal ultrasound
 Spermatic Cord Examination

Varicocele
Right sided varicocele or prominent varicose
veins around the umbilicus suggests renal cell
carcinoma

Pampiniform plexus
 Questions

Focused Urologic examination consists of:

a.) Inspection
b.) Palpation
c.) Percussion
d.) Auscultation
e.) All of the above
 Questions

Paraphimosis is:

a.) Inability to retract foreskin

b.) Inability to pull down the foreskin
 Questions

Epispadius is a condition where:

a.) Urethral meatus is located on the ventral

surface of the penis
b.) Urethral meatus is located on the dorsal
aspect of the penis
 Questions

Right-sided varicocele suggests:

a.) Renal cell carcinoma

b.) Testicular tumor
c.) Prostate cancer
d.) Epididymitis
 Questions

Testicular torsion is:

a.) Benign condition

b.) Urologic emergency
c.) Should be treated non-surgically
d.) Same as orchitis
 Questions

All men presenting with Urologic complaints require a prostate

examination whereas women require a pelvic examination:

A: true
B: false
 Questions

A 45 year-old African American male presents with lower

urinary tract obstructive voiding symptoms. What questions
should be included in your medical history?

A. history of benign prostatic hyperplasia (BPH)

B. American Urologic Association (AUA) 7 symptom score
C. family history of prostate cancer
D. prostatic specific antigen (PSA) level
E. all of the above
 Questions

A 35 year-old female with presents with history of gross hematuria.

You decide she needs an intravenous pyelogram (IVP).
During the medical history you should have asked her about:

A. drug allergies
B. current medications
C. any possibility she could be pregnant
D. any history of reaction to contrast dyes
E:. all of above