UNJ August 2006-290.
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Assessment of the Male
Reproductive System
Pamela D. Ceo
T
he importance of a good
physical examination
cannot be underestimat-
ed. A good clinician
must be able to differentiate nor-
mal from abnormal findings and
should be familiar with both func-
tion (see Table 1) and location (see
Table 2) of the organs involved. It
may be as subtle as a mole that
has changed slightly from last
examination or as obvious as a
new lesion that is draining.
Obtaining the History
Many diseases and medica-
tions can affect the urinary sys-
tem and its function. The initial
interaction with a patient should
begin in a nonthreatening way,
by reviewing his medical-surgi-
cal history and his current med-
ications. A complete assessment
of the male reproductive system
includes a thorough review of the
patient’s history, since many con-
ditions may present as com-
plaints of pain to the reproduc-
tive structures. Pain from a kid-
ney stone can radiate along the
spermatic cord and present as
testicular pain. Difficulty starting
the urinary stream and com-
plaints of perineal tenderness
may indicate prostatitis or
benign prostatic hypertrophy.
Urethral pain can be a result of
prostatitis, sexually transmitted
diseases, or recent instrumenta-
tion. Urgency and frequency may
be due to bladder dysfunction, a
Pamela D. Ceo, APRN,BC, CUNP, is
a Urology Nurse Practitioner, St.
Joseph Mercy Hospital, Ann Arbor, MI.
290
Many diseases and medications can affect the urinary system and its
function. Assessment of the male genitalia is accomplished with
inspection and palpation. It is important to chart what is seen, what
is felt, and what the patient reports.
urinary tract infection, or treat-
ment for low-grade bladder can-
cer. Complaints of a lump in the
scrotum can be an inguinal her-
nia. It is always important to dis-
cuss and clarify the details of any
previous genitourinary (GU)
surgeries, particularly if they
occurred during childhood.
Details of any previous treatment
for GU diseases or complaints
should be discussed. Ask the
patient whether he has been
treated recently in an emergency
department for the presenting
problem or any other problem.
There are some conditions
for which a physical examination
is only modestly helpful. Erectile
dysfunction cannot be seen or
felt during a physical examina-
tion; therefore, this issue should
be discussed with the patient.
Ask about his relationship(s) and
about his level of sexual satisfac-
tion. If the patient has diabetes,
hypertension, or depression and
takes medication for these condi-
tions, he may have erectile prob-
lems but may be too embarrassed
to talk about it. A statement such
as “Diabetes often causes erectile
dysfunction. Have you encoun-
tered any problems getting an
erection?” or use of a standard-
ized questionnaire may encour-
age the patient to discuss the
problem more openly (for exam-
ple, the Sexual Health Inventory
for Men [SHIM] by Rosen,
UROLOGIC NURSING / August 2006 / Volume 26 Number 4
Cappaleri, Smith, Lipsky, & Pena,
1999).
Examination Basics
Upon entering the examina-
tion room, the clinican should
greet the patient appropriately
with an introduction including
the clinician’s title. The patient
should be asked what he would
prefer to be called. This simple
introduction can help reduce
anxiety, particularly when the
specific encounter is related to a
man’s sexual or urological
health. If a genital examination is
necessary, permission is asked
before beginning the examina-
tion. This is especially important
when the clinician is a female,
since it allows the patient to
decline gracefully if he prefers a
male clinician to perform this
part of the examination. Genital
examination should be done last
if this is a full physical examina-
tion, in order to reduce embar-
rassment and to allow time for
the patient to become comfort-
able with the overall interaction.
A parent should always be pre-
sent when examining an infant or
minor. The adolescent should be
asked if he would like to have
anyone present during the exam-
ination. An adult male should be
asked the same question, espe-
cially if he is accompanied by his
wife. Social or cultural mores
may dictate that the wife leave
UNJ August 2006-291.ps 7/24/06 3:14 PM Page 291

Table 1. the room during her husband’s

Function of Male Genital Organs
Organ Function
Penis Protects the urethra; houses the corpora caver-
nosum which when engorged makes the penis
rigid and erect; prepuce protects the glans penis.
Scrotum Protective loose sac divided into two compart-
ments for the internal organs: testis, epididymis,
and vas deferens; temperature regulation of the
testes.
Testes Produce spermatozoa (seminiferous tubules) and
testosterone.
Epididymis Storage and transport of sperm cells; sperm mat-
uration.
Ductus (Vas) deferens Cord-like structure that transports sperm from
the testis and epididymis into the urethra.
Spermatic cord Protects the ductus (vas) deferens, internal and
external spermatic arteries, artery of the vas,
venous pampiniform plexus, lymph vessels, and
nerves.
Prostate gland Produces some of the seminal fluid; also pro-
duces a thin, white fluid that mixes with seminal
fluid to neutralize the urethra and vagina to main-
tain sperm viability.
Seminal vesicles Produces most of the seminal fluid.
examination.
Assessment of the male geni-
talia (see Figure 1) is accom-
plished with inspection and pal-
pation. Normally, only examina-
tion gloves and water-soluble
lubricant are needed but a stetho-
scope and flashlight may be use-
ful if the scrotal examination is
abnormal. A stethoscope can be
used to listen for bowel sounds if
there is a concern for a hernia
within the scrotal sac. The flash-
light would be used to transillu-
minate the scrotum during an
evaluation for a hydrocele. Prior
to any examination, the index
finger can be measured and used
as a ruler to measure the penis,
testes, and prostate.
With the patient in the
supine position, only the geni-
talia are uncovered and two
sheets are used, one to cover his
chest/abdomen area and the
other one to cover his legs.
Privacy for the patient is always

Table 2.
Developmental Changes in the Appearance of the Male Genital Organs
Developmental
Time Pubic Hair Appearance of Penis Testes and Scrotum
Stage 1 None except for fine body hair Size proportional to body Size proportional to body size
as on the abdomen. size as in childhood as in childhood
Stage 2 Sparse, long, slightly pigmented Slight enlargement Enlargement of testes and
thin hair at the base of penis. scrotum; reddened pigmenta-
tion; texture more prominent.
Stage 3 Darkens, becomes more coarse Elongation Enlargement continues.
and curly; growth extends over
symphysis.
Stage 4 Continues to darken, thicken, and Breadth and length Enlargement continues;
become coarser and more curly; increase, glans develops. skin pigmentation darkens.
growth extends laterally, superi-
orly, and inferiorly.
Stage 5 Adult distribution and appear- Adult appearance Adult appearance
ance; growth extends to inner
thighs, umbilicus, and anus, and
is abundant.
Stage 6 Sparse and gray Decrease in size Testes hang low in scrotum;
(Elderly clients) scrotum appears pendulous.

Source: Barkauskas, Baumann, & Darling-Fisher, 2002.

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Figure 1. provided. The room should be

Male Anatomy warm enough for the patient to
be comfortable. The patient
should be asked if the room is
warm enough. This is especially
important in examining the
elderly, since they may be less
tolerant of the cold. The warm
room will also avoid activation
of the cremasteric reflex that
causes the testes to ascend from
the scrotum upward toward the
pelvic cavity (Pulsifer, 2005).
This reflex can also be provoked
by touch. If possible, interrup-
tions should be avoided after the
examination is begun.

INSPECTION
Source: Marieb, 2006. Used with permission of Pearson Education, Inc. Pubic Area/Penis
The patient’s hair distribu-
Table 3. tion pattern is examined (see
Pubic Area/Penis Hair Distribution Table 3). Does it correlate with
his age? The suprapubic area is
Infant/child No hair inspected for any rashes,
Adolescence Few hairs on pubic area at first, then becomes fuller lesions, folliculitis, scarring,
(see Table 2). nodules, bulges, or scratch
marks (from a parasite). If the
Adult Abundant in pubic area, coarser than hair on other parts
of the body, curlier and on medial aspects of thighs hair is full it will need to be
parted during the examination.
Geriatric Gray and sparse The inguinal/groin area is
inspected. When the patient
coughs or bears down there
Figure 2. should not be any bulges or
Differentiating Hernias masses. If there are, this may
indicate a hernia. A direct
inguinal hernia would be near
the external inguinal ring, while
an indirect inguinal hernia
would be at the internal inguinal
ring (see Figure 2).
Penile growth rate is progres-
sive and predictable (see Table
4). An abnormally small penis
may be indicative of a clitoris,
Klinefelter’s or Down’s syndrome
(Gomella, 2002). An obese child
may appear to have a small
(retracted) penis secondary to
overlying skin folds and large
prepubic fat pad (Engel, 2002). A
penis that is large relative to stage
Source: Swartz, 2002. Used with permission of W.B. Saunders Company. of development may suggest pre-
cocious puberty or a possible tes-
ticular tumor (Engel, 2002).

292 UROLOGIC NURSING / August 2006 / Volume 26 Number 4

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Table 4. from the tip of the penis to the

Penis Size/Length penoscrotal junction. Both of
these disorders are congenital
Infant/child Size 1.9 cm newborn and up to 3 cm in young boys and are usually diagnosed at
until puberty. birth.
Adolescence Enlarges to adult size.
Urethral Meatus
Adult Size varies from male to male average: flaccid 4 to 10 When inspecting the urethral
cm; stretched 7 to 13 cm; color usually darker than the meatus, the glans is gently com-
skin on other parts of the body; skin should be smooth
and hairless and cylindrical in shape.
pressed between the index finger
(positioned on the dorsal surface)
Geriatric Retracted, small with some surface vascularities. and thumb (positioned on the ven-
tral surface). This will open the
Sources: Gomella, 2000; Jarvis, 2004; Shamloul, 2005.
meatus for inspection. Any dis-
charge, warts, lesions, swelling,
Table 5. inflammation, and shape are
Prepuce (Foreskin) noted. If the meatus is round this
may be indicative of meatal steno-
Infant/Child May or may not be present. sis secondary to repeated infection
Adolescence May or may not be present. (Engel, 2002) (see Table 7).
Many patients who have a
Adult/Geriatric May or may not be present.
sexually transmitted disease
(STD) present with dysuria and
penile discharge, but an asymp-
Table 6.
tomatic patient could also have
Glans Penis
an STD. That is why issues of
All ages Glans penis size should be proportional to the penis, and the sexuality should be addressed
skin should be smooth. during the examination, espe-
cially if an STD is suspected.
Questions about the number of
sexual partners, sexual prefer-
Prepuce/Foreskin are at a higher risk for penile can- ences, whether the current rela-
If the male is circumcised, cer, with the glans being the first tionship is monogamous, and
the prepuce is removed, and the site and the prepuce the sec- condom use can be asked in a
glans penis is exposed. For uncir- ondary site (see Table 5). professional, nonjudgmental
cumcised males the prepuce and nonthreatening manner. A
(foreskin) is retracted. The pre- Glans Penis clinician should never assume
puce is normally adherent in To inspect the glans penis the that elderly patients are not sex-
children younger than 3 years of prepuce must be retracted, if the ually active, especially if wid-
age. Older than 3 years of age, an male has not been circumcised. owed or divorced. Keep in mind
attempt can be made to retract Any lesions, drainage, warts, that symptoms associated with
the prepuce, but it should not be scars, rash, skin texture, color, or untreated gonorrhea could be
forced (Engel, 2002). An unre- swelling are noted. Inflammation interpreted as another disease
tractable prepuce may be indica- of the glans is called balanitis and more common in the elderly,
tive of phimosis and the patient may be caused by a fungal infec- such as prostate problems or
should be referred to a urologist. tion or tinea. Balanoposthitis is arthritis (Grigg, 2000). Older
Any drainage, lesions, scars, inflammation of both the glans adults may not use condoms
rash, or swelling are noted. There and prepuce (see Table 6). since they do not perceive a risk
may be a white, cheesy sub- If the male is uncircum- of pregnancy. Many older adults
stance, called smegma, and this cised, the prepuce is retracted do not understand STDs and
is normal. The prepuce must to expose the glans penis. If the their vulnerability to them.
always be replaced back over urethral meatus is located on When examining a child or ado-
the glans (head of the penis). If the dorsal (upper side) surface it lescent, sexual activity or sexual
the prepuce cannot be advanced is called epispadias. If it is abuse should be suspected if
over the glans, this is a condition located on the ventral (under- genital warts are present. Both
called paraphimosis. The patient side) surface it is called STDs and suspected sexual
should be referred emergently to hypospadias and can be located abuse are reportable events.
a urologist. Uncircumcised males anywhere on the ventral surface

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UNJ August 2006-294.ps 7/24/06 3:15 PM
Shaft of Penis
The color of the skin on the
shaft of the penis varies and the
dorsal vein may be prominent.
The skin is inspected for any
lesions, scars, genital warts, rash,
swelling, or noticeable nodules
(see Table 8).
Scrotal Sac
When the ambient air is
warm, the scrotal sac is more
pendulous and the skin is
smoother but when the ambient
air is cold, the scrotal sac
becomes contracted and the skin
more wrinkled (see Table 9)
(Swartz, 2002). Any rashes, geni-
tal warts, scars, lesions, or color
changes are noted. Sebaceous
cysts are common; these are cysts
that have a waxy appearance and
can become inflamed and drain a
cheesy material. Pain, necrosis,
and swelling of the scrotal sac in
a diabetic male may be signs of
Fournier’s gangrene; this is a uro-
logic emergency. Any drainage,
redness, bulges, lesions, or geni-
tal warts on the perineum are
noted. The anal area is stroked to
elicit the anal reflex. The anus
should contract quickly. Slow
reflex could indicate a disorder
of the pyramidal tract (Engel,
2002).
If the scrotal sac appears
“sunken in” on one side or both
sides, the testicle(s) may be
absent; an underdeveloped, non-
pendulous hemiscrotum com-
monly indicates undescended
testis (see Table 10). If the scrotal
sac is edematous it may be
indicative of a hernia or hydro-
cele. To differentiate between the
two, a flashlight is placed against
the scrotal sac posteriorly with
the room dark (transillumina-
tion). If there is a red glow, it is
likely a hydrocele. No light will
transmit through a solid tumor.
Another way to differentiate
scrotal swelling is to “get above”
the swelling. If this is possible,
the swelling is scrotal and if not,
the swelling is inguino-scrotal
and most likely an inguinal her-
294
Page 294
Table 7.
Urethral Meatus
All ages The urethral meatus should be positioned centrally at the tip
of the glans penis and appear as a pink slit.
Table 8.
Shaft of Penis
All ages The skin of the shaft should be smooth to slightly wrinkled
and hairless.
Table 9.
Skin of the Scrotum/Perineum
Infant/Child Rugae (wrinkles or folds) skin surface, color pink in white
infants and dark brown in dark-skinned infants; perineum:
moist and hairless.
Adolescence Skin surface becoming coarser with more rugae and skin
pigmentation darkens, the skin contains both hair and
sweat glands; perineum: hair growth to rectum.
Adult Skin slightly loose, skin surface coarse and with rugae, skin
darker than rest of body, the skin contains both hair and
sweat glands; perineum: hair growth to rectum; better
inspection with rectal examination.
Geriatric Skin becomes pendulous and less rugae, skin color darker
than rest of body and skin with hair; perineum: hair growth
to rectum; better inspection with rectal examination.
Table 10.
Contours of the Scrotum
All ages The left testicle may be lower than the right and therefore
appear asymmetrical.
nia (see Figure 2). soft, and without tenderness.
In the elderly patient, thick- During palpation any tenderness,
ening of the scrotal sac may nodularity, or induration is
occur in association with fluid noted. Tenderness along the ven-
retention which can be associat- tral (underside) aspect of the
ed with cardiac, renal, or hepatic penis is indicative of periurethri-
diseases (Gomella, 2002). Edema tis, which is often secondary to
may also occur in epididymitis or urethral stricture. The patient
other local inflammation and should fill out the International
obstruction of the inguinal lym- Prostate Symptom Score (I-PSS),
phatics (Jarvis, 2004). which is a helpful tool that
addresses bladder emptying, fre-
PALPATON quency, intermittency, urgency,
stream, and nocturia. This
Penis should be assessed annually and
The penis is palpated using as needed. Curvature, nodularity,
the thumb and first two fingers. or induration of the penis sug-
The penis should feel smooth, gests Peyronie’s disease. The
UROLOGIC NURSING / August 2006 / Volume 26 Number 4
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patient is asked if he is able to
obtain an erection, and if so,
whether there is any pain or cur-
vature.
Scrotum
The skin of the scrotum is
palpated using the thumb and
first two fingers. The scrotal sac
is divided into two compart-
ments. The contents should slide
easily. Abnormalities within the
scrotal sac are hydroceles and
hernias. A hydrocele is a collec-
tion of fluid that surrounds the
testes, which can be transillumi-
nated. Hydroceles can occur at
any age. A hernia is a portion of
bowel that protrudes into the
scrotal sac. A hernia does not
transilluminate but it may be
possible to auscultate bowel
sounds.
Testes
The testis is palpated gently
with the thumb and first two fin-
gers (see Table 11). Each testis is
palpated separately; they should
be ovoid, firm and smooth, much
like a hard-boiled egg. The testis
should feel suspended and move
easily in each sac. The testes
should have the same consisten-
cy and be nearly the same size. A
firm nodule may indicate a tes-
ticular tumor. The testes can
become infected (orchitis).
To prevent the creamateric
reflex during palpation in infants
and young children, either a fin-
ger is held over the inguinal
canal while palpating the scrotal
sac or have the child sit cross-
legged. Inability to palpate a
testis in an infant may indicate
cryptorchidism (undescended
testis) and the testis may be pal-
pated in the inguinal canal. The
testis may descend on its own as
the infant grows. If it has not
descended by 1 year old, surgical
correction should be done
(McAninch, 2000). If the cryp-
torchid testis is not corrected, the
male is at a higher risk of infertil-
ity and testicular cancer.
Testicular growth is a visible
UROLOGIC NURSING / August 2006 / Volume 26 Number 4
Page 295
Table 11.
Testes
Infant/Child Size 1.5 cm until puberty.
Adolescence/Adult Approximately 4.0 to 5.5 cm in length, 2.5 cm in
width.
Geriatric Less firm and slightly smaller.
Source: Rowland & Herman, 2002.
Table 12.
Normal Prostate
4 cm wide, 2.5 to 3.0 cm long
Source: Grayback, McVary, & Kozlowski, 2002.
sign of sexual maturation. This is absent, this is often associated
can occur as early as age 10 years with an absent kidney on the
(Engle, 2002). A small (<3.5 cm) same side (Swartz, 2002). The
and soft testis may indicate atro- spermatic cord may become tor-
phy as with cirrhosis, hypopitu- tuous which is a varicocele and
itarism, or may occur following feels like a “bag of worms.” The
estrogen therapy or androgen spermatic cord may also form a
blockade. If the testis is smaller cyst after a vasectomy that is
than 2 cm and alopecia in the painless and contains sperm
pubic region is noted, suspect (spermatocele).
Klinefelter’s syndrome (hypogo-
nadism) (Jarvis, 2004). Inguinal Area/Lymph Nodes
The inguinal area is palpated
Epididymis/Ductus (Vas) for pulses, using the pads of the
Deferens/Spermatic Cord index, middle, and ring fingers.
The epididymis is located on Decreased or absent pulses may
the posterior aspect of the testes. indicate a vascular problem. The
It is palpated gently with the inguinal (superficial) and subin-
thumb and first two fingers. The guinal (deep) lymph nodes are
epididymis should be nontender, palpated. The lymph nodes are
smooth, and feel softer than the usually not felt. An enlarged
testes. Palpate upwards toward lymph node may represent
the inguinal ring using only the inflammation or metastatic dis-
thumb and index finger to feel ease spread from the genital or
the ductus (vas) deferens. It peri-anal area. Note any tender-
should feel smooth and be non- ness and size of lymph node.
tender. It feels like partially
cooked spaghetti and is about 2 Prostate and Seminal Vesicle
mm to 4 mm in diameter. A normal prostate feels sym-
Upward, a thicker cord (spermat- metrical, smooth, rubbery, with-
ic cord) is felt. It should also be out tenderness and the median
smooth and nontender. Palpate sulcus is palpable; benign dis-
the right side first, then the left ease feels like the tip of a nose
side. whereas a cancerous nodule feels
Abnormalities are infection more like a forehead (see Table
of the epididymis, ductus (vas) 12). The prostate may also feel
deferens, and spermatic cord. flat, indurated (hardened), boggy
The epididymis can also be (spongy), or enlarged. Seminal
nodular, which may be indicate a vesicles lie cephalic to the
cyst or tumor. If the vas deferens prostate, are about 6 cm long and
295
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soft, normally nonpalpable; if
they are palpable, this may be
suspicious for cancer.
The digital rectal examina-
tion should be explained to the
patient. Advise him to report any
tenderness or pain experienced
during the examination. The
location of any significant dis-
comfort or abnormality is identi-
fied by using the face of a clock
as a reference point (for example,
the lesion is at the 3 o’clock posi-
tion on the rectum). The width of
the clinician’s index finger (usu-
ally about 1.5 cm-2 cm) and the
length of the finger can be mea-
sured and used as a reference to
help measure the prostate.
If the patient is unable to
stand, the rectal examination can
be done in either the Sims’ or dor-
sal recumbent position. To place
the patient in the Sims’ position,
he should lie on his left side with
his right thigh and knee, flexed as
much as possible, over his left leg,
which is also partially flexed. To
place the patient in the dorsal
recumbent position, have him lie
on his back with his hips and
knees bent (flexed), and feet flat
on the examination table or mat-
tress (if the patient is in the bed).
Otherwise, have the patient stand
on the floor. The scrotal sac is
inspected again since hydroceles
and hernias may be more promi-
nent in the standing position. Any
abnormalities not detected earlier
with palpation are noted. The
patient should turn around facing
the examination table for the
prostate examination. The patient
is told to bend forward (flexing at
hips) and rest his forearms and
elbows on the table while bending
his knees slightly. The patient is
advised that the examination is
about to begin. The buttocks are
spread to inspect the rectal area
for hemorrhoids, genital warts,
discharge, or rashes. The rectal
area is palpated for nodules and
tenderness. The clinician’s gloved
index finger of the dominant hand
is lubricated. The clinician places
it at the anal verge and the patient
296
Page 296
is instructed to bear down, as if he
were having a bowel movement.
This relaxes the rectal sphincter
and allows for easy insertion of
the finger. The index finger is
inserted as far as possible, as the
patient relaxes and breathes
deeply. The sphincter tone is
noted and the prostate is palpated
using the finger as a ruler to assess
the size of the gland (side to side
and top to bottom). With slight
pressure, palpate the lateral right
side from top to bottom (base to
apex), move the finger to the cen-
ter, which should dip down
(median sulcus), and continue to
move to the lateral left side, pal-
pating from top to bottom.
Normally the seminal vesicles are
not palpable. The prostate should
be symmetrical, feel smooth, rub-
bery, and without tenderness. The
prostate may be enlarged especial-
ly if the male is older. Prior to
removing the finger, palpate the
rectal wall for nodules and ten-
derness. This completes the digi-
tal rectal examination.
Any stool on the gloved finger
should be checked for occult
blood. Either the rectum is wiped
free of lubricant with a tissue or
the tissue is offered to the patient.
The patient is allowed to stand up
and get dressed.
Conclusion
No matter how long a clini-
cian has been performing a male
genital examination, there can be
some level of discomfort or anxi-
ety from the clinician, the nurse
(male or female), or the patient.
Confidence and competence in
the physical examination tech-
nique takes time to accomplish.
There may also be unusual find-
ings on the genitals such as tattoos
and/or piercings. The clinician
should always remain profession-
al and nonjudgmental. It is impor-
tant to chart what is seen, what is
felt, and what the patient reports.
• Philadelphia: W.B. Saunders.
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