EXAMINATION 5

Male genitalia

Level: *

GENITOURINARY
Setting: A male pelvis mannequin on a table
Time: 5 minutes

Scenario
E This is Mr Jones (pointing to a male mannequin). I would like you to show me
how you would examine his external genitalia.

Comment
The reason for including this station is that it is frequently badly handled by
students. Nine times out of ten this is because of a lack of clinical experience in
examining this area. Prior to OSCEs, it was rarely asked, even in postgraduate
exams, because of the difficulty in getting male patients to participate. Modern-
day mannequins, however, are very lifelike and of good quality. Thus, this is an
increasingly common task.

Getting clinical experience in this area may be difficult, but it is essential that
you seek out every opportunity. Many students find that attendance at several
genito-urinary or urology outpatient clinics is extremely useful.

An additional difficulty can arise when students are unfamiliar with the types of
mannequin available for this examination. Try to become as familiar as you can
with the resources available in your own clinical skills unit.

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Core skill Examination of the male genitalia

1. If asked – talk to the model or examiner (role play as far as you can)
2. Obtain clear consent
3. Inspection – ulcers/lesions around the penis and scrotum, mucosal
ulceration, and urethral discharge. Retract foreskin and inspect glans
4. Note whether the left testis is slightly lower. Palpate each testis and
vas deferens, and comment on its presence, shape, size, consistency,
swellings, asymmetry and any associated masses
5. Trans-illuminate any swellings
6. Examine local lymph nodes
7. Finish by saying you would examine, abdomen, groins and rectum
 EXAMINATION 5 Male genitalia

Inspection
1. Always use gloves
2. Look at the skin for any obvious scars, lumps or ulcers
GENITOURINARY

3. Retract the foreskin to detect any chancres or friable masses (carcinoma of

the penis in the early stages is frequently obscured by the foreskin)
4. The presence of cheesy white material accumulating under the foreskin
(smegma) is a sign of poor personal hygiene
5. Is the foreskin difficult to retract (phimosis)?
6. Look at the glans for ulcers or inflammation (balanitis)
7. Look at the base of the penis for any excoriations
8. Study the urethral meatus. Is it in the right place? Is it displaced to
the inferior surface (hypospadias)? Is it displaced to the upper surface
(epispadias)?
9. Look for urethral discharge by compressing the glans between the thumb
and index finger:
• profuse and yellow = gonococcal urethritis
• scanty, white or clear = non-gonococcal urethritis.
Palpation
1. Palpate the shaft of the penis between thumb and first two fingers of your
right hand
2. If the prepuce is retracted, replace it
3. Feel for any plaques, thickening or tight bands/scarring
4. Carefully palpate testis and scrotum. Feel for the epididymis and the body
of the testis. Gently feel for the spermatic cord
5. Palpate the inguinal lymph nodes.

Transillumination
Use a pen torch to shine a light from behind any testicular mass that you find.
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Comment
Examining the male genitalia does not take a long time; therefore the examiner
will almost always be armed with supplementary questions for you once you
have finished. Be familiar with the common disorders (Table 4.4).

Extension to station (Level***)

A thorough examination of the male genitalia may be performed in just a few
minutes. It is not uncommon for such a station to include a picture such as
the one in Figure 9. The examiner may ask you to comment on the test being
performed, the abnormality shown or the relevant clinical anatomy. Most
surgical atlases will have multiple examples of scrotal and penile abnormalities.
These atlases can be a useful adjunct to your own clinical experience.
 Male genitalia EXAMINATION 5

Table 4.4 Common disorders of the male genitalia

Common disorders of the Clinical findings

GENITOURINARY
male genitalia
Penis
Syphilitic chancre Dark, red painless ulcer
Genital herpes Cluster of small vesicles and shallow non-painful ulcers
with red bases
Venereal warts Often moist and malodorous friable masses
Carcinoma of the penis Indurated, non-tender nodule or ulcer
Scrotum
Varicocele Easily distinguishable from the testis, often does not feel
like the classical ‘bag of worms’
Hydrocele Non-tender fluid-filled mass, transilluminates and you can
normally ‘get above it’
Spermatocele Painless mobile cystic mass just above the testis
Testicular cancer Painless hard nodule on testis
Epididymitis/acute orchitis Tender, swollen epididymis. Scrotum may be red and
swollen. Inflamed, tender, swollen testis
Testicular torsion Acutely tender painful and swollen: a surgical
emergency!

If you are examining a real patient and detect a scrotal swelling, then consider
four questions:

Question 1: Can I get above the swelling?

• No – it is an inguinal hernia
• Yes – it is a primary scrotal swelling.
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Figure 9 A scrotal swelling in a 5-year-old child

 EXAMINATION 5 Male genitalia

Question 2: Is it cystic?
• Testis and epididymis felt separately – epididymal cyst. The cyst is usually
felt just above the testis
GENITOURINARY

• Testis and epididymis not felt separately and testis difficult to feel –
hydrocele (most will transilluminate).

Question 3: Is it solid?
• Arising in the testicle – most likely to be a tumour. Tumours are sometimes
associated with a lax hydrocele
• Arising in the epididymis – most likely to be a small epididymal cyst or
thickened epididymis secondary to infection.
• A varicocele is easily distinguished from the testicle and may feel like the
classic description of a ‘bag of worms’, though this is not always the case.

Question 4: Is the testis tender?

• If palpated too hard even the normal testis will be tender
• Most tumours are painless and non-tender
• A patient with epididymo-orchitis usually has an exquisitely tender testis.
Suggestions for further practice
The authors strongly recommend that you repeatedly revisit the anatomy of
the male genitalia throughout your clinical studies. It is an embryologically
complicated area that freque ntly forms the basis of clinical examination
questions in general surgery. It is insufficient to learn the anatomy from a book
or atlas alone as it can only be appreciated if observed in a three-dimensional
environment such as the dissecting room or in theatre. Many medical schools
now have joint tutorials between anatomists and surgeons to bring the anatomy
and pathology of such areas alive for the learner. If your institution has such
events you are strongly advised to attend.

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