GROSSANAT ● GROSS AND CLINICAL ANATOMY 1 SHIFT

CA 20: MALE REPRODUCTIVE SYSTEM

#4
ELVIS LLARENA, MD, FPCS, FPSGS, FPALES MARCH 31, 2022

LECTURE OUTLINE B. TESTICULAR SELF-EXAMINATION

I Male Reproductive System ● It is advised to male patients to do testicular self-examination, the same as
in female patients wherein it is advised to do breast self-examination
II Examination ● Scrotal contents (vas deferens, epididymis, testis) must be palpated for
A. Examination of Penis and Scrotum abnormal findings
B. Testicular Self-Examination ● Retraction of the foreskin of the penis must be performed
○ Need not to be done using a surgical instrument, unless ready to do
III Penis
circumcision in cases of phimosis
A. Phimosis
B. Circumcision
C. Epispadia & Hypospadia
D. Phimosis & Paraphimosis
E. Infections
F. Carcinoma of the Penis
G. Penile Fracture
IV Sperm
A. Semen Analysis
B. Vasectomy
V Scrotal Masses
A. Hydrocele
B. Spermatocele
C. Varicocele Figure 2. Testicular Self-Examination
VI Testis Dr. Llarena’s CA 20 Recorded Lecture
A. Cryptorchidism
B. Testicular Torsion
C. Testicular Cancer
VII APA References
VIII Review Questions

NOTE: Texts in blue are taken from Batch 2024’s CA 20 Trans.

I. MALE REPRODUCTIVE SYSTEM

● Includes the urethra, testicle, ejaculatory duct, vas deferens, penis, bladder,
seminal vesicle, epididymis, scrotum, prostate gland
Figure 3. Foreskin of Penis
Dr. Llarena’s CA 20 Recorded Lecture

Figure 1. Male Reproductive System

Figure 4. Foreskin of Penis
Dr. Llarena’s CA 20 Recorded Lecture
Dr. Llarena’s CA 20 Recorded Lecture

II. EXAMINATION
III. PENIS
A. EXAMINATION OF PENIS AND SCROTUM ● PENIS
● A keen observation is key in the physical examination of the male ○ An erectile shaft composed of 3 columns of cavernous tissue
reproductive system ■ Cavernosa (2)
● The penis is examined with the patient in an upright/standing position facing ■ Spongiosum (1)
the examiner ○ Average flaccid length: 7-10 cm (2.7 to 3.93 in)
○ If the patient is not circumcised, the foreskin should be retracted in order ○ Average flaccid diameter: 2-3 cm
to visualize the glans penis ○ Average tumescent length: 18-20 cm (7.08 to 7.87 in)
○ Note any discoloration, secretions, or deformities ○ Average tumescent diameter: not exceeding 5 cm
● The scrotum must also be likewise examined for any pathologies. If needed, ■ Greater measurements have been reported
transillumination test using a flashlight and palpation must be undertaken.
○ Careful observation and palpation of the scrotal area and the use of a
flashlight to transilluminate lesions offer the best means of making an
accurate diagnosis

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 Figure 8. Uncircumcised vs. Circumcised Penis
Figure 5. Internal Structure of the Penis Dr. Llarena’s CA 20 Recorded Lecture
Batch 2024 CA Trans

● FRENULUM PREPUTII
○ A thin fold of skin connecting the prepuce to the inferior end of the
external urethral meatus
○ Connects glans penis to foreskin

Figure 9. Phimotic (obstructed) opening of a

child’s penis due to chronic inflammation
Batch 2024 CA Trans

[BATCH 2024 TRANS] DORSAL PENILE NERVE BLOCK

● Apply local anesthetic before removing the prepuce of the penis
Figure 6. Frenulum Preputii (Pointed) ● Nerve supply: dorsal nerve of the penis (2)
Dr. Llarena’s CA 20 Recorded Lecture ○ Branch of the internal pudendal nerve
○ Two of them are beneath the Buck’s fascia
A. PHIMOSIS ○ Lateral to deep dorsal vein and dorsal arteries (2)
● PHIMOSIS
○ A condition where the prepuce is so constricted that the foreskin cannot
be retracted for hygienic purposes, thus becoming a medical indication
(surgical emergency) for circumcision

Figure 10. Penile Cross-Section

Batch 2024 CA Trans

Figure 7. Phimosis IMPORTANT: Both branches of the dorsal nerves of the penis must be
Aboutkidshealth.ca blocked.
B. CIRCUMCISION
● PREPUCE ● First, locate the triangular space
○ Freely retracted ○ Anterior to symphysis pubis
○ Loosened elastic skin covering the anterior end of the penis ○ Below the membranous layer of superficial fascia
○ In uncircumcised males, it extends over the distal end of the penis ○ Cavernous muscles
● CIRCUMCISION ○ Boundaries:
○ Removal of a portion of the prepuce or foreskin of the glans ■ Posterior: symphysis pubis
○ Aims to expose the head of the glans penis ■ Superolateral: membranous layer of the superficial fascia
○ The degree of the clearance depends on the technique used in the ■ Inferomedial: corpus cavernosum
operation ● In inserting the needle, hit the symphysis pubis first
○ Some uncircumcised males may have a retractable prepuce ● Once you hit the pubis, direct the needle downwards until you feel a “give”.
○ Non-removal of the prepuce may lead to: It means that you are already beyond the superficial fascia.
■ Infection of secretions ● After traversing the superficial fascia inject the anesthesia in the space,
■ Chronic inflammation (fibrosis) predisposes rightward and leftward to anesthetize both dorsal nerves of the penis
● Penile cancer
● Phimosis (obstrictured opening)
○ Indications:
■ Hygienic (medical)
● Avoid inflammation, avoid cancer
■ Religious rite
● Jews
● Bible (as early as 8th day of life)
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 C. EPISPADIA & HYPOSPADIA
● GLANS
○ AKA head of penis
○ Covered with very thin skin containing numerous nerve endings → most
sensitive part of penis
● EPISPADIA
○ Rare birth defect (congenital)
○ Defect in opening of urethra
○ Urethra does not develop into a full tube
○ Urine exits body from an abnormal location
○ Opening is dorsally located
● HYPOSPADIA
Figure 11. Triangular Space
○ Rare birth defect (congenital)
Batch 2024 CA Trans
○ Urethra does not reach penis tip
○ Opening ends in a different position along the bottom of the ventral
[BATCH 2024 TRANS] CIRCUMCISION TECHNIQUES aspect of the penis
○ Abnormal opening can form anywhere below the shaft of the penis
1. DORSAL SLIT technique ○ Treatment:
○ Most common circumcision technique ■ Done between ages 3-18 months
○ Cut the dorsal portion of the prepuce until you expose the corona of the ■ In some cases, the surgery is done in stages especially if complicated
glans ■ These patients are not advised to do circumcision early because the
○ Retract the cut prepuce and suture it at the edges foreskin may be used for repairing the defect
2. CORONAL SLIT technique
○ In addition to cutting the dorsal portion of the prepuce, the excess
[BATCH 2024 TRANS] TYPES OF HYPOSPADIA
prepuce around the glans is also removed
(based on the location of the meatus which corresponds to the severity)
3. PLASTIBELL technique
○ After cutting the dorsal portion of the prepuce, retract the prepuce and ● Type 1 (Glandular)
put the ring ○ Most common and less severe form of hypospadia
○ Wait for the foreskin to necrose and slack off ○ Location of external urethral meatus is within the glans but not on the tip
● Type 2 (Coronal)
○ External urethral meatus can be located in the corona
● Type 3 (Penile)
○ Location of the external urethral meatus is in the penile shaft
● Type 4 (Penoscrotal)
○ Penoscrotal area is the junction of penis and scrotum
● Type 5 (Perineal)
○ Most severe form

● All types are associated with Chordee EXCEPT Type 1

○ Chordee is the abnormal flexion of the penis secondary to fibrosis
● Types 3, 4, and 5 are associated with failure of genital folds to form.
● Types 1 and 2 are related to the failure of some ectodermal cells from the
Figure 12. Dorsal Slit Technique tip of the glans going to the body of the main bulk of the glans
Batch 2024 CA Trans

Figure 13. Coronal Slit Technique Figure 15. Epispadia

Batch 2024 CA Trans Dr. Llarena’s CA 20 Recorded Lecture

Figure 14. Plastibell Technique

Dr. Llarena’s CA 20 Recorded Lecture

Figure 16. Hypospadia

Dr. Llarena’s CA 20 Recorded Lecture
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 ● EMERGENCY CIRCUMCISION
○ Done when there is phimosis or paraphimosis
○ There are several techniques in doing this:
■ Dorsal Slit
● Less traumatic to the tissues involved
■ Coronal
● Entire skin is removed/ the entire redundant prepuce
■ Using a Gomco
● This is a device used during circumcision

E. INFECTIONS
● Infections are another problem of the male reproductive system.
● Most common infections include sexually transmitted diseases like
Figure 17. Epispadia vs. Hypospadia Chlamydia, Syphilis, Gonorrhea
Quizlet.com ○ Chlamydia and syphilis are both treated with antibiotics.
○ Gonorrhea is sometimes treated with IV antibiotics ceftriaxone and
sometimes oral azithromycin
D. PHIMOSIS & PARAPHIMOSIS
● Problems of the foreskin of the penis
● PHIMOSIS
○ Happens when the foreskin cannot be pulled up or retracted from the tip
of the penis
○ Common problem in young boys
● PARAPHIMOSIS
○ When the foreskin is retracted but cannot be moved backed up

Figure 20. Infections of the male reproductive organ.

Dr. Llarena’s CA 20 Recorded Lecture

Table 1. Infections of the Penis

INFECTION CAUSATIVE AGENT
Chlamydia Chlamydia trachomatis
Syphilis Treponema pallidum
Gonorrhea Neisseria gonorrhoeae
HIV/AIDS
Figure 18. Phimosis and paraphimosis
Dr. Llarena’s CA 20 Recorded Lecture Genital Herpes
Source: Dr. Llarena’s CA 20 Recorded Lecture
NOTE: The difference is that in phimosis, you cannot retract the foreskin
while in paraphimosis, you’ve retracted the skin but you cannot bring it back. F. CARCINOMA OF THE PENIS
● The penis can be a location of carcinoma just like any other part of the body.
● Penile cancer is a relatively rare form of cancer that affects the skin and
other tissues of the penis
○ The first noticeable symptom is typically a lump, a mass or an ulcer on
the penis itself like a small insignificant lump or a large infected sore
○ In most cases it may be located at the head or foreskin instead of the
shaft of the penis
○ Symptoms will include itching, burning, discharge, changes in the color of
the penis, thickening of the penile skin, bleeding, redness, irritation, and
presence of lymph nodes
● At risk for penile cancer:
○ Uncircumcised males
■ Also at risk for phimosis
■ SMEGMA
● A substance that forms from when dead skin cells moisture and oil
collect underneath the foreskin
● Whitish substance
● May lead to balanitis if there is prolonged exposure

Figure 19. Emergency circumcision for phimosis and paraphimosis.

A. Dorsal slit
Dr. Llarena’s CA 20 Recorded Lecture

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 G. PENILE FRACTURE
● Surgical emergency
● Injury to the tunica albuginea (cavernosa)
● Causes:
○ Forceful bending of the penis during intercourse
○ Sharp blow to the erect penis during fall or car accidents
○ Traumatic masturbation

Figure 21. Carcinoma of the penis. This shows the different forms of cancer.
The upper right image shows an advanced form of cancer.
Dr. Llarena’s CA 20 Recorded Lecture
Figure 25. True penile fracture. Note the bended area along erectile tissues.
Batch 2024 CA Trans

Figure 26. Intraoperative Penile Fracture

Batch 2024 CA Trans
Figure 22. Carcinoma of the penis.
Dr. Llarena’s CA 20 Recorded Lecture
IV. SPERM
● SPERM
○ Very important in the male reproductive system
○ Parts:
■ Head
■ Midpiece/body
■ Tail
○ Lifespan: depends on the location
■ Example:
● Tissue paper: once it dries up, sperm will no longer be viable
● Hot bath or Hot tub: Can live longer compared to dry surfaces
■ Inside female body: Up to 5 days inside
● There is still a chance for pregaancy even if you have sex days
before the ovulation period of the female in 2 to 5 days time
● Only one sperm is needed to impregnate a female
● To improve sperm count:
○ Improve your general health
■ Do not smoke
■ Avoid contact with toxins (pesticides, heavy metals)
■ Limit alcohol consumption
■ Observe a healthy diet
■ Keep your scrotum cool
Figure 23. Ulcerations on inguinal lymph nodes. ● Ideal environment for spermatogenesis in the scrotum
Dr. Llarena’s CA 20 Recorded Lecture ● Heat does not permit the sperm to survive and slows down sperm
formation
○ To avoid a warm environment in the scrotum refrain going to hot
tubs and hot showers, wear boxers instead of briefs, do not wear
tight pants
● Spermatogenesis does NOT stop
○ Only a deficiency in the volume can occur or a deficiency in the vigor of
the sperm itself

Figure 24. Ulcerations on the glans or on the shaft.

Dr. Llarena’s CA 20 Recorded Lecture

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 Figure 29. Vasectomy
Dr. Llarena’s CA 20 Recorded Lecture
Figure 27. Parts of a Sperm
Dr. Llarena’s CA 20 Recorded Lecture
[BATCH 2024 TRANS] Vasectomy
A. SEMEN ANALYSIS ● Done under local anesthesia
● Determination of the volume, motility, number, and morphology of the ○ Small incision made in the upper part of the scrotal wall
spermatozoa ○ Locate vas deferens and divide it between ligatures
● NV for human ejaculate: 3-5 ml ○ Medial to the epididymis
○ Variations in the volume are indicative of poor fertility ○ Posterior within the spermatic cord
● Motility: 80-85% of the spermatozoa are actively motile ● Important: Vas deferens is medial to the epididymis and posterior within
○ Motility below 35-40% or half of the NV are indicative of poor chances of the spermatic cord.
conception
● Abnormal forms of sperm: 20% abnormal forms are still compatible with
V. SCROTAL MASSES
fecundity or ability to reproduce
○ Low conception rate of greater than 40-50% abnormal forms
● Sperm count: 100-120 million sperm per ejaculate (ml)
○ < 60 million is considered the lower limit for fertility

Figure 30. Scrotal Masses

Dr. Llarena’s CA 20 Recorded Lecture

A. HYDROCELE
● Normally, there should be no communication because of the obliteration of
the proximal part of the tunica vaginalis or processus vaginalis
● 2 types: Communicating and Noncommunicating Hydrocele
Figure 28. Sperm Morphology
Dr. Llarena’s CA 20 Recorded Lecture

B. VASECTOMY
● Simple operation done to prevent pregnancy
● Blocks the sperm from coming out with the semen
○ Males can still experience orgasms
○ It will not affect the testosterone levels, erection, climax, and sex life in
general
● Nearly 100% effective
● Performed to produce permanent infertility
○ The vas deferens in disrupted
■ Can be corrected by re-anastomosis
● Microsurgical procedure
■ Spontaneous recanalization of the vas deferens may also occur
● If you really don't want children cutting it is better than just simply Figure 31. (Right) Communicating Hydrocele with Hernia vs.
ligating (Left) Noncommunicating Hydrocele

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● Communicating Hydrocele
○ There is communication between abdominal cavity and scrotum
○ Has a continuity or intact fluid from the abdominal cavity which is caused
by the failure of processus vaginalis to close at birth
■ Processus vaginalis: thin membrane that extends to the inguinal canal
down to the scrotum which is necessary for the transport of the testes
from the abdomen down to the scrotum
● If it remains intact/patent, there is potential for a hernia or hydrocele
to develop
■ Failure of obliteration of the tunica vaginalis
● Fluid coming from the abdominal cavity may go to the tunica
vaginalis.
■ Patent but narrowed processus vaginalis
● May be associated with hernia
● Fluid may not be the only element that could go down in the
opening. It could also include the bowels, mesentery, and omentum Figure 33. Upper two photos: Herniorrhaphy or Herniotomy
○ Most likely congenital Lower photo: Hydrocelectomy
○ Commonly seen in children
○ Treatment: B. SPERMATOCELE
■ High sac ligation
● Done by first identifying the patent processus vaginalis (sac)
● Ligate near the exit at the peritoneum or internal ring It is usually
done after 12 months because the patent processus vaginalis may
still close
● If it is still patent, it should be closed/treated to prevent the
development of hernia
■ Hydrocelectomy
● Indicated sometimes in newly encysted hydrocele where both the
proximal and distal part of the tunica is close but there is an
accumulation of hydrocele or fluid in between
● Removal of the hydrocele (sac)
● Noncommunicating Hydrocele
○ There is no continuous flow of fluid from your abdominal cavity
○ Closed processus vaginalis
○ Fluid around the testicle is only confined to the scrotum Figure 34. Spermatocele
○ Remains the same size and has very slow growth
○ Pathology is secondary to inflamed testis and infection. ● Fluid filled cyst located above or behind the testicle with a clear or cloudy
■ The nature of the tunica vaginalis is closely adhered to it and the fluid that may also contain sperm
inflammation or infection may go to the tunica. This now causes: ● Sometimes referred to as the spermatic cyst or epididymal cyst because
● Inflammation it is located in the epididymis
● Fluid accumulation ● Happens when sperm builds up within the epididymis that could have
○ Usually acquired caused blockage in the epididymal duct or cause inflammation
○ Secondary to testicular inflammation because proximal end is obliterated ● Remains small in size and does not necessitate treatment
○ Not associated with hernia ● Surgical treatment/intervention: Excision is done if needed due to long
○ Most commonly seen in adults term pain and uncomfortable symptoms
○ Treatment:
■ Hydrocele tapping
C. VARICOCELE
● A needle is inserted into the scrotal wall which is guided by an
ultrasound to avoid hitting the testis itself. Remember the layers of
the scrotum traversed by the needle to drain the fluid
■ Hydrocelectomy
● An incision is made in the scrotal wall, then isolate the hydrocele
(tunica vaginalis containing the fluid) and then remove or “unroof”
where the majority of the wall is removed and the edges are sutured
● Signs and Symptoms:
○ Child’s scrotum will appear swollen or large
○ Scrotum changes in size depending on the time of the day

Figure 35. Varicocele

● Engorgement of testicular veins or pampiniform plexus

● Most often seen:
○ On the left testicle
Figure 32. Hydrocele in children ■ Due to higher pressure of left testicular vein
■ Left testicular vein
● Diagnosis: Transillumination ● Drains into the left renal vein
○ One way to test if it is associated with hernia (communicating hydrocele) ■ Right testicular vein
or acquired (non-communicating hydrocele). The examiner puts a ● Drains directly into IVC
flashlight directly through the scrotal wall and transmits the light and most ■ A tumor on the left kidney encroaches on the left renal vein →
likely the content will be fluid and not hernia. Varicocele development
● Treatment: Reserved for those that don't regress after few months of life ○ When standing up
○ Hydrocelectomy: open the sac, evert it and close. ■ When lying down, it sometimes disappears because of the pull of blood
○ Herniorrhaphy or Herniotomy: those with concomitant hernia due to gravity

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● Signs and Symptoms:
○ Usually asymptomatic
○ Can be uncomfortable or painful at times
○ Can affect infertility
■ Due to increased blood stasis → more heat in the scrotum
○ Testicles may shrink in size
○ Upon physical examination: There’s a feeling like you're holding a bag of
worms
● Countercurrent Heat Exchange Mechanism
○ Related to spermatogenesis
○ Occurs between testicular artery and branches of the testicular vein
(Pampiniform Plexuses)
● Incidence: 10-15 males for every 100
○ Common in adolescents and young adults
○ Not uncommon for boys to develop this upon reaching puberty because
of development, hormones, and increase vascularity needed to develop
the testicle
● One of the most common causes of infertility in men Figure 37. Testicle located above the scrotum
○ Treatment: Varicocelectomy
■ Ligation or removal of the veins
■ Would improve sperm count, motility and infertility issues
● If no problem with infertility, this can remain untreated unless other causes
or indications exist
● Other treatment: Return of the normal Countercurrent heat exchange
mechanism

VI. TESTIS

A. CRYPTORCHIDISM
● AKA undescended testis
● Failure of the testis to descend down to the scrotum before birth
● Usually only one testicle is affected but there is a 10% chance of affecting
both testicles
● More common in preterm or premature infants because they did not develop Figure 38. Repairing undescended testes by pulling of it down to the scrotum
fully
● Testes are intra-abdominal organ that will eventually descend down from B. TESTICULAR TORSION
abdomen to the inguinal canal and scrotum (processus vaginalis)
○ In undescended testis ● Rotation of the testis around the spermatic cord within the scrotum
■ The processus vaginalis does not close ● Results in necrosis
■ Unknown cause, but can be affected by genetics, environmental, and ● Often associated with excessively large tunica vaginalis
pregnancy-related health problems ○ Common in:
● Complications of undescended testicle ■ Young men (25 years old and above)
○ Testicular cancer and fertility problem ■ Adolescents (12-18 years old)
○ Testicular torsion (twisting of spermatic cord) because it can be exposed ■ Newborn
to trauma in inguinal region ■ Children
○ Inguinal hernia ○ No defining cause and occurs spontaneously
● Treatment ○ Critical period for surgery is within 6 hours, delayed surgery will increase
○ Surgical correction the chance of removing the testicles
■ Bring down the testis to the scrotum to provide adequate temperature ■ Cases after 12 hours delay has a 75% chance that a patient will
for normal spermatogenesis undergo removal of testicle (orchiectomy)
● True undescended testis
○ Location of the undescended testis is along the path of the normal
descent
■ Retroperitoneal area → inguinal area → scrotum
● Ectopic undescended testis
○ Located in areas not included in the normal path of descend

Figure 39. Testicular torsion

C. TESTICULAR CANCER
● Not difficult to diagnose because it is readily palpable
● Manifest asa pea- sized lump or swelling on testicles
Figure 36. (Left) Undescended testis VS (Right) Normal testis ● Symptoms
○ Pain
○ Discomfort
○ Numbness without selling
○ Accompanied by breast tenderness or gynecomastia
● Diagnosis
○ Biopsy

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● Treatment options (depend on type of cancer)
○ Surgery
○ Radiation therapy
○ Chemotherapy
○ Stem cell transplant

Figure 40. Testicular cancer

VII. APA REFERENCES

Llarena, E. (2022). Recorded Lecture.
Batch 2024 CA 19 Trans

VIII. REVIEW QUESTIONS

No. QUESTION
1 What is the thin fold of skin that connects glans penis to
foreskin?
2 T/F. Testes are intra-abdominal organ
3 How long can sperm survive inside the female body?
4 Prolonged exposure to smegma may lead to what infection?

IX. RATIONALIZATION

No. RATIONALIZATION
1 Frenulum preputii
2 T. Testes will eventually descend down from the abdomen to the
scrotum before birth
3 5 Days
4 Balanitis

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