Genital problems ●
Essential skills of scrotal
examination: a step-by-step
technique
Helen Please, Junior Surgical Clinical Fellow (CT3);1 Vanessa Savopoulos, Endourology Fellow;1 Chandra Shekhar Biyani,
Consultant Urologist1 and Co-Director Cadaveric Simulation Programme2
1. Department of Urology, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, UK; 2. Anatomy Department, School of Medicine,
University of Leeds, UK
Examination of the scrotum
is an essential skill for
emergency, surgical and
general practice (GP)
clinicians. However, the
examination poses a number
of challenges due to its
intimate nature and wide
range of potential pathologies,
resulting in many UK trainees
feeling uncomfortable and
underconfident in this skill.
This article aims to address
this issue by training clinicians
in a stepwise, structured
approach.
S crotal examination is notoriously
difficult due to its intimate nature
and wide range of potential
pathologies. Furthermore, a common
scenario faced by GPs, surgical
trainees and emergency clinicians is
having to rely on their examination
skills to assess whether an acute
scrotum is caused by testicular
torsion, therefore requiring
exploration and fixation.
Most scrotal complaints present
first to GPs and emergency
departments, making initial
examination crucial for appropriate
onward referral versus reassurance.
Studies show that 28% of UK GP
trainees feel uncomfortable in
wchh.onlinelibrary.wiley.com
Transversus
abdominis muscle
Internal abdominal
oblique muscle
External abdominal
oblique muscle
Ductus deferens
External
spermatic fascia
Cremasteric fascia
and muscle
Epididymis
Internal spermatic fascia
Gubernaculum
Figure 1. Scrotal anatomy. Adapted, with permission, from Dr Pasindu
Suriapperuma, Pasindu’s Archives5
testicular assessment1 and 62% of
primary care providers have little/no
formal training in scrotal examination.
However, structured training can
significantly increase confidence in
scrotal examination,2 and can be
facilitated by simulation models.
Several robust models exist
(exemplified by the ‘Limbs and
Things’ model CMPT Mk 2 in our
images), with low-fidelity alternatives
also available.3,4
This article is especially useful for
doctors in GP, emergency, and core
surgical training who want to build
Trends in Urology & Men’s Health ❘ March/April 2022
Peritoneum
Obliterated tract of
processes vaginalis
Transversalis fascia
Scrotum
Testes
Tunica vaginalis
their clinical confidence in scrotal
examination. We hope it facilitates
clinicians’ confidence and
competency in examination and
diagnosis of serious and common
scrotal pathologies. It includes an
outline of the pertinent anatomy and
indications of this examination,
followed by a step-by-step
examination approach aided by
photographs using simulation
models. The standardised structure is
used: preparation, inspection,
palpation, auscultation, special tests,
followed by a list of important
❙ 9
● Genital problems
questions to be asked in cases of
scrotal masses. Finally, the examination
findings for common and concerning
scrotal pathologies are described,
supported by clinical images.
Anatomy
A detailed anatomical understanding
underpins the quality of any clinical
examination. The scrotum is a
cutaneous sac beneath the penis,
containing several important
structures (Figure 1). The testes are
ovoid structures suspended by the
spermatic cord, separated by the
scrotal septum. The epididymis lies
on their posterior aspect, consisting
of a head, body and tail. The
spermatic cord contains the vas
deferens, arteries (testicular,
cremasteric, artery to vas deferens),
veins (pampiniform plexus), nerves
(genital branch of genitofemoral,
sympathetic, parasympathetic) and
lymphatics. It is covered by multiple
layers, from internal to external:
tunica vaginalis, internal spermatic
fascia, cremaster muscle, external
spermatic fascia, dartos muscle
and skin.
Indications
Scrotal examination is required in
patients presenting with scrotal/
inguinal pain, lump(s) or trauma,
and in comprehensive abdominal
examinations for males with
abdominal pain.
Examination steps
All clinical examinations should follow
a structured approach, including
preparation, inspection, palpation,
auscultation and special tests. An
opportunistic approach may be
required in paediatric examinations,
allowing flexibility to rearrange
this order.
Step 1: preparation
Good communication skills are
essential in any examination. These
include greeting the patient,
introduction by name and role,
10 ❙ Trends in Urology & Men’s Health ❘ March/April 2022
Figure 2. Blue dot sign. Image
reproduced with permission from
Eleni Papageorgiou, Abraham
Cherian and Pankaj Mishra6
confirming identity, explaining the
examination and its indication,
ensuring privacy, and assessing for
pain. When any intimate region is
examined, clear verbal consent and
a chaperone are critical to patient
comfort. This also protects the
clinician from medicolegal allegations
or unwelcome behaviour. These
preparatory steps cannot be
overemphasised, as they provide
reassurance and build rapport, which
optimise a relaxed examination. In
the paediatric population this can
be facilitated by involving parents/
guardians or play specialists to
provide distraction.
The examiner should wash their
hands, ensure hands are warm and
consider exposure/positioning.
Ideally, the patient should be
exposed from the waist down and
the scrotum examined with the
patient first standing, then supine,
although paediatric patients may be
best in their carer’s lap. An
abdominal examination should also
be performed, as abdominal pain
can radiate to the scrotum and vice
versa. Continue verbal communication
and awareness of facial cues
throughout the examination to
ensure patient comfort.
Step 2: inspection
First perform a general inspection,
noting whether the patient is unwell
or in pain. Next, assess the
inguinoscrotal region for colour,
testicular lie, size, shape, symmetry,
presence of lesions/lumps/oedema/
scars. Continue inspection throughout
steps 3–5 as some signs, such as the
‘blue dot sign’, may become visible
only when the skin is stretched
(Figure 2).
Step 3: palpation
Ask the patient about pain before
palpating and begin with the normal
side to allow comparison when
examining the abnormal side. Palpation
is easiest in the supine position,
although some findings are best
appreciated with the patient standing
(for example, varicocele/hernia).
Due to testicular mobility, it is
recommended to ‘fix’ each testicle
between both thumbs and index/
middle fingers (Figure 3a). In this
position, feel the size, texture and
contour, and attempt to localise any
tenderness to the testicle or other
structures (Figure 3b). Characterise
any lumps and determine if they are
separate from the testis. Figure 3c
demonstrates palpation of a
simulated malignant lump.
Next, palpate the epididymis
systematically including the head
(Figure 3d), body and tail. Palpate the
spermatic cord at the scrotal neck by
rolling it between thumb and index
finger (Figure 3e); the vas deferens is
appreciated as a rubbery, cord-like
structure slipping between the
fingers. A varicocele, if present, will
be felt in this region (Figure 3f
demonstrates a simulated varicocele).
Finally, palpate the groin lymph
nodes (Figure 3g), particularly if
infection/neoplasm are suspected.
Step 4: special tests
Auscultation
Listen over masses for bowel
sounds. Positive findings suggest
inguinoscrotal hernia.
wchh.onlinelibrary.wiley.com
 Genital problems ●

a b c d e

f g h i j

Figure 3. Scrotal examination demonstrated on a simulated model. Image

reproduced with permission from Chandra Shekhar Biyani

Figure 4. Hydrocele. Original image

source from Shields L, White J, Peppas
D, 20198
Figure 5. Cremasteric reflex demonstrated on a simulated model. The black arrow
demonstrates the movement of finger stroking skin from position 1 to 2. The blue Step 5: questions about masses
arrow demonstrates the resulting retraction of the ipsilateral testis in normal If a scrotal mass/swelling is present,
physiology. Image reproduced with permission from Chandra Shekhar Biyani ask yourself the following:
1. Is it possible to get above the
Cough impulse between masses being fluid-filled mass (technique demonstrated in
Palpate masses with the patient (presence of a red glow) or solid Figure 3j)? If not, consider hernia
standing and ask them to cough. (no transmitted light), ie hydrocoele or infantile hydrocoele (Figure 4).
An impulse felt under the fingers (Figure 3h and Figure 4) versus 2. Is it possible to identify the testis and
suggests inguinoscrotal hernia epididymal cyst (Figure 3i). epididymis? If not, consider vaginal
or varicocele. hydrocoele, haematocele, tumour,
Cremasteric reflex torsion or epididymo-orchitis.
Transillumination Stroke the inner thigh to induce 3. Is the swelling translucent? If yes,
Darken the room and use a pen torch cremaster muscle contraction consider hydrocoele or epididymal
to shine light from behind any (Figure 5). This is positive if the cyst.
swelling/mass while inspecting ipsilateral testis elevates and is 4. Is the swelling tender? If yes,
anteriorly. This allows differentiation typically absent in torsion. consider torsion or epididymo-orchitis.

wchh.onlinelibrary.wiley.com Trends in Urology & Men’s Health ❘ March/April 2022 ❙ 11

● Genital problems
Pathologies
The following section lists several
common and concerning scrotal
pathologies, describing their expected
findings when using the examination
steps described below.
Torsion
• Clinical inspection (see Step 2).
Erythematous or dark hemiscrotum.
• Palpation findings (see Step 3).
Abnormal lie (horizontal, high),
firm and tender testicle
(generalised).
• Relevant special tests (see Step 4).
Absent cremasteric reflex, no
transillumination.
• Questions about masses (see
Step 5). Tender (sudden onset in
history), able to get above swelling,
testis and epididymis may or may
not be definable.
Torted testicular appendage
• Clinical inspection (see Step 2).
Blue dot sign (Figure 2).
• Palpation findings (see Step 3).
Normal lie, soft testicle with
pinpoint tenderness.
• Relevant special tests (see Step 4).
Cremasteric reflex present, no
transillumination.
Figure 6. Fournier’s gangrene. Image
reproduced with permission from
Nadiah Parry9
12 ❙ Trends in Urology & Men’s Health ❘ March/April 2022
• Questions about masses (see Step 5).
Tender, able to get above swelling,
testis and epididymis definable.
Fournier’s gangrene
• Clinical inspection (see Step 2).
Stepwise progression of oedema,
erythema, duskiness, necrosis and
gangrene (Figure 6).
• Palpation findings (see Step 3).
Oedema, tender skin, may have
subcutaneous crepitation or
purulent discharge.
• Relevant special tests (see Step 4).
Exquisite tenderness or pain out
of proportion to examination is a
cardinal finding. Presence of crepitus
and subcutaneous gas is very
specific for gas-forming organisms.
• Questions about masses (see Step 5).
Tender (intense), testis and
epididymis definable.
Hydrocoele
• Clinical inspection (see Step 2).
Asymmetrical swelling (Figure 4).
• Palpation findings (see Step 3).
Fluctuant swelling, not reducible.
• Relevant special tests (see Step 4).
Translucent, no cough impulse.
• Questions about masses (see
Step 5). Depending on type of
hydrocoele: may or may not be able
to get above mass. Testis and
epididymis may not be definable,
generally non-tender.
Varicocele
• Clinical inspection (see Step 2).
‘Bag of worms’ swelling.
• Palpation findings (see Step 3).
Asymmetrical soft swelling, not
reducible.
• Relevant special tests (see Step 4).
No transillumination, cough impulse
may be present.
• Questions about masses (see
Step 5). Able to get above mass,
testis and epididymis definable,
generally non-tender.
Epididymo-orchitis
• Clinical inspection (see Step 2).
Erythematous unilateral swelling.
Figure 7. Frog-legged position
to inspect the scrotum. Image
reproduced with permission from
Mau EE, Leonard MP10
• Palpation findings (see Step 3).
Tenderness localised to epididymis,
bulky epididymis, not reducible.
• Relevant special tests (see Step 4).
No transillumination, no cough
impulse.
• Questions about masses (see
Step 5). Tender (gradual onset),
able to get above mass. Testis and
epididymis may or may not be
definable (depending on severity).
Inguinoscrotal hernia
• Clinical inspection (see Step 2).
Unilateral swelling, abdomen may
be distended.
• Palpation findings (see Step 3). May
be soft and reducible, or firm and
irreducible.
• Relevant special tests (see Step 4).
Presence of bowel sounds on
auscultation; cough impulse may
be present.
• Questions about masses (see
Step 5). Unable to get above mass,
testis and epididymis definable,
may be tender (if irreducible/
strangulated, or non-tender).
Scrotal examination in infants
and children
Scrotal examination in infants and
adolescent boys is challenging, with
adolescent boys being especially
reserved about having their genitals
examined. It is therefore important
wchh.onlinelibrary.wiley.com
 Genital problems ●

the training received in urology on

the GP training scheme. Ir J Med Sci
2016;185:165–9.
2. Sarmah PB, Sarmah BD, Ibrahim H,
Panting J. Making models to simulate
testicular swellings. Clin Teach
2017;14:432–6.
3. Sharma D, Sohn JK, Zillioux JM, et al.
a b c Identifying and addressing training
deficiencies in the examination of
cryptorchidism – a quality improvement
study. J Pediatr Urol 2020;16:61.e1–61.e8.
4. Kailavasan M, Abdul-Rahman A,
Hanchanale V, et al. The validation
of the Clinical Male Pelvic Trainer
Mk 2 – advanced models for scrotal
examination simulation. J Surg Educ
d e f 2017;74:423–30.
Figure 8. Scrotal examination in the paediatric age group. Reproduced with 5. Suriapperuma P. Embryology and
permission from The Royal Australian College of General Practitioners from: surgical anatomy of testis and scrotum –
Yeap E, Nataraja RM, Pacilli M. Undescended testes: what general practitioners overview. Pasindu’s Archives April 2020
need to know. Aust J Gen Pract 2019;48:33–36. Available at: www.racgp.org.au/ (www.pasindusarchives.com/2020/04/
ajgp/2019/january–february/undescended-testes embryology-and-surgical-anatomy-of-
testis-and-scrotum-overview.html;
to collect maximum information prior position or flexing of both thighs accessed 8 December 2021).
to examination. GPs are most likely towards the abdomen may push the 6. Papageorgiou E, Cherian A, Mishra P.
to see children presenting with retractile testis into the scrotal sac. Testes congenital and childhood anomalies
absent testis. Once again, a ‘two- (https://abdominalkey.com/testes-
hand’ approach is recommended. In Acknowledgements congenital-and-childhood-anomalies;
neonates and infants, the inspection We would like to thank the Medical accessed 8 December 2021).
can be carried out in supine, frog- Education Department, Leeds 7. Davis JE. Scrotal Pain. In: Mahadevan SV,
legged position (Figure 7). Teaching Hospitals NHS Trust for the Garmel GM. An introduction to clinical
In a child with undescended use of their facilities, and thanks to emergency medicine. Cambridge:
testis, an inspection of the scrotum Limbs and Things for their scrotal Cambridge University Press, 2005;461–72.
may show a hypoplastic hemiscrotum examination model. 8. Shields L, White J, Peppas D. Scrotal
(Figure 8a). To locate the testis, the ultrasound is not routinely indicated in
the management of cryptorchidism,
deep ring should be occluded with a Declaration of interests
retractile testes, and hydrocele in
finger (Figure 8b–d), then gently milk Chandra Shekhar Biyani has received
children. Glob Pediatr Health 2019.
along the inguinal canal towards the a scrotal examination model from
doi:10.1177/2333794X19890772.
scrotum (Figure 8e–f). A testis may Limbs & Things on behalf of the 9. Parry N. Fournier gangrene. Clin Case
feel like movable ‘soft marble’ under Urology Simulation Boot Camp. Rep 2015;3:198–9.
the skin. An undescended testis 10. Mau EE, Leonard MP. Practical
may not reach the scrotal base; in References approach to evaluating testicular status in
contrast, a retractile testis will touch 1. Redmond EJ, Kelly NP, McCarthy C, infants and children. Can Fam Physician
the scrotal base. The squatting et al. Attitudes of GP trainees towards 2017;63:432–5.

wchh.onlinelibrary.wiley.com Trends in Urology & Men’s Health ❘ March/April 2022 ❙ 13