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Assessment of the Male Reproductive System

Pamela D. Ceo

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

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Table 1. the room during her husband’s Function of Male Genital Organs examination. Assessment of the male geni- Organ Function talia (see Figure 1) is accom- Penis Protects the urethra; houses the corpora caver- plished with inspection and pal- nosum which when engorged makes the penis pation. Normally, only examina- rigid and erect; prepuce protects the glans penis. tion gloves and water-soluble Scrotum Protective loose sac divided into two compart- lubricant are needed but a stetho- ments for the internal organs: testis, epididymis, scope and flashlight may be use- and vas deferens; temperature regulation of the ful if the scrotal examination is testes. abnormal. A stethoscope can be Testes Produce spermatozoa (seminiferous tubules) and used to listen for bowel sounds if testosterone. there is a concern for a hernia within the scrotal sac. The flash- Epididymis Storage and transport of sperm cells; sperm mat- light would be used to transillu- uration. minate the scrotum during an Ductus (Vas) deferens Cord-like structure that transports sperm from evaluation for a hydrocele. Prior the testis and epididymis into the urethra. to any examination, the index Spermatic cord Protects the ductus (vas) deferens, internal and can be measured and used external spermatic , of the vas, as a ruler to measure the penis, venous pampiniform plexus, vessels, and testes, and prostate. . With the patient in the Prostate gland Produces some of the seminal fluid; also pro- supine position, only the geni- duces a thin, white fluid that mixes with seminal talia are uncovered and two fluid to neutralize the urethra and to main- sheets are used, one to cover his tain sperm viability. chest/ area and the Seminal vesicles Produces most of the seminal fluid. 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 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 , 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 on pubic area at first, then becomes fuller lesions, folliculitis, scarring, (see Table 2). nodules, bulges, or scratch Adult Abundant in pubic area, coarser than hair on other parts marks (from a parasite). If the 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/ 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 , 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).

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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 (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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Shaft of Penis Table 7. The color of the skin on the Urethral Meatus shaft of the penis varies and the dorsal may be prominent. All ages The urethral meatus should be positioned centrally at the tip of the glans penis and appear as a pink slit. The skin is inspected for any lesions, scars, genital warts, rash, swelling, or noticeable nodules Table 8. (see Table 8). Shaft of Penis

Scrotal Sac All ages The skin of the shaft should be smooth to slightly wrinkled When the ambient air is and hairless. warm, the scrotal sac is more pendulous and the skin is smoother but when the ambient Table 9. air is cold, the scrotal sac Skin of the Scrotum/Perineum becomes contracted and the skin more wrinkled (see Table 9) Infant/Child Rugae (wrinkles or folds) skin surface, color pink in white (Swartz, 2002). Any rashes, geni- infants and dark brown in dark-skinned infants; perineum: tal warts, scars, lesions, or color moist and hairless. changes are noted. Sebaceous Adolescence Skin surface becoming coarser with more rugae and skin cysts are common; these are cysts pigmentation darkens, the skin contains both hair and that have a waxy appearance and sweat glands; perineum: hair growth to rectum. can become inflamed and drain a cheesy material. Pain, necrosis, Adult Skin slightly loose, skin surface coarse and with rugae, skin and swelling of the scrotal sac in darker than rest of body, the skin contains both hair and a diabetic male may be signs of sweat glands; perineum: hair growth to rectum; better Fournier’s gangrene; this is a uro- inspection with rectal examination. logic emergency. Any drainage, Geriatric Skin becomes pendulous and less rugae, skin color darker redness, bulges, lesions, or geni- than rest of body and skin with hair; perineum: hair growth tal warts on the perineum are to rectum; better inspection with rectal examination. noted. The anal area is stroked to elicit the anal reflex. The anus should contract quickly. Slow Table 10. reflex could indicate a disorder Contours of the Scrotum of the pyramidal tract (Engel, 2002). All ages The left testicle may be lower than the right and therefore If the scrotal sac appears appear asymmetrical. “sunken in” on one side or both sides, the testicle(s) may be absent; an underdeveloped, non- pendulous hemiscrotum com- nia (see Figure 2). soft, and without tenderness. monly indicates undescended In the elderly patient, thick- During palpation any tenderness, testis (see Table 10). If the scrotal ening of the scrotal sac may nodularity, or induration is sac is edematous it may be occur in association with fluid noted. Tenderness along the ven- indicative of a hernia or hydro- retention which can be associat- tral (underside) aspect of the cele. To differentiate between the ed with cardiac, renal, or hepatic penis is indicative of periurethri- two, a flashlight is placed against diseases (Gomella, 2002). Edema tis, which is often secondary to the scrotal sac posteriorly with may also occur in epididymitis or urethral stricture. The patient the room dark (transillumina- other local inflammation and should fill out the International tion). If there is a red glow, it is obstruction of the inguinal lym- Prostate Symptom Score (I-PSS), likely a hydrocele. No light will phatics (Jarvis, 2004). which is a helpful tool that transmit through a solid tumor. addresses bladder emptying, fre- Another way to differentiate PALPATON quency, intermittency, urgency, scrotal swelling is to “get above” stream, and nocturia. This the swelling. If this is possible, Penis should be assessed annually and the swelling is scrotal and if not, The penis is palpated using as needed. Curvature, nodularity, the swelling is inguino-scrotal the thumb and first two . or induration of the penis sug- and most likely an inguinal her- The penis should feel smooth, gests Peyronie’s disease. The

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patient is asked if he is able to Table 11. obtain an erection, and if so, Testes whether there is any pain or cur- Infant/Child Size 1.5 cm until puberty. vature. Adolescence/Adult Approximately 4.0 to 5.5 cm in length, 2.5 cm in Scrotum width. The skin of the scrotum is Geriatric Less firm and slightly smaller. palpated using the thumb and first two fingers. The scrotal sac Source: Rowland & Herman, 2002. is divided into two compart- ments. The contents should slide Table 12. easily. Abnormalities within the Normal Prostate scrotal sac are hydroceles and hernias. A hydrocele is a collec- 4 cm wide, 2.5 to 3.0 cm long tion of fluid that surrounds the testes, which can be transillumi- Source: Grayback, McVary, & Kozlowski, 2002. nated. Hydroceles can occur at any age. A hernia is a portion of bowel that protrudes into the sign of sexual maturation. This is absent, this is often associated scrotal sac. A hernia does not can occur as early as age 10 years with an absent kidney on the transilluminate but it may be (Engle, 2002). A small (<3.5 cm) same side (Swartz, 2002). The possible to auscultate bowel and soft testis may indicate atro- spermatic cord may become tor- sounds. phy as with cirrhosis, hypopitu- tuous which is a varicocele and itarism, or may occur following feels like a “bag of worms.” The Testes estrogen therapy or androgen spermatic cord may also form a The testis is palpated gently blockade. If the testis is smaller cyst after a vasectomy that is with the thumb and first two fin- than 2 cm and alopecia in the painless and contains sperm gers (see Table 11). Each testis is pubic region is noted, suspect (spermatocele). palpated separately; they should Klinefelter’s syndrome (hypogo- be ovoid, firm and smooth, much nadism) (Jarvis, 2004). Inguinal Area/Lymph Nodes like a hard-boiled egg. The testis The inguinal area is palpated should feel suspended and move Epididymis/Ductus (Vas) for pulses, using the pads of the easily in each sac. The testes Deferens/Spermatic Cord index, middle, and ring fingers. should have the same consisten- The epididymis is located on Decreased or absent pulses may cy and be nearly the same size. A the posterior aspect of the testes. indicate a vascular problem. The firm nodule may indicate a tes- It is palpated gently with the inguinal (superficial) and subin- ticular tumor. The testes can thumb and first two fingers. The guinal (deep) lymph nodes are become infected (orchitis). epididymis should be nontender, palpated. The lymph nodes are To prevent the creamateric smooth, and feel softer than the usually not felt. An enlarged reflex during palpation in infants testes. Palpate upwards toward lymph node may represent and young children, either a fin- the inguinal ring using only the inflammation or metastatic dis- ger is held over the inguinal thumb and index finger to feel ease spread from the genital or canal while palpating the scrotal the ductus (vas) deferens. It peri-anal area. Note any tender- sac or have the child sit cross- should feel smooth and be non- ness and size of lymph node. legged. Inability to palpate a tender. It feels like partially testis in an infant may indicate cooked spaghetti and is about 2 Prostate and Seminal Vesicle cryptorchidism (undescended mm to 4 mm in diameter. A normal prostate feels sym- testis) and the testis may be pal- Upward, a thicker cord (spermat- metrical, smooth, rubbery, with- pated in the inguinal canal. The ic cord) is felt. It should also be out tenderness and the median testis may descend on its own as smooth and nontender. Palpate sulcus is palpable; benign dis- the infant grows. If it has not the right side first, then the left ease feels like the tip of a nose descended by 1 year old, surgical side. whereas a cancerous nodule feels correction should be done Abnormalities are infection more like a (see Table (McAninch, 2000). If the cryp- of the epididymis, ductus (vas) 12). The prostate may also feel torchid testis is not corrected, the deferens, and spermatic cord. flat, indurated (hardened), boggy male is at a higher risk of infertil- The epididymis can also be (spongy), or enlarged. Seminal ity and testicular cancer. nodular, which may be indicate a vesicles lie cephalic to the Testicular growth is a visible cyst or tumor. If the vas deferens prostate, are about 6 cm long and

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soft, normally nonpalpable; if is instructed to bear down, as if he assessment (3rd ed.) (pp. 496-514). they are palpable, this may be were having a bowel movement. St. Louis: Mosby. Engel, J. (2002). Reproductive system. In J. suspicious for cancer. This relaxes the rectal sphincter Engel (Ed.), Pocket guide to pediatric The digital rectal examina- and allows for easy insertion of assessment (4th ed.) (pp. 215-229). tion should be explained to the the finger. The index finger is St. Louis: Mosby. patient. Advise him to report any inserted as far as possible, as the Gomella, L. (2002). The 5-minute urology tenderness or pain experienced patient relaxes and breathes consult (1st ed.) (pp. 30, 344). Philadelphia: Lippincott, Williams & during the examination. The deeply. The sphincter tone is Wilkins. location of any significant dis- noted and the prostate is palpated Grayback, J., McVary, K., & Kozlowski, J. comfort or abnormality is identi- using the finger as a ruler to assess (2002). Benign prostatic hyperplasia. fied by using the of a clock the size of the gland (side to side In J. Gillenwater, J. Grayhack, S. Howards, & M. Mitchell (Eds.), Adult as a reference point (for example, and top to bottom). With slight and pediatric urology (4th ed.) (pp. the lesion is at the 3 o’clock posi- pressure, palpate the lateral right 1401-1470). Philadelphia: Lippincott, tion on the rectum). The width of side from top to bottom (base to Williams & Wilkins. the clinician’s index finger (usu- apex), move the finger to the cen- Grigg, E. (2000). Sexually transmitted ally about 1.5 cm-2 cm) and the ter, which should dip down infections and older people. Nursing Standard, 14(39), 48-53. length of the finger can be mea- (median sulcus), and continue to Jarvis, C. (2004). Male genitalia. In C. Jarvis sured and used as a reference to move to the lateral left side, pal- (Ed.), Physical examination and help measure the prostate. pating from top to bottom. health assessment (4th ed.) (pp. 721- If the patient is unable to Normally the seminal vesicles are 748). St. Louis: W.B. Saunders. Marieb, E. (2006). Essentials of stand, the rectal examination can not palpable. The prostate should anatomy & physiology (8th ed.) (pp. be done in either the Sims’ or dor- be symmetrical, feel smooth, rub- 528-563). San Francisco: Pearson sal recumbent position. To place bery, and without tenderness. The Education, Inc. the patient in the Sims’ position, prostate may be enlarged especial- McAninch, J. (2000). Disorders of the he should lie on his left side with ly if the male is older. Prior to testis, scrotum and spermatic cord. In E. Tanagho & J. McAninch (Eds.), his right and , flexed as removing the finger, palpate the Smith’s general urology (15th ed.) much as possible, over his left leg, rectal wall for nodules and ten- (pp. 684-693). New York: Lange which is also partially flexed. To derness. This completes the digi- Medical Books/McGraw-Hill. place the patient in the dorsal tal rectal examination. Pulsifer, A. (2005). Pediatric genitourinary examination: A clinician’s reference. recumbent position, have him lie Any stool on the gloved finger Urologic Nursing, 25(3), 163-168. on his back with his and should be checked for occult Rosen, R., Cappalleri, J., Smith, M., Lipsky, bent (flexed), and feet flat blood. Either the rectum is wiped J., & Pena, N. (1999). Development and on the examination table or mat- free of lubricant with a tissue or evaluation of an abridged, 5-item ver- tress (if the patient is in the bed). the tissue is offered to the patient. sion of the International Index of Erectile Function (IIEF-5) as a diagnos- Otherwise, have the patient stand The patient is allowed to stand up tic tool for erectile dysfunction. on the floor. The scrotal sac is and get dressed. International Journal of Impotence inspected again since hydroceles Research, 11, 319-326. and hernias may be more promi- Conclusion Rowland, R., & Herman, J. (2002). Tumors and infectious diseases of the testis, nent in the standing position. Any No matter how long a clini- epididymis, and scrotum. In J. abnormalities not detected earlier cian has been performing a male Gillenwater, J. Grayhack, S. Howards, with palpation are noted. The genital examination, there can be & M. Mitchell (Eds.), Adult and pedi- patient should turn around facing some level of discomfort or anxi- atric urology (4th ed.) (pp. 1897- the examination table for the ety from the clinician, the nurse 1934). Philadelphia: Lippincott, Williams & Wilkins. prostate examination. The patient (male or female), or the patient. Shamloul, R. (2005). Treatment of men is told to bend forward (flexing at Confidence and competence in complaining of short penis. Urology, hips) and rest his and the physical examination tech- on the table while bending nique takes time to accomplish. his knees slightly. The patient is There may also be unusual find- CE test located on page 297. advised that the examination is ings on the genitals such as tattoos about to begin. The are and/or piercings. The clinician spread to inspect the rectal area should always remain profession- 65(6), 1183-1185. for hemorrhoids, genital warts, al and nonjudgmental. It is impor- Swartz, M. (2002). Male genitalia and her- nias.Need In M. SwartzCE Credit? (Ed), Textbook of discharge, or rashes. The rectal tant to chart what is seen, what is physical diagnosis history and exam- area is palpated for nodules and felt, and what the patient reports. Visitination the(4th “Education” ed.) (pp. 461-494). tenderness. The clinician’s gloved • Philadelphia: W.B. Saunders. index finger of the dominant section at is lubricated. The clinician places References it at the anal verge and the patient Barkauskas, V., Baumann, L., & Darling- www.suna.org Fisher, C. (2002). Health and physical

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