Male Genital Examination
It is not uncommon for patients to feel uncomfortable during
this portion of the exam. It can be embarrassing to have your genitals examined
in a way that you probably wouldn't do yourself, and it may be uncomfortable to
be in a position with your pants and underwear pulled down. As a physician I try
to do this examination as quickly as possible to minimize exposure of the
genitals, and I always wear gloves when examining patients. If your physician
fails to wear gloves when examining your genitals, you should ask him to do so.
This is similar to a dentist examining your mouth without a glove, or a
gynecologist not wearing gloves. It is inappropriate.
When checking the groin I look for evidence of bulges that can
indicate hernias. I then feel the spermatic cords. These are the structures that
carry blood to and from the testes and that also contain the tube called the vas
I then examine the testicles. It is important to note their size
and any adjacent structures. Testicles are roughly 4 cm in length and
approximately the size of a small egg. They should be smooth and their
examination should not be tremendously uncomfortable.
At this point I try to teach the patient what some of the other
lumps and bumps of the scrotum are. This way, the patient can familiarize
himself with what is a normal finding and what is abnormal. I always show the
patient what a normal testicle examination should be like, and I strongly
encourage monthly self-examinations.
I then examine the scrotum for evidence of rashes or infections.
Scrotal skin is typically hair bearing, and depending upon the temperature of
the room, may be contracted or relaxed. In some older men, the scrotum may be so
relaxed that it almost hangs down to the level of the kneecaps. I recommend
tighter underwear for men whose scrotums hang very low.
Long-term usage of boxer shorts tends to produce more problems
with the scrotum with rubbing on the inner side of the thighs. The structures
behind the testicles called the epididymis, a single coiled tube that carries
sperm from the testicles to the vas deferens, are a frequent site of
inflammation and enlargement. A cystic enlargement of this area in which fluid
may be trapped and then stored is known as a spermatocele. Spermatoceles may
become extremely large in size. I check the scrotum for the presence of small
cystic structures called sebaceous cysts. These cysts have a waxy appearance,
and they become inflamed and drain a cheesy material.
Additionally, fluid may collect around the testicle itself. This
fluid collection is known as a hydrocele, which is distinct from the
spermatocele. The difference lies in the position. A spermatocele usually sits
above and behind a testicle, whereas a hydrocele lies in front of and
encompasses the entire testicle. The hydrocele fluid collection can become
massive, and its size alone can not only be a cause of embarrassment, but a
physical impediment to intercourse by causing concealment of the penis.
If left untreated, fluid collections in the scrotum can come
close to the size of basketballs and totally conceal the penis. I see this at
least once or twice a month in my practice. These men, for a variety of reasons,
will choose to live with this problem and avoid sexual intercourse. This
condition is completely treatable by a simple surgical procedure, and it should
not be an impediment to satisfactory sexual intercourse.
Testicles that are poorly developed or have been damaged may be
a consequence of either testicle surgery or damage during vasectomy. More
commonly this is the result of a mumps infection. Small testicles are termed
atrophic. They can frequently be poor producers of testosterone.
If the penis is uncircumcised, I check whether the foreskin
easily pulls up and back on the glans. If the skin is tight and it is not
possible to pull the foreskin back, this is a condition called phimosis.
Phimosis makes it extremely painful to get an erection and may be the cause of
erectile dysfunction in some instances. I pull the foreskin back and examine the
moist inner side of the foreskin for lesions, such as early cancers or venereal
warts. Small firm bumps on the rim of the head of the penis, known as the
corona, are hirsutoid papillomas. This upsets many men who believe that this is
a venereal disease, but they are quite common. Men who examine their penis can
identify the location and duration of many of the small bumps and whether they
have been present their entire lives.
I inquire about any discoloration or small birthmarks on the
penis itself and how long the mole or discoloration has been present. Any mole
that changes color or consistency or bleeds easily needs to be biopsied.
I next examine the urethral meatus, the opening where the urine
comes out at the tip of the penis. I check its size and evaluate to see if it
has been narrowed or scarred. I always make sure that I can retract both edges
and examine the inside of the urethra since this is a common site for venereal
warts and discharges from sexually transmitted diseases.
An infection on the head of the penis is known as balanitis. The
most common cause of balanitis is a yeast infection. This is prevalent in men
with diabetes due to the high concentration of sugar in the urine that promotes
the growth of yeast under the foreskin causing infection. Balanitis can also be
transmitted from a sexual partner who has a yeast infection. It is generally
painful and is treated with topical creams to prevent infection. If the creams
do not get rid of the infection, then a procedure known as a circumcision is
performed in which the outer foreskin that covers the head of the penis is cut.
Circumcision was once a common operation in newborn babies, but it is being
performed less often because of concerns that it is painful for the infant.
I also gently pull on the penis to see how mobile it is. Certain
scarring conditions can cause the penis to be rigid and not allow it to be
pulled in a gentle fashion. I feel the shaft of the penis for evidence of
Peyronie's plaques and evaluate whether the superficial veins have become
fibrotic or cordlike. These cords always run in a vertical fashion on the penis
instead of around the penis. Any changes are usually the consequence of minor
trauma during sexual intercourse.
An optional part of the physical examination is to test the
sensation of the glans penis. The head of the penis has a number of receptors
for increased sensation or sensitivity. Most men don't realize that the majority
of sensation of their penis is actually on the glans. The shaft of the penis has
relatively few receptors for sensation. The uncircumcised head of the penis is
generally much more sensitive because the head is always covered by foreskin.
This prevents it from chronic rubbing on clothing and dulling of the sensation.
The final part of the external exam is to feel the area between
the rectum and the scrotum known as the perineum. In doing so, I am looking for
infected cysts, lesions, or draining sinuses. A draining sinus is an area that
drains from the rectum outside the anus to an area in the perineum. This is a
condition that may be seen with certain inflammatory diseases of the bowel and
can be an extremely painful situation.
E.B. was a twenty-nine-year-old man brought by his wife because
of decreased sexual desire. History indicated that he had mumps as a teenager
and that he had never really been sexually active or interested in sex. Upon
examination, he was found to have sparse facial and body hair and a normal-sized
penis, however, both testes were smaller than peas. In this situation, the
diagnosis of mumps orchitis was made. Treatment with testosterone replacement
showed dramatic results.
A digital rectal examination involves inserting a gloved
lubricated finger in the rectum to check not only the tone of the rectum and
anus but also the prostate and for the presence of any other rectal or anal
There should be sufficient tone in the rectum so that it is
tight around the examiner's finger. Decreased tone indicates either a neurologic
problem or a situation where the rectum is chronically dilated, a result of anal
intercourse or chronic insertion of foreign bodies into the rectum. Sometimes
the anal sphincter is so tight that digital penetration is not possible. This is
either a consequence of being unable to relax during the examination or a result
of a spinal condition or nerve damage. The reflex known as the bulbocavernosus
reflex is elicited by squeezing the head of the penis briskly with the finger
and causing the anal sphincter to contract suddenly around the finger in the
rectum. It is generally quite noticeable. Hyperreflexia, or an abnormal
bulbocavernosus reflex, generally occurs from certain nervous conditions such as
multiple sclerosis. Hyperreflexia refers to reflexes that are much more vigorous
than normal. For instance, if you tap your knee, your foot will reflexively kick
outward. Hyperreflexia means that the foot kicks out much higher and faster than
I also evaluate for the presence or absence of stool in the
rectum. Chronic constipation can cause the rectum to be extremely dilated
resulting in blockage, or fecal impaction. Hemorrhoids are also detectable at
this point, both external and internal. Patients who have had prior surgery to
the anus may have scarring or strictures that prevent rectal examination.
An examination of the prostate includes all areas of the
prostate. In thin individuals, I am frequently able to feel the top of the
prostate in the area called the seminal vesicles. If this area is inflamed, the
ejaculate may be bloody, a condition known as seminal vesiculitis.
I then feel the blood vessels in the groin, including the major
artery that runs from the groin to the legs called the femoral artery. A
decreased pulse in this area may be an important clue that there is decreased
blood flow to the bottom half of the body. This finding may also be an
indication as to the cause of erectile dysfunction. Examination of the legs
often reveals evidence of severe diabetes or decreased blood flow. These are
also important clues in the workup of erectile dysfunction.
P.F. was brought by his wife for evaluation of potential
erectile dysfunction. The patient's wife was a registered nurse who reported
that her husband had good desire but difficulty completing the act of
intercourse. Physical examination disclosed a congenital abnormality of the
penis where the urinary opening actually opened toward the base of the penis, a
condition called hypospadias. When he achieved an erection, it was so bent that
it precluded adequate vaginal penetration. The situation was easily remedied by
surgery. Interestingly, the patient's wife had seen numerous normal penises as a
nurse. They had been married several years before this condition became a
problem and vaginal penetration was not part of their lovemaking. Apparently,
she was now interested in becoming pregnant, which was what precipitated the
visit to the clinic.
Remember, the physical examination is extremely important and
should complement the medical history. It is important that the physical
examination be complete. If the physician fails to examine the prostate or does
only a cursory examination, then obtain another opinion.
One of the most common questions patients ask me is, "What is a
normal-sized penis?" There really is no consensus on how to measure the penis,
but generally speaking, an adequate penis is defined as one that allows
penetration of the vagina sufficient enough to permit fertilization and the
ability to stand upright to urinate. When these two criteria are met, the penis
is an adequate size.
A flaccid and an erect penis differ tremendously in length.
Measurement of a flaccid penis is not a good predictor of the length of an erect
penis. Actual penile length measurement should be made with a full erection with
a rigid ruler starting at the top of the penis between the tip to the point
where the penis anchors the body at the bone, called the symphysis pubis. It is
extremely important not to include the foreskin, especially in men who have
elongated droopy foreskin. It is also important to avoid as much of the
superficial fat as possible.
Studies show that the typical erection is roughly 5 inches in
length, and I would certainly concur with this in my own busy urologic practice.
The amount of body fat dictates the length of the penis as well. A general rule
of thumb is that for every 30 pounds over ideal body weight, one can generally
expect to lose an inch of penis size. The penis does not actually shrink, but
more of it is concealed under a layer of fat. The more fat that surrounds the
base of the penis, the less that length is apparent. While it is unusual to see
a very large penis on an obese man, it is also true that a short penis can look
quite long on an extremely thin man.
I look at the physical examination as a "blue light special." It
allows me the opportunity to do a complete physical examination of a man who
probably otherwise would never get a complete physical.
A careful history and physical examination is essential in
determining the etiology of the erectile dysfunction. Laboratory tests should
only be performed when the history and physical examination determine the need