Physical Assessment of the Male Genitalia

Anatomy Review INSPECTION:

• Penis TANNER SCALE

• Scrotum
Testis
Epididymis
Spermatic cord
Muscle layer
Prostate gland

Minimizing the Patient’s Anxiety

✓ Be open, direct, and reassuring
✓ Know the language and use it effectively
✓ Do not apologize
✓ Never make jokes
✓ Light, casual talk or jokes about genitalia or
sexual function are inappropriate
✓ Be mindful of your facial expression

Male Genitalia & Hernia Assessment: History

• Present Problem
o Erectile dysfunction
o Difficulty with ejaculation Inspection and Palpation
o Discharge or lesion on penis
o Infertility with pt. standing
o Enlargement in inguinal area Have a chaperone in the room for the exam:
o Testicular pain or mass • Pubic hair
• Past Medical History • Penis Glans
o Surgery of GU tract o Dorsal vein
o STDs o Uncircumcised
o Chronic illness o Retract foreskin
o Medications o Inspect glans
• Family History - smegma
o Infertility in siblings - lesions
o Hernias o Circumcised
• Personal & Social History o Inspect glans
o Employment: trauma risk - Color and texture
o Exercise: protective device • Urethral meatus
o TSE practices o Shape
o Concerns about sexual practices - Slit like
o Reproductive function • Location
o Use of alcohol, cigarettes & street drugs o Ventral surface close to tip of glans
• Color/discharge
• Penile shaft
o Tenderness, induration
o Strip urethra for discharge
o Nodules
o Replace foreskin!
 Testicular Self-Examination (TSE): Step 1
• Scrotum ◼ Look for swelling. Hold your penis out of the
o Color way and examine the skin of the scrotum.
o Texture
o Asymmetry
o Swelling
o Masses
o Tenderness
o Rashes/lesions
• Scrotal Contents
o Testes, Epididymis, Vas deferens
- Consistency
- Size
Testicular Self-Examination (TSE): Step 2
- Tenderness
◼ Examine each testicle. Using both hands,
- Nodules
place your index and middle fingers under the
- Transillumination prn
testicle and your thumbs on top.
Inspection: Trans-illumination prn:

To assess masses, swelling

Strong penlight placed behind scrotum
Red glow seen in fluid filled masses
o Hydrocele, spermatocele
No glow seen:
o in solid masses
Testicular Self-Examination (TSE): Step 3
o hernias,
o tumors, ◼ Gently roll the testicle between your thumbs
o orchitis and fingers. Look and feel for any changes to
your testicle. These could include hard lumps,
Testicular Self-Examination (TSE) smooth rounded bumps, or new changes in
Bates text- p. 555- the size, shape or consistency of the testicle.

“Although the USPSTF and the American

Cancer Society have not recommended
routine TSE for screening, the clinician and the
patient may wish to teach the TSE to enhance
health awareness and self-care”
✓ Why: Testicular cancer is the most
common cancer of men ages 15-34
(estimated lifetime risk of 1:260)
✓ When: 1 x each month; Best to perform
after a warm bath or shower, while
standing and in front of a mirror
✓ When to see a provider: Any hard lump,
absent or enlarged testicle, painful or
swollen scrotum or any other abnormality
 INSPECTION AND PALPATION SOME ABNORMALITIES

◼ Hernia Scrotal Masses

• Have pt stand and bear down
⧫ Inspect ◼ Varicocele - varicose veins of the spermatic
cord. Feels like a soft “bag of worms”. May be
• Have pt relax
associated with pain or heaviness, but often
Insert finger into the lower part of scrotum and
asymptomatic.
follow the spermatic cord up towards the inguinal
canal, until your finger reaches the external ◼ Hydrocele - Non tender, fluid-filled mass
inguinal ring within the tunica vaginalis (serous covering of
the testes). Transilluminates. Common in
◼ Elicit the cremasteric reflex infancy but can occur at any age.
◆ If neurologically intact, stoking the inside ◼ Orchitis - acute inflammation of the testis-
of the thigh will cause the ipsilateral swollen, tender/painful, with possible
testicle to retract in the scrotum erythema. Seen with mumps and other viral
infections- usu. unilateral
INDIRECT VS. DIRECT HERNIA
◼ Tumors - usually non-tender, Irregular, hard
◼ Indirect- Most common, all ages, often in mass fixed on the testes. Does not
children. Above the inguinal ligament, near transilluminate. Must rule out malignancy. Is
internal inguinal ring. Often into the scrotum. the most common tumor in males ages 15 to
34.
◼ Direct- Usually occur in men over 40 yrs.
Above the inguinal ligament, near the pubic Acute Testicular Swelling/ Pain
tubercle and the external inguinal ring. ◼ Torsion
o twisting of testis on spermatic cord
◼ Femoral- Least common. More common in
o most common in newborns to adolescences
women than men. Below the inguinal
but can occur at any age.
ligament; more lateral.
o acute onset of pain
o scrotum often becomes red and edematous
o vomiting & anorexia are common
o fever & dysuria are uncommon
o no cremasteric reflex on affected side
SEXUALLY TRANSMITTED DISEASES
Chlamydia

- Urethral discharge- cloudy or clear (watery

or milky)
- Dysuria
INSPECTION AND PALPATION OF INGUINAL NODES - Pain or swelling in one or both testicles
• Small, shotty nodes are common
Gonorrhea
• Enlarged, tender nodes often associated with
o Viral STI’s such as HSV - Urethral discharge- green, yellow or white
o Chancroid - Dysuria
• Enlarged, discrete, firm, rubbery, non-tender - Pain or swelling in one or both testicles
often unilateral nodes associated with - Majority of men show no symptoms
• Syphilis
 PHYSICAL EXAMINATION
Syphilitic Chancre INSPECTION
◼ General Considerations
• Primary stage - chancre- 3 weeks to 3 months o Be calm, slowly paced, and gentle
after infection o Explain what you are going to do step by step
• Secondary stage - rash, flu like symptoms- up o Use appropriate draping but retain good
to 2 years visualization
• Late stage- damage to the neurologic o Glove both hands
symptoms: tumors, blindness, paralysis,
death- 10-20 years after infection ◼ Positioning
• Males
Genital herpes o Left lateral with top hip and knee flexed
o Standing, flexed at waist with upper body
Pediculosis Pubis supported on exam table, toes together
- Also known as “crabs”. and knees slightly flexed
ANATOMY REVIEW • Females
o Most often done as part of the
◼ Prostate rectovaginal exam in the lithotomy
◼ Rectum position
◼ Anus ◼ Sacrococcygeal & Perianal Area
o Skin characteristics
o Lesions
o Pilonidal dimpling & tufts of hair
o Inflammation
o Excoriation
◼ Anus
• Skin characteristics
o Lesions, fissures, hemorrhoids or polyps
HISTORY
o Fistulas
◼ Present Problem o Prolapse
o Changes in bowel function • Ask patient to bear down…repeat
o Anal discomfort inspection
o Rectal bleeding PALPATION
o Males: changes in urinary function ◼ Sphincter
◼ Past Medical History o Lubricate index finger
o Hemorrhoids o Place pad of finger over anus as patient
o Spinal cord injury strains down . . . insert fingertip as patient
o Males: prostate hypertrophy or cancer relaxes
o Females: cancer, episiotomy/lacerations o Ask patient to tighten external sphincter
o Risk factors for colorectal cancer (see p. 468 around finger
in Bates) - assess tone, tenderness, lesions
◼ Family History ◼ Anal Ring
o Rectal polyps o Rotate finger
o Colon cancer - note: smoothness, evenness
o Colon or prostate cancer ◼ Lateral and Posterior Rectal Walls
◼ Social History o Insert finger farther
o Travel history o Rotate hand clockwise
o Diet/ use of alcohol and counterclockwise
noting
- nodules, masses, polyps
- tenderness
 - irregularities • American Urological Association BPH Sx Score
◼ Anterior Rectal Wall Index:
o Same procedure with patient bearing • 7 questions- rank Sx 0-5- the higher the score,
down the more severe the Sx.
- nodules
- tenderness PROSTATITIS SYMPTOMS
◼ Prostate • Symptoms of acute prostatitis can start
o Palpate the posterior surface of the quickly, and can include:
prostate through the anterior rectal wall • Chills
noting: • Fever
- Size and symmetry- 4 x 3 x 2cm • Flushing of the skin
- Contour • Symptoms of chronic prostatitis are similar,
- Consistency but not as severe. They often begin more
- Mobility slowly:
- Tenderness • Blood in the urine
- Nodules • Burning or pain with urination (dysuria)
- Median sulcus- palpable? • Difficulty starting to urinate or emptying the
o Normal is firm, smooth (like a pencil bladder
eraser) and nontender • Foul-smelling urine
◼ Slowly withdraw finger
• Weak urine stream
◼ Examine any fecal material
• Other symptoms that may occur with this
o color
condition:
o consistency
• Pain or achiness in the abdomen above the
o blood or pus
pubic bone, in the lower back, in the area
◼ Test stool for occult blood using chemical
between the genitals and anus, or in the
guaiac test
testicles
PROSTATE DISORDERS • Pain with ejaculation or blood in the semen
• Pain with bowel movements
• Benign Prostatic Hypertrophy (BPH) - may
feel enlarged, smooth, and firm with
obliteration of the median sulcus
• Prostatitis - may be tender, swollen, boggy
and warm
o Acute - bacterial
o Chronic - may be bacterial or non-bacterial
• Prostate Cancer - hard, irregular, painless
nodule
• See p. 623 of Bates text- Abnormalities of the
Prostate

GENERAL SYMPTOMS OF BPH

• Urinary Frequency; Nocturia
• Urinary Urgency
• Change in stream
– Weak
– Difficulty starting
– Post void dribbling
– Incomplete emptying of the bladder
• Dysuria
 Physical Assessment of the Female Genitalia

THE EXTERNAL FEMALE GENITALIA • Cervix

TERMINOLOGY - A smooth doughnut-shaped area with a small
• Vulva circular hole or os, found at the end of the
- (or pudendum) The external genitalia. canal that leads into the uterus.
• Mons pubis • Anterior fornix
- A round, firm pad of adipose tissue covering - A continuous recess, present in front of the
the symphysis pubis. cervix.
• Labia majora • Posterior fornix
- Two rounded folds of adipose tissue - Continuous recess found in back of cervix.
extending from the mons pubis down and • Rectouterine pouch, or cul-de-sac of Douglas
around to the perineum. - Found behind the posterior fornix, a deep
• Labia minora recess, formed by the peritoneum, dips down
- Two smaller, darker folds of skin inside the between the rectum and cervix.
labia majora. • Uterus
• Frenulum - A pear-shaped, thick walled, muscular organ
- A transverse fold which joins the labia minora which a fetus develops. Flattened
posteriorly. anteroposterior, measuring 5.5 to 8 cm by 3.5-
• Clitoris 4 cm wide, and 2-2.5 cm thick.
- A small, pea –shaped erectile body, • Fallopian tubes
homologous with the male penis and highly - Two pliable, trumpet-shaped tubes, 10 cm
sensitive to tactile stimulation. long, extending from the uterine fundus
• The labial structures encircle a boat-shaped laterally to the brim of the pelvis. Transports
space termed the Vestibule. an egg cell from the region of the ovary to the
• Urethral meatus uterus.
- A dimple 2.5 cm posterior opening posterior • Ovaries
to the clitoris. - The primary reproductive organ of the
female; An egg-cell producing organ which is
oval shaped, 3 cm long by 2 cm wide.

Equipment For Female Examination

• Gloves
THE INTERNAL FEMALE GENITALIA • Protective clothing
TERMINOLOGY • Vaginal Speculum of appropriate size
• Vagina • Large cotton-tipped applicators (rectal swabs)
- A flattened, tubular canal extending from the • Materials for cytologic study:
orifice up and backward into the pelvis. Leads • Glass slide with frosted end
into the female reproductive tract. • Sterile Cytobrush or cotton-tipped applicator
• Rugae • Ayre’s spatula
- Thick transverse folds which enable the • Spray fixative
vagina to dilate widely during childbirth. • Specimen container for gonorrhea
Cx/chlamydia
• Small bottle of normal saline, potassium ◼ Abnormal Findings:
hydroxide, and acetic acid (white vinegar) Inspection:
• Lubricant Note:
• Refer any suspicious lesion for biopsy
POSITIONING FOR FEMALE EXAMINATION
• Consider delayed puberty if no pubic hair
1. Begin with woman in sitting position to or breast development has occurred by
establish equal status and trust. age of 13.
2. Place woman in lithotomy position, with the • Nits, or lice at base of pubic hair
examiner sitting on a stool. • Swelling
3. Help the woman into position, feet in stirrups,
knees apart, and buttocks at edge of ◼ Normal Findings:
examination table. • No lesions, except for occ. Sebaceous
4. Arms should be at the woman’s sides, not cysts. (With gloved hand separate labia
across chest or over the head. majora to inspect).
5. Drape the woman fully, covering the stomach, • Clitoris
and legs, exposing only the vulva to your view. • Labia minora- dark pink, and moist,
usually symmetric.
• Urethral opening appears stellate or slit
like, midline.
• Vaginal opening (introits) may appear as
narrow, vertical slit or as a larger opening.
• Perineum-smooth. A well-healed
TECHNIQUES episiotomy scar, midline or mediolateral
• Have woman empty bladder. following vaginal birth.
• Position the exam table so her perineum is not • Anus- course skin of increased
exposed to inadvertent open door. pigmentation.
• Ask if she would like a friend, family member
present. ◼ Abnormal findings:
• Elevate her head and shoulders to a semi- • Excoriation, nodules,
sitting position to maintain eye contact rash, or lesions.
• Place stirrups so the legs are not abducted too • Inflammation or lesions.
far. • Polyp
• Explain each step in the exam before you do it. • Foul-smelling, irritating discharge.
• Assure the woman she can stop the exam at
any point she should feel uncomfortable. PALPATION
• Use a gentle, firm, touch, and gradual ◼ Normal Findings:
movements. • Assess the urethra & Skene’s glands with
• Communicate throughout the exam. Maintain gloved finger.
dialogue to share information. • Asses vagina, gently milk the urethra by
applying pressure up and out.
ASSESSMENT OF THE FEMALE GENITALIA • Assess Bartholin’s glands, post. Of labia
◼ Normal Findings: majora with index finger inside and
Inspection: thumb outside. Should feel soft and
Note: homogeneous.
• Hair distribution- usual pattern • Assess pelvic musc. by
• Skin color, no lesions of inverted triangle. 1. Palpate perineum, should feel thick, smooth,
• Labia Majora symmetric, plump, and well and musc. In nulliparous, thin and rigid in
formed. Nulliparous woman, labia meet multi-parous.
in midline; following vaginal delivery, 2. Ask woman to squeeze vaginal opening
labia are gaping and slightly shriveled. around fingers, should feel tight in nulliparous.
3. Separate the vaginal orifice and ask pt. to ◼ Abnormal Findings:
strain down. No bulging of vaginal walls or • Redness, inflammation
urinary incontinence. • Pallor wit anemia, cyanotic other than
with pregnancy.
◼ Abnormal Findings: • Lateral position- adhesion or tumor.
• Tenderness Projection >3 cm may be prolapsed.
• Induration along urethra, pain, urethral • Hypertrophy > 4 cm occurs with
discharge inflammation or tumor.
• Swelling, induration, pain with palpation, • Surface reddened, granular, asymmetric,
erythema around or discharge from duct around os.
opening • Friable, bleeds easily.
• Tenderness, paper thin perineum, absent • Any lesions: white patch on cervix,
or decreased tone may diminish sexual strawberry spot.
satisfaction. • Refer any suspicious, red, white, or
• Bulging of vaginal walls indicates pigmented lesion for biopsy.
cystocele, rectocele, or uterine prolapses.
• Urinary incontinence INSPECT THE VAGINAL WALL
◼ Normal Findings:
Speculum Examination • As you remove the speculum, inspect
vaginal wall. Pink, deeply rugates, moist,
o Warm and lubricate speculum under warm smooth, normal discharge thin, clear,
running water. opaque, stringy, odorless.
o Avoid gel lubricant – bacteriostatic, distorts ◼ Abnormal Findings:
cell in cytology specimen collected. • Inflammation, lesions.
o Insert by asking woman to bear down. Relaxes • Leukoplakia, appears as spot of dried
perineal muscles and opens introitus. paint.
o Insert speculum at 45-degree angle downward • Vaginal discharge: thick, white, curd-like
toward the small of woman’s back. with candidiasis, profuse, watery, gray-
o After blades are fully inserted, open them by green, frothy with trich.; or gray, green-
squeezing handles together. yellow, white, or foul odorous discharge.
o Cervix should be in full view.
o Try closing blades by tightening the BIMANUAL EXAMINATION
thumbscrew.

INSPECT THE CERVIX AND ITS OS

◼ Normal Findings:
• Color: normally pink, even; 2nd month
preg. Blue (Chadwick’s sign); past
menopause-pale.
• Position: midline, anterior or post.
Projects 1-3 cm into vagina.
• Size: Diameter-2.5 cm (1”).
• OS: Small, round in nulliparous, horizontal Technique of exam:
irreg. slit, may show healed laceration on 1.Lithotomy position,
sides. 2.lubricate fingers of gloved hand.
• Surface: Smooth, eversion, or ectropion, 3. Insert fingers into vagina posteriorly.
past vaginal delivery; 4. Use both hands to palpate internal genitalia to
• Endocervical canal everted or rolled out. assess location, size, & mobility, screen for
Red, beefy halo inside the pink cervix tenderness or mass.
surrounding os.
 RETROVAGINAL EXAMINATION
5. One hand is on the abdomen, the other into the Technique:
vagina. 1. Use this tech. when assessing rectovaginal
6. Palpate the vaginal wall. Should feel smooth, no septum, post. Uterine wall, cul-de-sac, and
area of induration or tenderness. rectum.
7. Locate cervix in midline. Palpate using palmar 2. Change gloves- avoids spreading poss.
surface of fingers. Note consistency. Infection.
3. Lubricate first two fingers.
◼ Normal findings of cervix: 4. Instruct pt. poss. Feeling of discomfort.
• Consistency: smooth, firm, tip of nose. 5. Ask pt. to bear down as fingers are inserted
Softens, feels velvety at 5-6 weeks gest. into vagina, middle finger is gently inserted
(Goodell’s sign). into rectum, while pushing with abdominal
• Contour: Evenly rounded. hand.
• Mobility: With finger on either side, move 6. Note: Rectovaginal septum-smooth, thin, firm,
cervix gently from side to side. No pain. pliable.
7. Rectovaginal pouch, or cul-de-sac- not
◼ Abnormal findings of cervix: palpated.
• Nodule, Tenderness. 8. Uterine wall and fundus feel firm, smooth.
• Hard with malignancy, Nodular, Irregular, 9. Rotate intrarectal finger to check rectal wall
Immobile with malignancy. and anal sphincter tone.
10. Give pt. tissue to wipe area, help her up.
PALPATION OF PELVIC ORGANS Remind her to slide hips back from edge
1. Palpate Uterus with intravaginal fingers in ant. before sitting up.
fornix. Palpate with abdomen Hand midway
ABNORMAL FINDINGS OF EXTERNAL GENITALIA
between umb. And symphysis.
2. Palpate uterine wall with fingers in fornixes, • Pediculosis Pubis (Crab Lice)
firm, smooth, with contour of fundus - Severe perineal itching, excoriations,
rounded, freely movable, nontender. erythematous areas. May see little dark
3. Palpate Adnexa on lower quadrant inside ant. spots, nits (eggs) adherent to pubic hair
iliac spine with intravaginal fingers in lateral near roots.
fornix.
May not be palpable. • Syphilitic Chancre
- Begins as small, solitary silvery papule,
Abnormal findings: erodes to red, round or oval, superficial
Painful with inflammation or ectopic pregnancy. ulcer with yellowish serous discharge.
• Enlarged uterus, lateral displacement, - Palpation- nontender indurated base; can
nodular mass, irregular, asymmetric be lifted like button between thumb and
uterus, fixed, immobile, tenderness. finger.
• Enlarged adnexa, nodules or mass.
• Herpes Simplex Virus- Type 2
Immobile, marked tenderness, pulsation,
- Episodes of local pain, dysuria, fever.
palpable fallopian tube.
- Clusters of small, shallow vesicles with
surrounding erythema, erupt on genital
areas, inner thigh.
- Vesicles on labia rupture in 1-7 days,
leaving painful ulcers.
- Initial infection lasts 7-10 days.
- Virus remains dormant indefinitely;
recurrent infections last 3-10 days with
milder symptoms.
 • Red Rash- Contact Dermatitis • Vas Deferens
- History of skin contact with allergenic - A muscular duct or tube that leads from
substance in environment, intense the epididymis to the urethra of the male
pruritus. reproductive tract.
- Primary lesion- red, swollen, vesicles. • Spermatic cord
- May have weeping of lesions, crusts, - Ascends along the posterior border of the
scales, thickening of skin, excoriations testes and runs through the tunnel of the
from scratching. May result from reaction inguinal canal into the abdomen.
to feminine hygiene spray, synthetic • Ejaculatory duct
underclothing. - A duct of the seminal vesicle behind the
bladder which empties into the urethra.
• Genital Human Papillomavirus (HPV, • Lymphatics
Condylomata Acuminata, Genital Warts) - Where the penis and scrotal surface drain
- Painless warty growths, may into the inguinal lymph nodes, those of
- Be unnoticed by woman. testes drain into the abdomen.
- Pink or flesh-colored, soft, pointed,
moist, warty papules.
- Single or multiple in cauli-flowerlike
patch. Occur around vulva, introitus,
anus, vagina, cervix.
TERMINOLOGY RELATED TO ASSESSMENT OF MALE
REPRODUCTIVE SYSTEMS:
• Penis
- External reproductive organ of the male
through which the urethra passes.
Composed of three cylindrical columns of
erectile tissue: two corpora cavernosa on
dorsal side, one corpus spongiosum
ventrally.
• Glans
- (Corpus spongiosum) Cone of erectile
tissue, found at the distal end of shaft.
• Urethra:
- Tube leading from urinary bladder to
outside of body, transverses the corpus
spong., and its meatus forms a slit at the
glans tip.
• Frenulum
- A fold of foreskin extending from urethral
meatus ventrally.
• Scrotum
- A loose, protective sac, encloses testes.
• Epididymis
- Highly coiled tubule that leads from the
seminiferous tubules of the testis to the
vas deferens. Main storage site of sperm.