A genital examination is a key clinical assessment for male children, adolescents and adults.
It can be used to detect conditions like testicular cancer, Klinefelter syndrome and urinary problems, as well as assess normal development. It’s important to conduct this examination routinely with patients to identify and treat problems early. This reduces the risk of complications like infertility.
This article outlines how to examine the penis and testes, as well as assess secondary sexual characteristics.
How to approach an examination with a patient
Patients may feel nervous or uneasy about their genitals being examined, or about bringing up sexual and reproductive health issues.
Here are some steps you can take to help them feel more comfortable:
- Display posters or pamphlets in your clinic to raise awareness about men’s health examinations and convey that patients can discuss reproductive health concerns with you
- Explain why you need to perform the examination and ask for permission to proceed
- Allow the patient to ask questions and express if they feel any discomfort before and during the examination
- Ask specific questions during history-taking to assist patients who are reluctant to raise sensitive issues.
How to perform a testicular examination
Check testicular volume
1. Examine the patient on their back, in a warm environment.
2. Gently isolate the testis and distinguish it from the epididymis. Then stretch the scrotal skin, without compressing the testis.
3. Use an orchidometer — a sequential series of beads from 1 mL to 35 mL — to assess the size of the testes. Manually compare the testis and the beads side-by-side.
4. Identify the bead most similar in size to the testis, not including the scrotal skin.
5. Use the size of the bead to check whether the testes fall in the normal range for testicular volume:
- Children: less than 3 mL
- Adolescents: 4-14 mL
- Adults: 15-35 mL.
Testes are normally roughly proportional to body size. Low testicular volume suggests impaired spermatogenesis1. Testes less than 4 mL from mid-puberty are a consistent feature of Klinefelter syndrome2.
Asymmetry between testes is common (e.g. 15 mL versus 20 mL) and not medically significant. Asymmetry is sometimes more pronounced if there’s been unilateral testicular damage.
Check testis and scrotal contents
Here’s how to examine different parts of the testes and scrotum and what to look out for.
- Gently palpate the testis between your thumb and first two fingers. Atrophic testes are often more tender to touch than normal testes.
- If you cannot feel the testis, gently palpate the inguinal canal to see if it can be ‘milked’ down. Testis retraction can be caused by a cold room, anxiety or cremasteric reflex.
- Examine the testis surface for irregularities. It should be smooth with a firm, soft, rubbery consistency. Deep or surface irregularity, or differences in consistency between testes may indicate a tumour.
- Locate the epididymis, which lies along the posterior wall of the testis. It should be soft, slightly irregular and non-tender to touch.
- Tenderness, enlargement or hardening can occur from obstruction (vasectomy) or infection. This can be associated with obstructive infertility.
- Cysts in the epididymis are quite common and are sometimes mistaken for a testicular tumour.
- Locate the vas deferens, a firm rubbery tube approximately 2-3 mm in diameter.
- Nodules or thickening around the vas deferens ends may be seen after vasectomy.
- The vas deferens should be distinguished from the blood vessels and nerves of the spermatic cord.
- Absence of the vas deferens is a congenital condition associated with low semen volume and azoospermia.
- Perform the examination with the patient standing. A Valsalva maneuver or coughing helps delineate smaller varicoceles.
- Palpable swelling of the spermatic veins above testis may indicate infertility. This swelling is usually easy to feel and can be compressed without discomfort. It’s nearly always on the left side.
How to identify penile abnormalities
When examining the penis, look for indicators of the following abnormalities.
This is the abnormal position of the meatus on the underside of the penile shaft. It may be associated with a notched penile head.
In this disease, fibrous tissue causes pain and curvature of the erect penis. Check for tenderness or thickening.
If prior to puberty, this may indicate androgen deficiency.
This is where the foreskin cannot be pulled back behind the glans penis. It can be normal in boys up to 5-6 years.
This is an abnormal urethral narrowing, which alters urination. It can be caused by scar tissue, disease or injury.
What to look for when examining secondary sexual characteristics
Secondary sexual characteristics can be assessed in conjunction with a genital examination.
Onset of puberty
The average onset is 12-13 years.
The signs include:
- Facial and body hair development
- Muscle development
- Penile growth.
Gynaecomastia is the excessive and persistent development of benign glandular tissue evenly distributed in a sub-areolar position of one or both breasts3. In obese patients, you will need to distinguish glandular tissue from sub-areolar fat.
Gynaecomastia is commonly seen during puberty and usually resolves in later adolescence3. Patients may feel soreness and considerable embarrassment5.
Gynaecomastia can be caused by increased oestrogen, low testosterone, various medications, marijuana, androgen abuse and abnormal liver function3,4,5. Rare secondary causes include hypothalamic/pituitary and adrenal/testis tumours (oestrogen excess)4. If gynecomastia is developing rapidly, it may indicate testicular tumour5.
In contrast to gynecomastia, breast cancer can be located anywhere within the breast tissue and feels firm or hard3.
1. Takihara et al., 1987. Significance of Testicular Size Measurement in Andrology: II. Correlation of Testicular Size with Testicular Function. The journal of urology
2. Groth, 2013. Klinefelter Syndrome – A Clinical Update. Clinical Endocrinology and Metabolism
3. Deepinder & Braunstein, 2011. Gynecomastia: incidence, causes and treatment. Expert Review of Endocrinology & Metabolism
4. Johnson & Murad, 2009. Gynecomastia: Pathophysiology, Evaluation, and Management. Mayo Clinic Proceedings
5. Narula & Carlson, 2014. Gynaecomastia—pathophysiology, diagnosis and treatment. Nature Reviews Endocrinology