This male genital examination OSCE guide provides a structured approach to examining the penis and testicles. This is an intimate examination and therefore extra attention should be paid to the communication aspect to ensure the patient feels as comfortable as possible.
Introduce yourself – name / role
Confirm patient details – name / DOB
“I need to carry out an examination of your genitals, this will involve me examining your penis, testicles and the surrounding area“
“I’m required to have a chaperone present, this will most likely be a nurse from the ward, are you ok with that?“
Gain consent :
“Do you understand everything I’ve said?“
“Are you happy for me to examine you?“
Get a chaperone – this is absolutely essential
Position the patient lying on an examination couch (you can ask the patient to stand at the end of the examination)
Expose the patient – exposure should be from the waist down
Inspect the patient’s genital region and the surrounding areas (i.e. penis / groin / lower abdomen):
- Skin changes – rash / bruising / swelling / erythema / hair loss
- Scars – especially in the inguinal region (hernia or orchidopexy)
- Obvious masses
Inspection of the scrotum and perineum
Ask the patient to hold their penis out of the way to allow easier inspection of the scrotum.
Inspect the scrotum from the front, sides and the posterior aspect by lifting the scrotum.
Inspect the perineum
Inspect the scrotum and perineum for the following…
- Skin changes – rash / ulcers / erythema (e.g. cellulitis / fungal infection)
- Scars – may provide clues as to previous operations (e.g. vasectomy or testicular fixation)
- Masses – note any obvious lumps, these will require examination later
- Swelling – unilateral or bilateral? / associated with erythema?
- Necrotic looking tissue – Fournier’s gangrene is a diagnosis not to be missed and is often first noted on the perineum
1. Retract the foreskin to check for phimosis (narrowing of the foreskin) or adhesions and describe any abnormalities on the glans (ulcers/discharge/scarring)
- If you are unable to retract the foreskin, ask the patient to do this himself
- Be aware that a patient may be circumcised and comment on this to the examiner
2. Open the urethral meatus to check patency.
3. Replace the foreskin once examined to prevent paraphimosis (this is where the retracted foreskin obstructs venous return from the glans, thus resulting in painful swelling of the glans.
Examine each testicle individually.
If abnormalities have been identified on inspection or the patient is concerned about a particular testicle, start examination on the other testicle.
Ask the patient to report any pain or discomfort they experience during the examination.
1. Use both thumbs and index fingers to gently palpate the whole testicle:
- Your remaining fingers should be placed behind the testicle to immobilise it
- Palpation involves a gentle rubbing motion between thumb and index finger to methodically examine the whole body of the testicle
2. If you are unable to locate a testicle, palpate along the path of the inguinal ligament for an undescended testicle (if the patient also has a scar in their inguinal region this would suggest a previous orchidectomy or orchidopexy).
If a mass is found assess the following…
- Size / shape
- Regularity – regular vs irregular
- Consistency – hard (solid) / soft (cystic) / “Bag of worms” (varicocele)
- Discomfort – try to identify the specific area causing pain
- Are you able to get above the mass?- No = inguinal scrotal hernia
Is the mass fixed to the testicle or separate?
- Separate + hard (solid) = epididymitis / orchitis
- Separate + cystic (soft / fluctuant) = epididymal cyst / spermatocele
Is there a cough impulse? – presence of a cough impulse suggests hernia / varicocele
Does the mass transilluminate?
- To transilluminate place a pen torch behind the scrotal swelling in a darkened room and it will produce a red glow
- Transillumination suggests the mass is fluid filled – e.g. hydrocele (some hydroceles are so large that you cannot properly palpate the testicles)
Palpate the epididymis (located at the posterior aspect of the testicle).
Pain in the epididymis may suggest epididymitis.
If testicular pain is relieved by elevating the testes this is strongly suggestive of epididymitis.
Stroke or pinch the patient’s medial thigh which leads to stimulation of the cremaster reflex and elevates the testicle
Loss of cremaster reflex may suggest testicular torsion
Start palpation at the superior aspect of the testicle using your thumb and index finger.
The spermatic cord should be palpable connecting to the testicle at this region.
Palpate along the cord assessing for masses and tenderness.
Assess the scrotum whilst the patient is standing
At the end of the examination, ask the patient to stand.
Inspect and palpate the posterior scrotum for varicocele (a bag of worms) or a hernia (a mass which you cannot get above).
To complete the examination
Allow patient time to get dressed
Dispose of gloves
“Today I performed a testicular examination on John Doe, a 42 year old gentleman. On inspection there were no abnormalities identified, however on palpation there was a 1cm smooth solid mass noted on the left testicle. The mass was non tender and fixed to the underlying testicle. I was able to get above the mass and there was no cough impulse or transillumination.“
Suggest further assessments and investigations
- Full abdominal examination including digital rectal examination (if indicated)
- Ultrasound scan of the testicles
Urology terms/conditions overview
- Accumulation of fluid in the tunica vaginalis, may be congenital or acquired
- Transilluminates and may not be able to palpitate the testicle
- Separate from the testicle and fluid filled structures
- Can be larger than expected
- Smaller cysts of the epididymis/cord
- Pea sized
- Varicosities of the gonadal vein, classically described as bag of worms.
- If on left side, new onset, always recommend renal tract ultrasound to rule out renal cancer as left gonadal vein drains into left renal vein
- Painful swelling of epididymis +/- testicle (orchitis) of a progressive nature.
- If under 35, likely due to sexually transmitted infection.
- If over 35, urinary pathogens such as Escherichia Coli are the most common
- Sudden onset of testicular pain (severe in nature)
- Always have a high level of suspicion
- Bell clapper deformity can increase chance of torsion
- Peak age range between 20-40
- Between 20-30, non-seminomatous germ cell tumours such as teratomas
- Between 30-40 more likely to be a seminoma
- If suspicion, all patients should have urgent ultrasound scan of testicles, chest x-ray and tumour markers checked (Beta-HCG, Alpha fetoprotein and Lactate Dehydrogenase [LDH])
- Treatment is most commonly INGUINAL orchidectomy due to lymph node drainage of the testicle
- An operation performed in children for undescended testicles where the testicle is brought down from the inguinal canal into the scrotum
- Undescended testicles can increase risk of testicular malignancy
Unilateral testicular atrophy
- Shrinkage of one testicle
- May occur following mumps, vascular compromise (e.g. missed testicular torsion) or related to surgery (orchidopexy or inguinal hernia repair)
Bilateral testicular atrophy
- May suggest primary or secondary hypogonadism therefore should check for secondary sexual characteristics, hormonal abnormalities or anabolic steroid use
- Narrowing of the distal foreskin leading to inability to retract
- Swelling of the glans due to the foreskin being stuck behind the glans following retraction (resulting in impaired venous return)
- Commonly occurs following catheterisation
- Needs urgent correction
Dr Kenneth Mackenzie
Urology registrar (ST4)