Shared article

Testicular Examination

This examination should include the surrounding area, penis and scrotum as well as the testicles. A full male genitalia examination would also include a rectal examination to check the prostate. 

 

*Remember*

This is an intimate but very important examination, which can cause embarrassment for both the doctor and patient if not conducted in a professional manner. Be sensitive towards the patient's feelings, and practice in the skills labs to avoid awkward pauses when doing this examination on patients. 

Introduction

As the patient walks in, note whether he looks like he is in any pain and how he is walking.

  • Introduce yourself
  • Confirm the patient's identity
  • Establish reason for consultation
  • Explain examination to patient
  • Any questions?
  • Chaperone
  • Confidentiality
  • Consent
  • Leave the patient to undress whilst collecting equipment

 

For example:

"Hi, my name is ******** and I am a * year medical student. Can I confirm your name and date of birth? I understand that you are concerned about your testicles and so I have been asked to perform a testicular examination on you. Have you had this done before? It will involve you removing all clothing from the waist downwards, so that I can inspect the area whilst you stand up and then lie down. I will then need to gently feel your penis and testicles. The examination should not hurt, but if you feel any discomfort at any point then please don't hesitate to tell me.

Do you have any questions? Are you happy for me to do this examination? I would like a chaperone to present throughout the examination if this is okay with you. Everything that we discuss will be kept confidential within the medical team."

Provide the patient with a sheet to cover himself, and leave him for a few minutes to undress whilst you go to find a chaperone and record their name in the notes. Ensure you have a light source and the room is well lit and warm. Find a pair of gloves and a small pen torch.

General Inspection

  • Wash hands
  • Put on gloves 
  • Ask the patient if he is in any pain 
  • Note general hygiene of the area

 

Ask the patient to remove the sheet and inspect the general area, looking for:

  • Redness
  • Skin changes
  • Lumps
  • Swellings
  • Scars 
  • Hair distribution

 

When inspecting the scrotum and groin, the patient should be standing up

When inspecting the penis, the patient should be lying on their back on the bed.

 

The Penis

 

Inspection

Ask the patient to lie down on his back and inspect the penis looking for:

  • Size and shape
  • Abnormal curvature
  • Skin colour
  • Presence of foreskin
  • Position of the urethral meatus
  • Discharge
  • Lesions, scaling, chancres, scabs, erythema, ulcerations or scars.

Make sure you gently lift the penis to check the posterior as well. 

 

Palpation

  • Palpate along the whole length of the penis, starting at the tip and finishing at the perineum. Are there any areas which are firmer than the rest? (plaques of Peyrone's disease)
  • Look for the superficial dorsal vein, which should run the entire length of the penis on the dorsal midline. 
  • Retract the foreskin to examine the urethral meatus and glans penis. The foreskin should retract easily and not cause any pain. In phimosis, the foreskin will be non-retractile and painful. Are there any signs of swellings, inflammation or adhesions? Does the glans have any vesicles or skin alterations? 
  • Is there any discharge? If so take a urethral swab
  • REPLACE THE FORESKIN. (Failure to do so may cause a paraphimosis)

 

      The Scrotum and Contents

       

      Inspection

      Now ask the patient to stand up so that you can inspect the scrotum. You can ask the patient to hold his penis to one side. Look specifically for:

      • One testis hanging lower than the other (often the right)
      • The scrotum should be wrinkled with darker skin
      • Scars
      • Oedema
      • Sebaceous cysts (common), ulcers and swellings
      • Scabies
      • Erythema

       

      Don't forget to inspect the posterior aspect as well.

       

      Palpation

      Use both your hands when palpating the scrotum: use your left hand to support the scrotal contents, and two fingers and your thumb on your right hand to gently palpate.

       

      • Feel to check the patient has two testes. (If not, palpate the inguinal canal and perineum to feel for an undescended testis. Ask the patient about it - excision, failure to descend or retractile testis.) 
      • The scrotum should be freely mobile from the testes. 
      • One at a time, palpate the body of each testicle, feeling both poles and the centre whilst looking at the patients face to check for pain. Ask them if it hurts. 
      • Compare the size, shape and consistency of each testicle with each other. (They should be equal sized and feel smooth, rubbery and firm.)
      • Note any unusual lumps, change in consistency, tender areas and swelling. (malignancy?)
      • Palpate for each epididymis along the posterolateral border of each testis. 
      • Palpate up each spermatic cord, whilst gently pulling the respective testis downwards. It should feel regular and smooth. 

       

        You may also want to check for the cremasteric reflex, which is elicited by stroking the superficial medical aspect of the thigh near the testis, and the testis should rise on the respective side. (It will not rise in torsion.)

         

        If the patient has pain on palpation (Prehn's sign) raising the testes may relieve the pain. This is suggestive of epididymitis. 

        Scrotal Swellings

        If a lump/swelling is palpable:

        • Can you feel above it? (ie, is it a scrotal swelling or does it descend from the inguinal canal?)
        • Is it attached to the testicle?

         

          Ask the patient to cough to see if it moves downwards.

           

          Shine a torch through the posterior aspect of the swelling. If you cannot see the light from the front, the mass is solid. If the mass transilluminates, it is cystic or fluid filled.

           

          Common causes of scrotal masses:

          Can you get above it?

          • NO - inguinoscrotal hernia, hydrocele extending proximally

           

          Is it separate from the testis?

          • YES - epididymal cyst, epididymitis, varicocoele
          • NO - hydrocele, tumour, orchitis, haematocele, granuloma, gumma

           

          Does it transilluminate?

          • YES + separate from testis - epididymal cyst
          • YES + not separate from testis - hydrocele
          • NO + separate from testis - epididymitis, varicocoele
          • NO + not separate from the testis - orchitis, tumour, haematocele, granuloma, gumma.

           

          For more information on testicular lumps, please see the fastbleep article on this topic here.  

            Common Scrotal Lumps

            The Perineum and Rectum

            In a full male genitalia examination, you will need to inspect the perineum and perform a PR examination to assess the prostate gland and seminal vesicles.

            The Inguinal Lymph Nodes

            The inguinal lymph nodes drain the skin of the penis and the scrotum. The common iliac lymph nodes drain the testes and the spermatic cord. The para-aortic nodes drain lymph from the body of the testes. To palpate for the inguinal lymph nodes, ask the patient to lie on their back. The horizontal group is found along the inguinal ligament, and the vertical group is along the medial adductor longus.

            Finishing the Examination

            • Cover the patient with the sheet 
            • Wash your hands
            • Thank the patient 
            • Leave him to dress in private 

            Further Investigations

            If you are concerned about your findings or find anything abnormal, then you may want to request further investigations:

            • Mid-stream urine sample + urine dipstick to test for infection as this may suggest epididymo-orchitis
            • Urethral swab + full STI screening
            • Ultrasound - to investigate any abnormal swellings or lumps that you are unsure about
            • Colour Doppler Imaging - to assess the testicular blood flow 
            • Explorative surgery
            • Serum PSA levels - raised in prostate cancer
            • Serum Beta-HCG, Alpha-fetoprotein and Lactate Dehydrogenase - raised in some types of testicular cancer
            • CT Scan - undescended testicle/stage testicular cancer
            • MRI Scan - staging of prostate cancer
            Advertisement

            Fastbleep © 2019.