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.
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.
As the patient walks in, note whether he looks like he is in any pain and how he is walking.
"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.
Ask the patient to remove the sheet and inspect the general area, looking for:
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.
Ask the patient to lie down on his back and inspect the penis looking for:
Make sure you gently lift the penis to check the posterior as well.
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:
Don't forget to inspect the posterior aspect as well.
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.
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.
If a lump/swelling is palpable:
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?
Is it separate from the testis?
Does it transilluminate?
For more information on testicular lumps, please see the fastbleep article on this topic here.
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 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.
If you are concerned about your findings or find anything abnormal, then you may want to request further investigations:
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