Download Skill: Male genital and scrotal examination

Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
Tutors:
The PBL case is Gabi and boyfriend. It covers sexual differentiation, male genital development,
scrotal and testicular anatomy and function
Issues relating to intimate examination are included in this session
We will not be covering examination of the hernia orifices in the session, the examination of
hernia is included in the SDL section in preparation for T year and clinical attachments. The
students can view the video “Examination of the groin, the hernial orifices and the male external
genitalia” in their own time. The aim of this session is to encourage a sensitive, thorough and
systematic male genital examination. Please try and ensure that the students take this situation
seriously.
In the practical part of the session we will be practising the male external genital examination,
only using a volunteer where appropriate and the manikins for the majority of the examination.
Lesson plan
13.30-13.35
(5 mins)
13.35-13.45
(10 mins)
13.45-14.05
(20 mins)
14.05-14.55
(50 mins)
14.55-15.00
(5 mins)
Introductions (Relevance, Aims and overview of the session). Sign
registers
Discuss the principles of intimate examination and issues related to
intimate examinations as per your hand out;
Please emphasise the importance of
 informed consent, privacy, respect for patient’s wishes
and dignity
 chaperones
 supervision for this procedure as a medical student
continued communication skills during the examination
 Run through the examination of the male external genitalia
and scrotum on a manikin, using the 4 stage teach.
 Then go straight onto stage 4 – students perform while they
describe the steps (you may need to prompt).
 During the examination:
o The volunteer patient should be standing up for the
general inspection, skin and major joints part of the
examination
o At the point of asking the patient to expose the
genital area, hold the manikin in front of the volunteer
for the inspection of the groin and scrotal region, and
scrotal palpation whilst standing up.
o Then place the manikin in a lying down position for
the rest of the examination.
o Try to get some feedback from the volunteer patient.
Split your group. Half the group to practice the full examination on
pelvic models. The other half of the group to practice the full scrotal
examination on scrotal models. Then swap after 25 min. Use any free
cubicles if you wish. Students should practice the introduction and
preparation every time.
Please give individual constructive feedback to the students.
Closure. Encourage the students to practice in the SDL room and
watch the video available on Moodle. ‘Examination of the groin, the
hernia orifices and the male external genitalia.’ They should read the
‘self directed learning’ in their notes.
15.30-15.35
(5 mins)
15.35-15.45
(10 mins)
15.45-16.05
(20 mins)
16.05-16.55
(50 mins)
16.55-17.00 (5
mins)
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
Learning Outcomes
In this session you will
 Perform an examination of the male genitalia on a manikin.
 Consider issues highlighted by the intimate nature of genital examination, including
consent, privacy, chaperones and respect for patient’s wishes and dignity
Clinical relevance
Male genital examination is an important skill. Unfortunately many doctors find it challenging. It
may be indicated in children (especially to assess for descent of the testes, and occasionally for
urethral abnormalities), adolescents (to assess for stage of sexual maturity) and in adults (e.g.to
look for signs of STI’s (sexually transmitted infections) and other infections, skin problems, and
to examine for abnormalities within the scrotum such as testicular cancer.)
Links with other learning
This session links with future and previous sessions;
 The principles of examining a lump
 Male catheterisation (T-year)
 Abdominal and rectal examination
 Other intimate examinations – rectal, breast, gynaecological examination
Related Basic Sciences - Essential anatomy
To help you during this session you should understand and revise the anatomy of the following
structures:
 Penis, prepuce (foreskin) and the scrotal contents.
 Spermatic cord
 Inguinal lymph nodes.
 Anterior abdominal wall, inguinal ligament and femoral canal,
 Direct and indirect inguinal hernias and femoral hernias
The anatomy of hernias is important, and you should learn this carefully alongside a clinical
skills text and clinical textbooks.
Moodle
There is a DVD on Moodle – ‘Examination of the groin, the hernia orifices and the male external
genitalia’ which will be useful for you to watch but the content and steps are different to what
you will be learning today.
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
Principles of an intimate examination
This is an intimate examination. Please read the GMC guidance on intimate examinations and
chaperones (http://www.gmcuk.org/static/documents/content/Intimate_examinations_and_chaperones.pdf)
Please note the following in relation to this intimate examination;

When carrying out an intimate examination such as this, it is particularly important to use
excellent communication skills to explain the examination/procedure carefully and obtain
informed consent.

Physical contact with the patient should be kept to a minimum and all contact should be
explained to the patient as you go along. Example: “I am just looking around the base of
your penis for any warts or skin rashes, and now I am looking at the skin of the shaft. I’m
pulling back the foreskin to have a look around the head of the penis”You must respect the
patient’s dignity and keep the exposure of them to a minimum.
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Professional boundaries must be kept both in terms of the way that you perform the
examination/procedure and your verbal and nonverbal communication
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In all intimate examinations you must make it clear to the patient that they will be
examined again by your clinical supervisor. This will be the case for most
examinations, but is particularly important for intimate examinations as patients may
well be uncomfortable and anxious.
General notes
In clinical practice an examination of the scrotum and male genitalia is carried out after you
have gathered information about the patient, the context is usually clearer after the history has
been taken. It may form part of a more comprehensive examination.
 The groin, hernial orifices, scrotum and genitalia may be examined all together or
separately. There is a degree of overlap.
 Often these examinations are performed after an abdominal examination.
When examining the scrotum and genitalia you will need to examine the groin and
at least inspect the lower abdomen. Following your examination of the scrotum and genitalia it
may be necessary (depending on the context and your findings) to perform other examinations
as well e.g. the hernial orifices, abdomen, perineum and rectum.
Some clinicians will initially examine the patient standing up and some
clinicians will initially examine the patient lying down and then stand them up. We will position
the patient standing initially - this is because hernia swellings may be more obvious
when standing, and varicoceles are rarely palpable when lying flat.
It is important to also examine the scrotum. A large indirect hernia can descend into it, and
varicoceles originating in the spermatic cord may present with scrotal signs and scrotal
pathology may drain to the inguinal lymph nodes. Depending on the your clinical findings it may
be necessary to perform other examinations as well.
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
In this examination it is important to explain to the patient what you will be examining and the
exposure required.
It is also important to be very gentle whilst palpating- note that the frenulum tends to be a
particularly sensitive area.
Occasionally an erection may develop and if it occurs it is important that the situation is dealt
with appropriately. If this happens just explain to the patient in a matter of fact way that this
sometimes happens and that you will take a short break from the examination, leaving the
patient in private.
STEPS
Introduction and Preparation
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Introduce yourself by giving your full name and role
Check the name of the patient
Explain the nature and purpose of what you are going to be doing using non-technical
language, and explain that your supervisor will also examine the patient
afterwards.
Explain how much exposure is necessary - the patient will need to be exposed from the
umbilicus downwards. You also need to able to see the arms and legs if you are
performing a genital examination. Attention to patient comfort and dignity is of
paramount importance.
Obtain consent
Offer a chaperone
Ask if the patient has any pain, and if so, to show you where it is.
Ask the patient to report any pain or tenderness when you are examining them
Gather equipment e.g. gloves, pen torch (for transillumination)
Clean your hands and put on gloves
Inspection with the patient standing
Ask the patient to stand up
 General inspection
 Does the patient look well?
 Does he look in pain?
 Look at his skin – any signs of skin disease which may explain a genital rash e.g.
excoriations of scabies, keratoderma blennorrhagica
 Look at the joints for any signs of inflammation which may be associated with genital
conditions e.g. gonorrhoea, reactive arthritis
 Look at his eyes for any signs of conjunctivitis or uveitis
Explain the need to expose the lower abdomen, groin and genital areas
 Lower abdomen and pubic area.
o Look for erythema, swellings, lumps, ulcers, scars
o Look for rashes, excoriations, infestations
 Inguinal and femoral region.
o Ask the patient to take a deep breath and bear down – look for any visible
swellings to enlarge or new swellings to appear.
o Look for any signs of lymphadenopathy, scars
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
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Scrotum: gently move the scrotum to one side to inspect it thoroughly.
 Look for any obvious lumps or swellings
 Ask the patient to bear down and look specifically for a varicocele.
 Look for erythema, scars, ulcers, superficial lesions.
Palpation with the patient standing
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Scrotum: palpate for a varicocele and ask the patient to bear down again – it may
become more obvious.
Palpate other lumps/swellings detected on inspection. A detailed examination is required
(we will be covering the assessment of lumps in detail in another session)
Inspection and palpation with the patient lying down
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Testes: Techniques vary. Isolate either testis by lifting gently away from the body. You
can gently fix the testis toward the bottom of the scrotum with the thumb and first finger
of your non-dominant hand. Palpate the entire surface of the testis. The surface should
regular and smooth with no lumps or tenderness, and the consistency should be firm
(NB: Consistency: Firm = similar to tip of nose, hard = similar to forehead, soft = similar
to lip. This will be covered in more depth later). Check for mobility, the testes should lie
free and not tethered to the skin or subcutaneous tissue. Note the testicular size for
comparison.
Epididymis: Palpate the head, body and tail of the epididymis over the
superior/posterior aspect of the testes, feel for nodules, swellings or tenderness.
Vas Deferens: Trace the Vas Deferens running up superiorly from the epididymis in the
spermatic cord, rolling it gently between thumb and index finger. Assess the space
above the testis for any mass e.g. an indirect hernia.
If a lump /mass is found in the scrotum assess it further:
 Attempt to palpate above it.
 If you cannot get above it then the lump has not originated in the scrotum and
might possibly be a hernia.
 If your fingers and thumb can meet above the swelling, then it is scrotal in origin.
 Does it have a cough impulse or bowel sounds?
 Is it separate to the testicle?
 Is it tender?
 Does it transilluminate?
 Is it only present on standing?
 Other features
Examine the other testis, epididymis and vas deferens. A slight difference in
testicular size is not uncommon.
Penis: Inspect all aspects from base to tip. Look for evidence of hypospadias on the
ventral aspect. Inspect the skin thoroughly for any ulcers, nodules, rash, masses, skin
colour change etc.
Foreskin (prepuce): If present explain that the foreskin needs to be drawn back. Some
clinicians are more comfortable asking patients to withdraw and replace their own
foreskin. Otherwise draw the foreskin back gently to examine the glans. Do not force it the foreskin will not retract if it is stenosed (phimosis).
Urethral meatus: Note its position and look for any discharge.
Frenulum: This should be present and intact.
Corona: Inspect around the corona and look for warts, inflammation, rashes and ulcers.
You may see pearly papules which are non pathological.
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
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Replace the foreskin to prevent a paraphimosis, whilst checking briefly to see if this
produces any discharge.
Penis: Opinions vary on the need to palpate the penis. For example a history
suggestive of Peyronies disease (progressively worsening deviation of the penis on
erection) or a malignant looking lesion would necessitate palpation. Some doctors
advocate palpation as part of the examination and would palpate the two corpus
cavernosum on the dorsal aspect and the urethra on the ventral aspect for any nodules
and tenderness.
Lymph nodes. Palpate the following areas for any lymphadenopathy with the flat of
three fingertips starting away from any reported pain or lumps and then palpate
systematically to locate the site of any swelling or lumps. Remember that these nodes
drain a wide area of superficial structures.
 the region of the inguinal ligament
 inferior to the inguinal ligament
 upper medial aspect of the thigh.
Femoral pulses – palpate in the approximate area of the mid inguinal points and
auscultate for bruits.
Additional examinations
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You may wish to consider examining the abdomen, hernial orifices, perineum, anus and
rectum depending on the clinical context and your examination findings.
Closure
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Remove your gloves
Thank the patient and allow them to get dressed in privacy
Ensure that they are comfortable and in a state of dignity
Wash your hands
Clean your pen torch/stethoscope (if used)
Record/report findings
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
SUMMARY OF MALE GENITAL+SCROTAL EXAMINATION
INTRODUCTION+PREPARATION
 Full name + role
 Check patients name
 Explain examination + that your supervisor will also examine the patient later
 Explain exposure necessary
 Obtain consent
 Offer a chaperone
 Ask about pain + to report any pain during the examination
 Gather equipment (eg. gloves, pen torch)
 Clean your hands and put on gloves
STANDING: INSPECTION
 General inspection
 Wellbeing
 Pain
 Skin (excoriations of scabies, keratoderma blennorrhagica)
 Joints (inflammation which may be associated with genital conditions e.g.
gonorrhoea, reactive arthritis
 Eyes (conjunctivitis/uveitis)
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Lower abdomen+ pubic area
o Swellings, lumps, ulcers, scars
o Erythema, rashes, excoriations, infestations
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Inguinal + femoral region
o Bear down  swellings
o Lymphadenopathy
o Scars
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Scrotum
 Lumps or swellings
 Bear down  varicocele
 Skin abnormalities: erythema, scars, ulcers, superficial lesions.
STANDING: PALPATION
 Scrotum
o Varicocele (bear down)
 Lumps/swellings
LYING DOWN: INSPECTION+PALPATION
 Testes:
o Surface (smooth, regular)
o Consistency (firm)
o Mobility
o Tenderness
o Mobility
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
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o Tethering to underlying skin or subcutaneous tissue
o Size
Epididymis:
o Nodules, swellings or tenderness.
Vas Deferens:
o Assess space above testis for masses / indirect hernia.
Lump/mass in scrotum:
o Attempt to palpate above it.
 If you cannot get above it  ?hernia.
 If you can get above it  ?from scrotum
o Cough impulse
o Bowel sounds
o Separate to testicle
o Tenderness
o Transilluminability
o Only present on standing
o Other features
Examine the other testis, epididymis and vas deferens.
Penis:
o Inspect all aspects from base to tip
o Hypospadias
o Skin: ulcers, nodules, rash, masses, skin colour
Foreskin:
o Draw back
o Phimosis
Urethral meatus:
o Position
o Discharge.
Frenulum
Corona
o Warts, inflammation, rashes and ulcers.
Replace the foreskin.
Penis: if indicated
Lymph nodes
o Inguinal ligament region
o Inferior to inguinal ligament
o Upper medial aspect of the thigh.
Femoral pulses
o Palpate
o Auscultate for bruits.
ADDITIONAL EXAMINATIONS
 Consider
o Abdomen
o hernial orifices
o Perineum
o Anus/rectum
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
CLOSURE
 Remove gloves
 Thank patient and allow them to get dressed in privacy
 Wash your hands
 Clean your pen torch/stethoscope (if used)
 Record/report findings
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
Self-directed learning
From T year onwards you will be examining patients with hernias and other pathology relating to
the groin so it would be useful for you to prepare in advance. Note that this will be covered in Tyear, and you will not be asked to do a hernia examination this year.
Examination of the groin and hernial orifices
Hernia Please refer back to your anatomy preparation in relation to how the different types of
hernia in the groin region present (we are not covering any other types of hernias in these
notes). Consider what the following terms mean in relation to hernias – reducible, irreducible,
obstructed, strangulated. Always seek urgent senior help if a hernia is significantly tender or
there are other signs of obstruction/strangulation.
The following is a discussion on inguinal and femoral hernias (not any other type).
Note:
 An indirect inguinal hernia will enter the inguinal canal at the internal (deep) inguinal ring
(just above the mid-inguinal point, half way between ASIS and symphysis pubis,
approximately 1cm above the femoral pulse). If this hernia is reducible, a finger over the
internal (deep) ring will prevent the hernia from reappearing.
If an inguinal hernia protrudes through the external (superficial) ring, it can be felt to lie
above and medial to the pubic tubercle. An indirect hernia may follow the spermatic
cord all the way to the scrotum and present as a scrotal swelling.
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A direct inguinal hernia represents a bulging directly through the posterior wall of the
inguinal canal, medially to the internal (deep) inguinal ring.
Please note that direct and indirect hernias can be difficult to distinguish from each other
clinically. The definite way to tell is through exploration during surgery.
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A femoral hernia will lead to a cough impulse and swelling over the femoral canal (below
inguinal ligament, “below and lateral to the pubic tubercle”)
A large indirect inguinal hernia may extend into the upper scrotum, and may be confused with a
scrotal lump (see below)
General notes
This is an intimate examination (see notes above).
You should start by carrying out a full abdominal examination. As well as examining the hernial
orifices you should also examine the scrotum – this is because a large indirect hernia can
descend into the scrotum, varicoceles originating in the spermatic cord may present with scrotal
signs and scrotal pathology may drain to the inguinal lymph nodes.
Introductions and Preparation
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Introduce yourself by giving your full name and role
Check the name of the patient
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
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Explain the nature and purpose of what you are going to be doing using non-technical
language and explain that your supervisor will also examine the patient afterwards
Explain how much exposure is needed. Attention to patient dignity is of paramount
importance.
Offer a chaperone (see GMC guidance)
Obtain consent
Ask if the patient has any pain, and if so, to show you where it is.
Ask the patient to report any tenderness when you are examining them
Gather equipment e.g. gloves, pen torch (for transillumination)
Clean your hands
Start with the patient lying down
Inspection with the patient lying down
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General inspection of the patient
o Do they look unwell/in pain?
o Are they vomiting/have been vomiting?
Carry out a full abdominal examination.
Put on gloves
Now explain need for uncovering the groin and genital areas.
Inspect the lower abdomen and pubic region for erythema, swellings, lumps, scars
etc.
Inguinal and femoral region
o Look for any erythema, swellings, lumps, scars etc.
o Ask the patient to take a deep breath and bear down/cough – look for any visible
swellings to enlarge or new swellings to appear. Look to see if any herniasappear
and/or spontaneously reduce
Inspect the scrotum (you may need to gently move the scrotum to one side to inspect it
thoroughly)
o Look for skin abnormalities: erythema, swellings, lumps, ulcers, superficial
lesions, scars etc.
o Look for varicoceles – ask the patient to bear down/cough
Palpation with the patient lying down
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Scrotum – palpate for a varicocele/s in the scrotum, ask the patient to bear down/cough
again – it may become more obvious.Carry out a full scrotal examination (as in notes
above).
Cough impulse
o If a hernia is suspected and the history confirms that it can be reduced by the
patient, then ask the patient to reduce the hernia (if they can’t then your
supervisor may do this).
o Once it is reduced, place one finger over the internal (deep) ring (just above the
midpoint of the inguinal ligament). Ask the patient to cough. If the hernia is an
indirect hernia your finger will prevent the hernia from reappearing. If the hernia
reappears it is more likely to be a direct hernia or a femoral hernia (2).
In patients without an obvious swelling check for a cough impulse bilaterally over
 Internal (deep) inguinal ring (just above the mid inguinal point, 1-2cms above the
femoral pulse) lateral to the inferior epigastric artery
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
 External (superficial) inguinal ring (locate the position relative to the pubic
tubercle and then palpate with the index finger from the upper aspect of the
scrotum.
 Inguinal/Hasselbach’s triangle (use the flat of the hand placed medial to the site
of the internal (deep) inguinal ring). The borders of the triangle are as follows:
o Inferior aspect = inguinal ligament
o Superior + lateral border = inferior epigastric vessels
o Superior + medial border = lateral aspect of rectus sheath
 Femoral canal (inferior to the inguinal ligament and lateral to the pubic tubercle)
 Hernias will not transilluminate, and auscultation may reveal bowel sounds (if it is a
large hernia that contains bowel).
 Seek urgent senior help if a hernia is tender or if there are other signs/symptoms of
obstruction/strangulation.
 A large indirect inguinal hernia may extend into the upper scrotum, and may be confused
with a scrotal lump (see below)
 Other lumps or swellings detected on inspection– a detailed examination is required
(we will be covering the assessment of lumps in detail in another session)
 Lumps, swellings and lymph nodes - palpate the inguinal region (in the region of the
inguinal ligament) with the flat of three fingertips starting away from any reported pain or
lumps and then palpate systematically to locate the site of any swelling or lumps or
lymph nodes. Also palpate inferior to the inguinal ligament and the upper medial aspect
of the thigh. Remember that the lymph nodes in these areas drain a wide area of
superficial structures.
 Femoral pulses – palpate in the approximate area of the mid inguinal points and
auscultate for bruits.
Ask the patient to stand up
Stand to the side of the patient when you then examine them and move your head so it is at the
same level as the part of their body you are examining.
Inspection with the patient standing up
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Inspect the lower abdomen and pubic region for erythema, swellings, lumps, scars
etc.
Inguinal and femoral region
o Look for any erythema, swellings, lumps, scars etc.
o Ask the patient to take a deep breath and bear down/cough – look for any visible
swellings to enlarge or new swellings to appear. Look to see if any hernias
appear and/or spontaneously reduce
Inspect the scrotum (you may need to gently move the scrotum to one side to inspect it
thoroughly)
o Look for erythema, swellings, lumps, ulcers, superficial lesions, scars etc.
o Look for varicocele/s – ask the patient to bear down/cough
Palpation with the patient standing up
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Scrotum – palpate for a varicocele/s in the scrotum, ask the patient to bear down/cough
again – it may become more obvious. A large indirect inguinal hernia may extend into
the upper scrotum, and may be confused with a scrotal lump. Carry out a full scrotal
examination (as in notes above).
Cough impulse– repeat these (as above)
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
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Other lumps or swellings detected on inspection– a detailed examination is required
(we will be covering the assessment of lumps in detail in another session)
Lumps, swellings and lymph nodes - palpate the inguinal region (in the region of the
inguinal ligament) with the flat of three fingertips starting away from any reported pain or
lumps and then palpate systematically to locate the site of any swelling or lumps or
lymph nodes. Also palpate inferior to the inguinal ligament and the upper medial aspect
of the thigh. Remember that the lymph nodes in these areas drain a wide area of
superficial structures.
Additional examinations
You may wish to consider examining the external genitalia, scrotum, perineum, anus and
rectum depending on the clinical context and your examination findings.
Closure
Remove your gloves
Thank the patient, tell them that they can get dressed. Ensure that they are comfortable.
Wash your hands
Clean your pen torch/stethoscope (if used)
Record/report findings
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You may also find the following aspects of basic science useful in your understanding of normal
scrotal contents and abnormal swellings.
Embryology
Essentially the testes develop high up on the posterior abdominal wall. It is necessary for the
testes to leave the abdominal cavity since the temperature there retards the normal process of
spermatogenesis. During fetal life the testes “descend” behind the peritoneum, dragging their
blood supply, nerve supply and lymphatic drainage after them through the inguinal canal into
the scrotum.
Anatomy
Inguinal canal
This is an oblique passage through the lower part of the anterior abdominal wall. It is present in
both sexes and lies parallel to and immediately above the inguinal ligament. It is 4cm long
and passes downwards and medially, and from deep to superficial, from the internal (deep) to
the external (superficial) inguinal rings.
The inguinal ligament is attached laterally to the anterior superior spine (ASIS) and curves
downwards and medially to be attached to the pubic tubercle, a small
protuberance along the superior surface of the pubis.
The internal (deep) inguinal ring is an opening in the fascia transversalis about 1-1.5cm
above the mid point of the inguinal ligament, lateral to the inferior epigastric artery.
The external (superficial) inguinal ring is a triangular aperture in the aponeurosis of the
external oblique muscle situated above and lateral to the pubic tubercle.
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
A hernia is the protrusion of an organ through a defect in the wall of the cavity
containing it, into an abnormal position. In the inguinal region there are inherent
weaknesses in the abdominal wall which may result in herniation.
There are different types of hernia in the region of the groin, however in the context of scrotal
examination, it is a hernia known as an indirect hernia which may present itself as a scrotal
swelling. This type of hernia emerges from the abdominal cavity through the internal (deep) ring,
passes along the inguinal canal, and, if large enough, emerges through the external (superficial)
ring from where it descends into the scrotum.
Scrotum
This is a pouch of skin containing the testes, the epididymides and lower ends of the spermatic
cords
The spermatic cord begins at the internal (deep) inguinal ring, emerges from the external
(superficial) inguinal ring and descends into the scrotum ending at the testis. It contains many
structures including vas deferens, testicular artery, testicular vein and lymph vessels.
If the valves inside the testicular (spermatic) veins are defective or the venous drainage of the
testicle is compressed, blood will be prevented from flowing properly, the blood will back up,
leading to dilatation of the veins in the pampiniform plexus (1). This is called a varicocele - you
may be able to feel a non-tender, twisted mass along the spermatic cord (it feels like a bag of
worms). NB. There are other reasons why varicoceles may develop which are beyond the scope
of this session.
The testis is a firm ovoid body surrounded on its lateral, anterior and medial surfaces by the
tunica vaginalis – a closed sac invaginated from behind by the testis. Efferent ductules connect
the testes to the head of the epididymis, a coiled tube nearly 6m long. It lies posterior to the
testis.
The vas deferens, a thick walled muscular duct which transports spermatozoa from the
epididymis to the urethra, emerges from the tail of the epididymis and ascends medially to enter
the spermatic cord. The vas deferens can be palpated between the finger and thumb in the
posterior aspect of the cord in the upper part of the scrotum.
Penis
This consists of a root, body and distal glans.
The dorsal surface is located anteriorly, its ventral surface is in contact with the
scrotum. The two corpus cavernosum lie dorsally and the urethra is situated ventrally.
The base of the glans is encircled by the corona and foreskin attachment which
extends onto the ventral aspect of the glans via the frenulum.
The normal site of the external urethral meatus is at the tip of the glans. Hypospadias is a
common abnormality, occurring as a result of incomplete fusion of the urethral groove producing
a urethral meatus located in an aberrant location on the ventral surface of the penis. The
meatus can be located anywhere along the ventral penile shaft from the meatus distally to the
perineum proximally
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
Inguinal lymph nodes
There are two types of inguinal lymph nodes located below the inguinal ligament – superficial
and deep.
The superficial inguinal lymph nodes (about 10 in total) form a chain underneath the inguinal
ligament between the borders of the sartorius muscle and the adductor longus muscle. These
lymph nodes drain into the deep inguinal lymph nodes.
The deep inguinal lymph nodes (between 3 and 5) are located deeply on the medial side of the
femoral vein.
Clinical reasoning

Skin lesions and rashes will be covered elsewhere in the course. Some conditions and
infections are more common in the genital area than others.

Urethral discharge usually relates to infection (Chlamydia, Gonorrhoea and others) and
warrants further investigation and management.

An undescended testicle is at increased risk of malignant change (so always check
that there are two), even once it has been surgically brought down to the scrotum (so a
particularly careful examination is recommended in these patients, and it would be very
relevant to ensure that they are able to examine themselves).

Scrotal swellings /masses
Scrotal masses can be categorized by the origin of the mass:
Origin
Testicle
Testicle
(with marked
tenderness)
Mass
Malignancy
Testicular
torsion
Testicular
infection
(Orchitis/
Features
Nodules that you are not able to feel as separate from
the testis are malignant until proven otherwise. May be
tender or non-tender, overlying skin may be normal or
erythematous. Remember that the lymphatic drainage
of the testes is principally to the intra-abdominal paraaortic nodes.
Occasionally small testicular lumps may represent old
scarring or adherent epididymal cysts.
An urgent ultrasound is essential
A surgical emergency (leads to necrosis). Very
tender, often a sudden onset, abdominal pain,
nausea and vomiting, absent cremester reflex.
Often red scrotal skin and elevated horizontal lie of the
affected testis
Tenderness, sometimes quite marked, often more
insidious onset and may or may not be related to
urinary symptoms. Always think torsion and be sure
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
epidimoorchitis)
Various origins
(Inability to feel
testicle
because of
scrotal mass)
Hydrocele
Epididymal
cysts
Epididymis
Epididymal
thickening
Varicocele
Above the testis
Indirect
inguinal hernia
you have excluded it.
The testis may be embedded within a tense sack of
fluid called a hydrocele, which may be
congenital or acquired. Transillumination may
help with this diagnosis, but an ultrasound is
recommended to exclude testicular malignancy.
These small cysts originate from either the
anterior or posterior head of the epididymis.
They are palpated as separate from the testis, and
generally have very little clinical
significance.
A normal epididymis feels rather like a plastic bag
between your fingers, thin, non-tender and slightly
slippery. Tender thickening of the epididymis may
represent active infection (“epididymitis”). Non-tender
thickening may represent old infection or trauma.
These classically feel like a “bag of worms” and tend to
disappear on lying flat. Usually idiopathic and slow to
develop. They are more common in men aged 15-25
and occur more commonly on the left.
Always consider secondary causes of varicoceles
e.g. a renal tumour, a retroperitoneal tumour – you
should read about the clinical presentation of these
varicoceles.
Varicoceles are often the cause of infertility in men.
Usually reducible (unless incarcerated), can’t get
above it (originates in abdomen), may have bowel
sounds, likely to have a cough impulse unless
strangulated. If any features of strangulation, then
urgent review required.
Skill: Male genital and scrotal examination
MBBS4 Year 1: Tutor Notes 2015-16. Lead Lecturer: Dr Hamed Khan
Further Reading & References
STD’s:
 Adler, M. W. (2004). ABC of sexually transmitted infections. London, BMJ Books.
 Wisdom, A. (1989). A colour atlas of sexually transmitted diseases, Wolfe.
Surgery


Ellis H, Calne R, Watson C (2006) Lecture Notes General Surgery 11th Edition,
Blackwell, Oxford.
McLatchie G, Borley N, Chikwe J (ed) (2007) Oxford Handbook of Clinical
Surgery 3rd Edition, Oxford University Press, Oxford
Chaperones & Consent for intimate examination
 GMC guidance on intimate examinations and chaerones http://www.gmcuk.org/static/documents/content/Intimate_examinations_and_chaperones.pdf
 Coldicott, Y., Pope, C., Roberts, C., Nesheim, B.-I. & Macdougall, J. 2003. The ethics of
intimate examinations---teaching tomorrow's doctors * Commentary: Respecting the
patient's integrity is the key * Commentary: Teaching pelvic examination---putting the
patient first. BMJ, 326, 97-101.
 Stott, D. 2008. Chaperones for intimate examinations. Student BMJ, 16.
Other references
1. Varicocele. Department of Urology James Buchanan Brady Foundation available
athttps://www.cornellurology.com/clinical-conditions/male-infertility/generalinformation/varicocele/ [Accessed 30/7/2013]
2. Palpation of the hernia available at
http://www.gpnotebook.co.uk/simplepage.cfm?ID=731512836&linkID=9797&cook=yes
[Accessed 30/7/2013]
Acknowledgements
This resource was adapted from a skills sheet “The systematic male genital examination” by Dr.
Dason Evans, and the MBBS4 skills sheet “Principles of intimate examination Scrotal and male
genital examination” by Deborah Horton and ‘Examination of the groin, the hernia orifices and
the male external genitalia’ by Scarpa Shoeman and the DVD “Examination of the groin, the
hernial orifices and the male external genitalia” by Scarpa Schoeman. With thanks to Dr. Laura
Tincknell for reviewing the hernia examination part of the notes.