Male Genital Examination Procedure

Harrell Professional Development and Assessment Center

Preparation and Beginning the Examination

Prepare supplies and explain procedure to the patient. Gloves are used throughout.
Patient is gowned with opening to the front and clothing on upper torso. Ask him to stand comfortably at the end of the exam table with feet about shoulder width apart. If necessary, the exam can also be done with the patient supine.
Position for the examiner: seated on a low rolling stool in front of the patient.
Before you sit down, say to the patient, "I will examine your penis, scrotum, and testes. I will also instruct you on how to perform a Genital Self Exam (GSE). This should not cause discomfort; however if you feel discomfort, please let me know."
Examiner should forewarn patient of contact by saying, "I will begin by examining the outer genital area."

General Inspection and considerations:

Assess sexual maturity by visual inspection.

Note hair pattern.
Note -size and shape of penis and testes.
Note color and texture of scrotal sac.

Throughout exam, inspect for pubic lice or excoriations suggestive of lice or scabies. Look for ulcers, scars, nodules, discoloration, inflammation, lesions, rashes, genital warts and masses.
If erection occurs at any time during exam, assure patient this is a natural reaction, and continue exam.
As you perform the exam, instruct the patient on how to perform Genital Self Exam. The patient may use a mirror to visualize all areas.

Palpation and Inspection of the Penis

Gently grasp shaft of penis and inspect all side, including the inferior side and base of the penis. Inspect the glans for ulcers, scars, nodules, inflammation and hygiene. If a mass or irregularities are located, determine if attached to the shaft or to the foreskin.
Retract any foreskin present or ask patient to retract.
Foreskin should be easily retractable from glans. Phimosis is a tight foreskin that cannot be retracted and paraphimosis is a tight prepuce that once retracted cannot be returned causing edema. Smegma or a white cheesy material may accumulate normally under the foreskin.
Patient or examiner should replace the foreskin.
Examine urethra meatus and note position and size of opening. Hypospadias is a congenital, ventral displacement of the meatus.
Open the distal end of the urethra by compressing the glans between the index finger and thumb. Inspect inside the opening for discoloration, inflammation, discharge, or lesions.

Scrotum and its contents

Examine all sides of the scrotum by having patient flex leg on side being examined to increase access to area.
Lift the scrotum to visually inspect the posterior side and examine the scrotal sac by rolling the skin between the fingers of one or both hands.
Gentle palpation should diagnose common problems such as a hydrocele, varicocele, testicular lesions, and inguinal hernias.
Take note that any swelling within the scrotum should be transilluminated for further evaluation.
Testes should feel smooth and glassy in texture, note size (4 cm), shape, and symmetry (left may hang slightly lower). Individually examine each testicle between the fingers of one hand for nodules, masses, or tenderness. A grainy texture indicates an irregularity i.e. testicular cancer. Avoid excessive pressure during palpation, which could cause a deep aching sensation for the patient.
Gently palpate the epididymis between the thumb and index finger. It lays at the back of the testes and moves with the testes, yet can also move independently. The texture feels like a "cluster of soft noodles".
Next palpate the spermatic cord and vas deferens between the thumb and index finger. To aid in locating the spermatic cord and vas deferens: gently grasp the scrotal sac between the thumb the thumb and index finger close to the base, of the penis. Move thumb / finger outward laterally until contact is made. Spermatic cord feels like a soft, pliable tubing. The vas deferens usually can be felt as a separate, movable cord within the tubing.
Ask patient to flex other leg and repeat procedures on remaining side.

Lower Abdomen: Examining the lymph nodes and inguinal Canal

Tell the patient, "I am going to examine lymph nodes in the lower abdominal area and check for hernias"
Visually inspect the femoral and inguinal area. Using the pads of the fingers of one hand, palpate for any bulges or protrusions.
Repeat on the opposite side.
Tell the patient, "I am going to examine the canal which runs along your groin area for any hernia. I will be inserting my finger into the canal. You should feel some pressure. If you feel any other discomfort please let me know.
Positioning for patient and examiner: Ask patient to flex the leg on the side examiner will be evaluating, use the right hand for the patient's right side and left hand for the patient's left side.
Insertion Technique: gather enough loose skin from the base of the scrotal sac so that there will be comfortable insertion of the finger. Avoid entrapment of the testicle or spermatic cord as you gather the skin. The spermatic cord moves upward through the slit opening of the inguinal ring and into the inguinal canal. Follow the spermatic cord up towards the inguinal canal. The inguinal canal is parallel to and about 1 cm above the inguinal ligament. Examiner should follow the cord in an oblique angle. Direct the one finger into the inguinal canal approximately 1-2 cm below the surface. Avoid directing the finger into the body.

Evaluation of Hernias:

On insertion, if a mass or resistance is felt do not attempt to continue.
If no mass is felt, ask patient to bear down or turn his head and cough. These techniques will cause most hernias to present.
Examiner may want to place fingers of free hand over inguinal canal during maneuvers to aid in evaluation of the area.
Avoid excess movement of finger during invagination of loose scrotal skin and removal.
Evaluate for two types of hernias: direct inguinal hernia can be felt pressing on the side of the examiner's finger and an indirect inguinal hernia can be felt pressing on the tip of the examiner's finger. Slowly remove finger in the same oblique angle.

Rectal Examination:

Inform the patient that, "I am going to examine the anus, rectum, and the prostate. I will be inserting my finger into the rectum. You should feel some pressure, but if you feel any other discomfort; please let me know. "
A standing position for the patient is most commonly used and the patient should be facing the end of the exam table, bending over with arms resting on table, feet should be slightly separated, and one leg should be slightly flexed or resting on a stool.
The left-lateral or Sims position is most frequently used for non-ambulatory patients.
Generously lubricate the index finger of the gloved dominant hand with lubricant.
Ask patient to lift his gown above the waist. Separate the buttocks with two hands and visually inspect the area for lesions, rashes, and masses. Visually inspect the anus for fissures, hemorrhoids, skin tags. Use thumb and index finger of non-dominant hand to separate buttocks for digital insertion. Place index finger of gloved dominant hand at the anal opening.
Instruct the patient, "To make the insertion of my finger into the rectum more comfortable, please bear down as though you were going to have a bowel movement. You will only feel pressure. "
Apply gentle posterior pressure and slowly insert finger palmar surface down.
Insert fingers in downward angle towards umbilicus.
Allow a few seconds for the external and internal sphincter to relax.
Evaluate the tone of the sphincter muscles as inserting finger and rotate finger 360° to evaluate anal sphincter muscle ring.
Evaluate all four walls of the rectum: posterior, left lateral, anterior, and right lateral. Rotate finger 360 degrees during exam to ensure proper palpation.
Stool is usually present, but is soft and mobile. Tumors or polyps are firmer and fixed. Gently palpate levator ani muscles attached at the posterior and lateral walls of the rectum for muscle tone, if possible.

Prostate Examination

To examine the prostate, position finger palmar surface down and palpate posteriorly to locate prostate. Palpate in a circular motion to increase ability to identify the lobes and groove.
The prostate should be 2-4 cm long and triangular. The two lateral lobes are separated by a deeper central grove. Note the following: width and length of gland, presence of groove, mobility, tenderness, enlargement and nodules.
Consistency should be firm and rubbery. Softness can occur with infection and hardness can occur with tumors and diseases. The seminal vesicles are soft, elongated structures extending above the prostate. These are normally not palpable.
Examiner should forewarn patient before removing finger and remove slowly to avoid any sphincter muscle spasms.
Any feces on finger of gloved hand should be tested for occult blood.

Completing the Examination:

Remove glove away from and out of sight of patient.
Offer patient box of tissues to remove lubricant from anus and buttocks.
Conclude with a reassuring statement. Allow patient privacy to dress.
Discuss findings of examination with patient in office.