1. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Chapter 19
Male Genitalia
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.

2. Male Genitalia
Examination of the male genitalia is typically performed:
When patient has a specific complaint
As part of the newborn examination
As part of an overall well child or well person examination
In adults, examination of the anus, rectum, and prostate (see Chapter 20) is often performed at the same time. 2

3. Male Genitalia
Inspect the pubic hair characteristics and distribution.
Retract the foreskin if the patient is uncircumcised.
Inspect the glans of the penis with foreskin retracted, noting the following:
Color
Smegma
External meatus of urethra
Urethral discharge 3

4. Male Genitalia (Cont.) Palpate the penis, noting the following:
Tenderness
Induration
Strip the urethra for discharge. 4

5. Male Genitalia (Cont.)
Inspect the scrotum and ventral surface of the penis for the following:
Color
Texture
Asymmetry
Lesions
Unusual thickening
Presence of hernia
Transilluminate any masses in the scrotum. 5

6. Male Genitalia (Cont.)
Palpate the inguinal canal for a direct or indirect hernia.
Palpate the testes, epididymides, and vas deferens for the following:
Consistency
Size
Tenderness
Bleeding, masses, lumpiness, or nodules
Palpate for inguinal lymph nodes.
Elicit the cremasteric reflex bilaterally. 6

7. Male Genitalia Penis Testicles Epididymis Scrotum Prostate gland
Seminal vesicles 7

8. Male Genitalia (Cont.) Penis Penis function Corpora cavernosa
Corpus spongiosum
Urethra/orifice
Prepuce
Penis function
Excretes urine
Introduces sperm into vagina 8

9. Male Genitalia (Cont.) Scrotum Septum Testis Epididymis Spermatic cord
Muscle layer
Cremasteric muscle 9

10. Male Genitalia (Cont.) Testicular functions Epididymal functions
Spermatogenesis
Testosterone production
Epididymal functions
Storage/maturation/transit of sperm
Vas deferens begins at the tail of the epididymis, ascends the spermatic cord, travels through the inguinal canal, and unites with the seminal vesicle to form the ejaculatory duct 10

11. Male Genitalia (Cont.) Prostate gland
Approximately the size of a testis
Surrounds the urethra at the bladder neck
Produces the major volume of ejaculatory fluid
Contains fibrinolysin, which liquefies the coagulated semen―important in sperm motility 11

12. Male Genitalia (Cont.) Sexual physiology
Erection of the penis occurs when the two corpora cavernosa become engorged with blood.
Increased blood supply is produced by increased arterial dilation and decreased venous outflow.
Autonomic nervous system
Local synthesis of nitric oxide
Ejaculation during orgasm consists of the emission of secretions from:
Testes
Vas deferens
Epididymides
Prostate
Seminal vesicles
Orgasm is followed by constriction of the vessels supplying blood to the corpora cavernosa and gradual detumescence. 12

13. Infants and Children Sexual differentiation by 12 weeks’gestation
During the third trimester, the testes descend from the retroperitoneal space through the inguinal canal to the scrotum
Descent of testes may occur after birth.
Complete separation of prepuce from the glans at about 3 to 4 years in uncircumcised males 13

14. Adolescents Puberty: functional maturation of reproductive organs
Increased size
Penis
Enlarges in length and breadth
Testes
Scrotal skin reddens, thins, and becomes increasingly pendulous.
Development of pubic hair 14

15. Older Adults Pubic hair becomes finer and less abundant.
Pendulous scrotum
Decreased sexual activity
Slower erection
Orgasm less intense 15

16. History of Present Illness
Difficulty achieving and maintaining erection
Pain
Constant or intermittent, with one or more sexual partners
Associated with alcohol ingestion or medication
Medications: diuretics, sedatives, antihypertensive agents, anxiolytics, estrogens, inhibitors of androgen synthesis, antidepressants, carbamazepine, erectile dysfunction agents 16

17. History of Present Illness (Cont.)
Persistent erections unrelated to sexual stimulation
Curvature of penis in any direction with erection
Difficulty with ejaculation
Painful or premature, efforts to treat the problem
Ejaculate color, consistency, odor, and amount
Medications: alpha-blockers, antidepressants, antipsychotics, clonidine, methyldopa 17

18. History of Present Illness (Cont.)
Infertility
Lifestyle factors
Time attempting pregnancy
Sexual activity pattern
History undescended testes
Diagnostic evaluation to date
Medications: testosterone, glucocorticoid steroids, hypothalamic releasing hormone 18

19. History of Present Illness (Cont.)
Enlargement in inguinal area
Intermittent or constant, association with straining or lifting, duration, presence of pain
Change in size or character of mass; ability to reduce the mass
Pain in groin
Efforts to treat
Medications: analgesics 19

20. History of Present Illness (Cont.)
Testicular pain or mass
Change in testicular size
Onset
Lumps
Soreness
Heaviness
Medications: analgesics, antibiotics 20

21. Past Medical History Surgery of genitourinary tract STDs
Undescended testes, hypospadias, epispadias, hydrocele, varicocele, hernia, prostate; vasectomy
STDs
Single or multiple infections, specific organism (gonorrhea, syphilis, herpes, warts, Chlamydia), treatment, effectiveness, residual problems
Chronic illness
Testicular or prostatic cancer, neurologic or vascular impairment, diabetes mellitus, arthritis, cardiac or respiratory disease 21

22. Family History Infertility in siblings
History of prostate, testicular, or penile cancer
Hernias
Peyronie disease (contracture of penis) 22

23. Personal and Social History
Occupational risk of trauma to suprapubic region or genitalia, exposure to radiation or toxins
Exercise risks
Concerns about genitalia
Testicular self-examination practices
Concerns about sexual practices
Reproductive function
Use of alcohol and drugs 23

24. Infants and Children Maternal use of sex hormones
Circumcised: complications
Uncircumcised: hygiene measures
Scrotal swelling with crying or bowel movement
Congenital anomalies
Masturbation and sexual exploration
Swelling or sores on penis or scrotum
Concern of sexual abuse 24

25. Adolescents Knowledge of reproduction and sexual function
Presence of nocturnal emissions, pubic hair, enlargement of genitalia, age at time of each occurrence
Concern of sexual abuse
Sexual activity, protection used for contraception and STI prevention 25

26. Older Adults Change in sexual desire or activity
Change in sexual response
Longer time required to achieve full erection
Less forceful ejaculation
More rapid detumescence
Longer interval between erections
Prostate surgery 26

27. Inspection and Palpation
Genital hair distribution
Coarseness
Abundance
Penis
Dorsal vein
Foreskin retraction
Texture
Tenderness or induration
Discharge 27

28. Inspection and Palpation (Cont.)
Urethral meatus
Orifice size and location
Color and moisture
Scrotum
Color
Texture
Cysts
Edema 28

29. Inspection and Palpation (Cont.)
Hernias
Inguinal
Indirect
Direct
Femoral
Testes
Tenderness
Texture
Nodules 29

30. Inspection and Palpation (Cont.)
Epididymis and vas deferens
Texture
Tenderness
Cremasteric reflex
Stroke the inner thigh with a blunt instrument.
Testicle and scrotum should rise on the stroked side.
Prostate
Detailed in Chapter 20 30

31. Infants Inspect and palpate Transilluminate scrotum if mass found
Congenital anomalies
Incomplete development
Sexual ambiguity
Urethral placement
Retractability of foreskin
Descent of testicles
Masses
Transilluminate scrotum if mass found 31

32. Children Inspect and palpate Penis Foreskin retraction Scrotum Testes
Size, lesions, swelling, inflammation, and malformation
Foreskin retraction
Scrotum
Descent of testes
Testes
Masses 32

33. Adolescents
Examination of older children and adolescents is the same as for adults.
Allay anxiety.
Protect privacy.
Inspect and palpate.
Expected maturational changes 33

34. Older Adults
Examination procedure for older adults same as that for younger men
Age-related changes
Graying and less abundant pubic hair
Pendulous scrotal sac and contents 34

35. Abnormalities Hernia Strangulated hernia
Protrusion of a peritoneal-lined sac through some defect in the abdominal wall
Indirect: soft swelling in area of internal ring
Direct: soft swelling that bulges anteriorly
Femoral: occurs at the fossa ovalis, where the femoral artery exits the abdomen
Strangulated hernia
Nonreducible hernia in which the blood supply to the protruded tissue is compromised
Requires prompt surgical intervention 35

36. Abnormalities (Penis)
Syphilitic chancre
Skin lesion associated with primary syphilis
Paraphimosis
Inability to replace the foreskin in its usual position after it has been retracted behind the glans
Hypospadias
Congenital defect in which the urethral meatus is located on the ventral surface of the glans penile shaft or the base of the penis 36

37. Abnormalities (Penis)
Herpes
Genital herpes is sexually transmitted infection caused by herpes simplex virus (HSV-2)
Condyloma acuminata
“Genital warts” caused by human papillomavirus (HPV)
Lymphogranuloma venereum
Sexually transmitted infection of the lymphatics caused by Chlamydia trachomatis 37

38. Abnormalities (Penis)
Molluscum contagiosum
Benign skin infection caused by a poxvirus that infects only the skin
Peyronie disease
Fibrous band in the corpus cavernosum causing bending and/or indentation of the erection
Penile cancer
Squamous cell carcinoma usually originating in the glans or foreskin 38

39. Abnormalities (Scrotum)
Spermatocele
Benign cystic accumulation of sperm occurring on the epididymis
Hydrocele
Fluid accumulation in the scrotum
Varicocele
Abnormal tortuosity and dilation of veins of the pampiniform plexus within the spermatic cord
Orchitis
Acute inflammation of the testis secondary to infection 39

40. Abnormalities (Scrotum)
Epididymitis
Inflammation of the epididymis often seen in association with a urinary tract infection
Testicular torsion
Twisting of testis on spermatic cord
Surgical emergency 40

41. Scrotum (Cont.) Testicular cancer Klinefelter syndrome
Seminomas and nonseminomas arise from germ cells (sperm-producing cells).
Klinefelter syndrome
Congenital anomaly associated with XXY chromosomal inheritance 41

42. Infants Ambiguous genitalia
Newborn’s genitalia are not clearly either male or female.
Presence or absence of male hormones controls the development of the sex organs during fetal development. 42