CHAPTER 10

The Male Genitalia

Doctors are aware and sensitive to the fact that patients in general are anxious about the physical examination, particularly as this relates to the examination of a man's genitals. For example, adolescents and men may fear experiencing an erection while being examined. However, such an occurrence is unlikely. In addition, boys and adolescents may worry about whether their genitals are normal. Since there is variation in the size and appearance of the genitals, as there are in all the rest of our body parts, rest assured, in most cases, you're "normal".

Physicians understand these feelings in their patients, and therefore make every effort to examine the genitalia carefully, completely, but also briskly!

The Physical Examination of the male genitalia begins with a visual inspection of the genitals followed by palpation of both the external and internal organs. [ Figure 10A ]

Visual Inspection: During the visual inspection the doctor notes the distribution of pubic hair and the size of the penis and testicles. The secondary sex characteristics are assessed in relationship to the patient's age and general development. The onset of adult development varies from one person to the next. Pubic hair appears and the testicles enlarge between the ages of 12 and 16 years of age. Enlargement of the penis and the ability to ejaculate semen usually occurs between the ages of 13 and 17 years of age.

The Penis: The penis is observed for such things as discharge, the presence of lumps or small knots, wounds or lesions, as well as inflammation and swelling. If the patient is not circumcised, he is asked to retract the foreskin from the head (glans) of the penis so that the glans and foreskin may be observed. The patient is also asked to squeeze the glans so that the doctor may observe the opening at the end tip (meatus) of the penis. If any discharge is observed, a smear is made of the secretion. This is done for the purpose of determining, through culture, the cause of the discharge. If, while taking the history, the patient reports a penile discharge, he is asked to squeeze (milk) the penis from the base to the meatus. If a discharge is present, it is cultured.

The more common penile lesions which are apt to be observed may be syphilitic chancre, condulomata acuminata (venereal warts), and cancer. (The first two listed are sexually transmitted diseases). The syphilitic chancre is the primary lesion of syphilis. It begins as a single pointed pimple that eventually develops into a crater-like ulcer that discharges the germ that causes the disease. As bad as it may appear, it is usually painless. Condylomata acuminata may occur on the glans, foreskin, or shaft of the penis. These growths may either be pink or red in color with a cauliflower-like appearance.

Carcinoma (cancer) of the penis usually appears on the glans and on the inner lip of the foreskin. It may appear dry and scaly, ulcerated, or like a small rounded mass or lump. It is usually painless.

The meatus on most men appears at the end tip of the glans, in the middle. If this opening, however, is on the underside of the glans, but still on the bottom of the glans, the condition is called hypospadias. Urethral openings further back and away from the glans on the underside of the shaft of the penis are referred to as epispadias.

In uncircumcised men it should be easy to pull the foreskin back over the glans of the penis and return it to its original position. Phimosis is a condition in which this is not possible to do. In other words, the foreskin cannot be pulled over the head of the penis. In this situation it is not possible for the doctor to observe the glans or interior surfaces of the foreskin. This condition may also present problems with personal cleanliness. A condition in which the foreskin can be retracted over the glans, but cannot easily be returned to its original position because it tightens around the glans, is called paraphimosis.

Palpation: The shaft of the penis is palpated to determine if there are hard plaque-like structures lodged inside the shaft of the penis in the spongy tissue responsible for erections. The presence of these fibrous structures may make erection painful and penetration during sexual intercourse impossible. This condition is known as Peyronie's Disease.

The Scrotum: With the patient holding his penis out of the way, the doctor is able to visually inspect the scrotum for its general size, appearance and symmetry. The scrotum is naturally more deeply pigmented than the body skin and has a wrinkled appearance. In most men, the left testicle hangs lower than the right one; this is so because the left spermatic cord is generally longer than the right one. Normally, the scrotum hangs loosely from the body; however, influences such as temperature, sexual stimulation, emotional states and age can cause it to move closer up to the body.

Palpation: The scrotum is palpated by spreading out the wrinkled surface of the scrotal sack. This allows for visual inspection to determine if there may be abnormal growths on the scrotum such as sebaceous cysts. (A cyst is a bladder-like sac found in tissue which contains fluid or semi-fluid matter). Sebaceous cysts are firm in texture. They may appear yellow to white in color and are not tender to the touch. These skin lesions may measure up to 1 cm. in diameter.

An unusual thickening of the scrotum caused by an accumulation of fluid in the scrotal sac generally is associated with cardiovascular, kidney or liver disease. The doctor palpates the testicles using the thumb, index and middle fingers. [ Figure 10B ] The testicles should be sensitive when gently squeezed, but not tender. They should feel smooth and rubbery to the touch, and be free of any bumps or lumps called nodules. In some diseases such as syphilis, a testicle may become completely insensitive to excessive squeezing. Irregularities in the structure or size of the testicles may indicate an infection, cyst or tumor.

Testicular Cancer: While cancer of the testicles is a rare form of cancer, the majority of these cancers occur in young to middle aged men between 20 and 44, a time in life when men may be concerned with fertility and planning for a family. The American Cancer Society estimates there are approximately 5,500 cases of testicular cancer that occur in the United States each year. Four hundred of these cases end in death yearly.

Given that the best line of defense against any disease is an informed consumer, men should learn as much as they can about their own bodies, including how to examine their testicles as a preventive measure in early detection of testicular cancer. This simple test is known as testicular self-examination (TSE) and should be performed once a month. It is best done following a warm shower or bath when the skin of the scrotum is relaxed, making it easier to feel anything unusual.

The man should stand in front of a mirror and gently roll each testicle between his thumb and fingers of both hands. If he detects lumps or any other changes from his previous examinations, he should report them to his doctor immediately.

The Epididymis: The doctor next palpates the epididymis, which is a maze of tiny ducts that make up this C-shaped structure that adheres to the back and upper surface of each testicle. These organs are examined to assess their size, shape, consistency, and to determine if there is any tenderness.

A painful disease of the epididymis known as epididymitis may include a sensation of heaviness in the affected testicle, inflammation of the scrotum, accompanied by the formation of a small area of hard, painful swelling at the bottom of the testicle. This inflammation is usually associated with a urinary tract infection; however, times of excessive stress may cause these symptoms to appear as well.

The Vas Deferens: The vas deferens are long, thin ducts that come away from each testicle, travel up through the scrotum inside the spermatic cord, and up into the abdomen through the inguinal canal. The doctor palpates the vas deferens by grasping each between the thumb and index finger. They should feel like smooth cords that are movable. These structures should not feel beaded or lumpy as the doctor traces them along their path on either side from each testicle to the external inguinal ring, the point at which they enter the abdomen.

Inguinal Hernias: Essentially, a hernia is the protrusion or projection of an organ through the wall of the cavity which normally contains it. Inguinal hernias are conditions in which the inguinal canals serve as passageways for the intestines to protrude through the inguinal canal and into the scrotum. This happens when there is a weakness in the abdominal muscles that separate the abdomen from the inguinal canals.

The inguinal canals are the passageway through which the spermatic cords pass from the abdomen into the scrotum. It is this passageway that the testicles follow in descending from the abdominal cavity (where they develop embryonically) into the scrotum just before birth. One and one half inches in length, they have an internal opening where they meet the abdomen called the internal ring. The other end that opens into the scrotum is called the external ring.

There are two types of inguinal hernias: direct and indirect.

1. Direct Inguinal Hernias: The doctor examines for direct inguinal hernias by placing two fingers over each external ring and instructing the patient to bear down as if having a bowel movement. The presence of a direct hernia will produce a bulge that the doctor can feel.
2. Indirect Hernias: The hernia is indirect if it lies up inside the inguinal canal. To determine the presence of an indirect hernia, the doctor inserts a finger into the path of the inguinal canal. [ Figure 10C ] When the finger passes as far as it will go, the patient is asked to turn his head (so he won't cough on the doctor) and cough. A hernia, if present, will be felt as a mass of tissue meeting the finger and then withdrawing. In cases of extreme weakening of the abdominal musculature, the intestine may pass all the way through the inguinal canal and into the scrotum. Indirect hernias occur more frequently in young men and are the most common of the abdominal hernias.

Examination of the Anus, Rectum and Prostate: While it is recognized that the rectal examination is generally uncomfortable and embarrassing for the patient, it provides such important information that it cannot be overlooked as part of a comprehensive and thorough examination of the body.

Visual Examination: The first thing the doctor does in visually inspecting the anal region is to look for the presence of lumps, rashes and inflammations. In carefully inspecting the anus itself, the doctor looks for skin lesions, warts and external hemorrhoids.

Palpation of the Anus, Rectum and Prostate: This examination is done with the patient standing, hips flexed, with his upper body bent over, supported by the examining table.

Carefully placing the pad of the index finger over the anal opening, the doctor gently pushes the finger into the rectum. The patient is asked to bear down to relax the anal muscles. As relaxation occurs, the tip of the finger more easily enters the anal canal. The patient is warned that there may be a feeling of urgency for a bowel movement. The doctor rotates the finger to examine the muscular structures within. Inserting the finger still further, the doctor feels for any irregularities like tenderness, lumps, masses of tissue, polyps or internal hemorrhoids. The walls of the rectum should feel smooth and even. The doctor next palpates the prostate gland. [ Figure 10D ] Feeling this organ may make the patient feel like he wants to urinate but he will not. The doctor notes the size, contour, consistency and the mobility of the prostate gland. The gland should feel like a pencil eraser -- firm, smooth, and slightly movable. It should not be tender. Any deviations from the normal size, shape and consistency of the prostate gland may be indicative of enlargement of the gland, which may lead to difficulties in urinating. The presence of lumps or a change in its consistency may indicate cancer.

The Prostate Gland: The prostate gland is a structure about the size and shape of a chestnut. Anatomically, it is located at the base of the bladder. The urethra, the tube that conveys urine from the bladder through the penis to the outside, passes through the prostate gland. During sexual excitement, sperms move into the prostate gland and mix with various secretions produced by the prostate gland and seminal vesicles to make up semen. At the time of ejaculation, the prostate gland contracts, ejecting the semen through the urethra. Thus the prostate gland plays a significant and important role in a man's sexuality. Like all organs of the human body, it too is subjected to various infections and diseases.

Among some of the more common ailments of the prostate gland are prostitis and cancer.

Prostatitis is a condition in which the prostate gland becomes enlarged and inflamed, usually as a result of various infectious agents (like those responsible for sexually transmitted diseases). This condition may occur in men of any age. Symptoms may include difficulty in urinating, feelings of urgency to urinate frequently, a burning sensation while urinating, bloody semen, cloudy penile discharge, aching testicles, pain in the pelvic area or base of the penis, back ache, lower abdominal ache, and difficulties with sexual functions, like painful erections or ejaculations.

Cancer of the Prostate Gland: According to the American Cancer Society, approximately 22,000 men die from this form of cancer each year. As with most cancers, early detection can provide early diagnosis and treatment. Consequently, it is important for men to know and be aware of the signs and symptoms of this disease, which may include many of those already listed above for prostatitis. Men should also be sensitive to weak or interrupted flow of urine, inability to urinate, or the presence of blood in the urine. Persistent low back pain or pain in the upper thighs and pelvic area should also be reported to a doctor. Since the potential for developing this form of cancer becomes greater with increasing age, an annual rectal examination for men over 40 years of age is highly recommended.

Chapter 11