1 What are the main components of the male reproductive system?

The penis, the scrotum (with testicle, epididymis, and deferens), the seminal vesicles, and the prostate (Fig. 16-1).

Figure 16-1 Male pelvic anatomy.

(From Meszaros G: Crash Course Endocrine and Reproductive Systems. St. Louis, Mosby, 2006.)

2 What is the best technique for examining male genitalia?

The same as for examining the rectum: with the patient either standing up or lying down on one side. Still, it is probably easier to assess the testes (and search for hernias) with the patient standing up and the examiner seated in front of him.

3 What should I focus on during inspection of this region?

(1) Penis

4 Describe the anatomy of the penis.

The penis consists of a shaft, formed by three juxtaposed columns of spongy and vascular tissue: the corpora cavernosa. These can be temporarily filled with blood, thus providing a unique erectile capacity to the organ. The distal tip of the penis consists of a cone-shaped structure called the glans (“acorn” in Latin), which contains the vertical slit-like opening of the urethra (urethral meatus). The glans is separated from the shaft by a circular sulcus called the corona (“crown” in Latin), which in uncircumcised men is covered in a hood-like fashion by the prepuce or foreskin, a fold surgically removed during circumcision. All areas must be examined (see Fig. 16-2).

Figure 16-2 Structure of the penis.

(From Meszaros G: Crash Course Endocrine and Reproductive Systems. St. Louis, Mosby, 2006.)

5 What steps should I take to properly examine the penis?

The first, of course, is precautionary: put on a pair of gloves because some sexually transmitted diseases (including syphilis) can be acquired through simple skin abrasions. With gloves on, examine the penis by first palpating the shaft, and then by carefully looking for areas of induration or tenderness. Then, look for unusual curvatures (see Peyronie’s disease, question 47). Retract the prepuce to gain access to the glans, and inspect it for abnormalities. After completing the exam, return the foreskin to its original position since failure to do so may cause severe edema in unconscious patients. Finally, gently compress the glans between your thumb and forefinger to visualize the urethral meatus, and possibly express secretions. Note that this maneuver may be unyielding even in patients with a history of penile discharge. In this case, milk the shaft of the penis (from its base to the glans), since this may produce a few precious drops for analysis. Finally, examine the base of the penis for hair or skin abnormalities.

6 What is priapism?

A fancy term for a protracted erection, usually associated with pain. If we look back at the American presidency, we might conclude that priapism qualifies as a White House occupational hazard, were it not for the fact that this condition is usually not associated with sexual desire. The term “priapism” is actually rooted in Greek mythology, specifically in Priapus, one of the many illegitimate sons of Zeus, King of the Gods (which confirms our suspicion that power and sex may be linked, at least among American presidents and Greek deities). According to tradition, Hera (Zeus’ unfortunate wife) found out about this umpteenth illicit affair of her husband and decided to attend the child’s birth, to cast a mortal spell on the baby. Things, however, did not go as expected, since Priapus was born so well endowed that Hera, taken by surprise, completely missed her chance. Hence, the baby was rushed to safety, and a new medical term was born. Priapism eventually came to signify a condition characterized by chronic, protracted, and painful erections. Still, Priapus also prompted great respect for the penis, which became a symbol not only of fertility, but also of luck, since it had literally saved his owner’s life. From that time on, Romans developed a penchant for wearing little phalluses around their neck, usually made in coral (because of its apotropaic virtue [i.e., the ability to ward off the evil eye]), but occasionally also in gold. They also carved phalluses on buildings—as hopeful lucky charms. For example, the great Roman wall erected (no pun intended) in England by Emperor Hadrian during the 1st century AD was riddled with various penile carvings, still visible today and accurately catalogued in local museums by serious British archeologists. Stone phalluses were supposed to bring good luck to the wall’s defenders but unfortunately fell short of expectations: Hadrian’s wall was pierced by raiding Scots and Picts and eventually abandoned. The reverence for the penis, however, continued unabated throughout the Mediterranean basin. Indeed, in some parts of Italy and Greece (not to mention South Philadelphia) it is still possible to see golden pricklets hanging from people’s necks, a reminder of the long-lasting value of Greek mythology and penile lore.

7 What is the pathophysiology of priapism?

It is a persistent erection of the corpora cavernosa of the penis, due to disturbances in the mechanisms controlling penile detumescence.

8 Does priapism involve all erectile tissue?

No. Only the corpora cavernosa of the penis. The one surrounding the urethra and the corpus spongiosum of the glans remains instead flaccid.

9 What is the cause of priapism?

Often idiopathic. Yet, priapism also may reflect systemic or local abnormalities:

10 And what about drugs?

Many drugs can cause priapism. In addition to the various products that release nitric oxide into the corpora cavernosa (e.g., sildenafil [Viagra]) or the intracavernosal injection of medications for impotence, drugs that can induce priapism include:

11 What is phimosis?

From the Greek phimos (muzzle or snout), this is a narrowed opening of the prepuce, so that the foreskin cannot be retracted over the glans penis (Fig. 16-3). Usually congenital (from membranes binding the prepuce to the glans), phimosis also may result from acquired adhesions, often the sequela of poor hygiene, previous infections (chronic balanoposthitis), or a too-forceful retraction of a congenital phimosis. If untreated, it can degenerate into squamous intraepithelial cancer of the penis.

Figure 16-3 A, Phimosis. B, Paraphimosis.

12 Is a phimosis always pathologic?

No. A congenital phimosis can be quite physiologic in children, in fact well into the teenage years. In a recent study from Japan (where circumcision is not routinely done), a congenital phimosis was seen in 88.5% of children aged 1–3 months, and 35% of those aged 3 years. In fact, only 39.7% of these children had foreskins fully retractable by 3 years of age. Other studies have shown persistence of congenital phimoses in 6% of boys aged 8–11, and 3% of those aged 12–13. Only 20% of 200 boys aged 5–13 years had fully retractable foreskins.

13 What is paraphimosis?

A condition related to, but actually different from, a phimosis. Once a phimotic prepuce is forcibly retracted over the glans, the edematous foreskin cannot be brought forward again, thus resulting in paraphimosis, a tight band of retracted foreskin behind the coronal sulcus (see Fig. 16-3). This is a very painful condition, which, if unrelieved, can cause urinary tract obstruction, venous engorgement, edema, and even necrosis of the foreskin and glans.

14 What are the causes of paraphimosis?

The same as those of phimosis: an uncircumcised or incorrectly circumcised penis. In fact, both conditions are often indication for circumcision to prevent vascular or infectious complications. In children, the narrowed preputial opening of a congenital phimosis often results in paraphimosis, especially if parents forcibly retract the foreskin while attempting to clean the glans. In adults, there is often a history of catheterization (without allowing the foreskin to return over the glans) or poor hygiene (with balanoposthitis eventually leading to phimosis and then to paraphimosis). Vigorous sexual activity can predispose to paraphimosis, too. Finally, body piercing with penile rings that prevent the reduction of a retracted foreskin can be a unique, but not too uncommon, cause.

15 What is balanoposthitis?

It is the inflammation of the glans (balanos is Greek for acorn) and prepuce (posthe is Greek for foreskin) due to a wide variety of organisms. This is often seen in uncircumcised males because of poor local hygiene, with accumulation of (and irritation by) smegma—a mix of desquamated epithelial cells, sweat, debris, and transudated oils (from the Greek term for “soap”). Examination of prepuce and the glans reveals a red, moist, and macular lesion, at times with areas of yellow-to-black discoloration. Irregular borders and lichenification suggest instead human papillomavirus or a chronic bacterial process, eventually leading to phimosis. Ulceration and deep erosion occur only with fungal infection in immunocompromised hosts.

16 What are the causes of balanoposthitis?

The most common is infection, either by bacteria (staphylococci and streptococci, but also anaerobes, Gardnerella sp., and S. pyogenes sp.) or yeasts (usually candidal). This is usually facilitated by poor hygiene and poorly retractile foreskin. Contact dermatitis also may cause it, and in one third of cases no specific etiologies are established. Associations with ulcerative colitis and Crohn’s disease also have been reported. Refractory or recurrent forms may benefit from circumcision. Still, do not confuse balanoposthitis with balanitis.

17 What is balanitis?

An inflammation of the glans, usually in uncircumcised men with poor personal hygiene. It is common, affecting 11% of American men in a urology clinic. Irritation from smegma causes edema and inflammation of the glans, with eventual adherence of the foreskin to the penis (i.e., phimosis). Local burning and a red rash also are common. The skin may appear to peel off, as if scalded. Predisposing conditions include diabetes, but also morbid obesity, edema (nephrosis, cirrhosis, and heart failure), and old age. Seborrheic and contact dermatitis can do it, too. Given its frequent infectious nature, it may be sexually transmitted.

18 What is Reiter’s syndrome? What are its manifestations?

Reiter’s is a reactive arthritis, usually triggered by an infection. This may be sexually transmitted (Chlamydia, genital mycoplasmas, and, to a lesser degree, gonococci) or enteric (Shigella, Salmonella, Yersinia, and Campylobacter spp.). Its clinical manifestations include acute arthritis/arthralgia, lower urogenital tract inflammation, mucocutaneous lesions, and conjunctivitis/iridocyclitis. One quarter of affected men have small, ulcerated plaques around the glans and foreskin. In fact, the most common mucocutaneous lesion involves the penis and is called circinate balanitis (circinata means round in Latin, and balanitis is the Greek term for inflammation of the glans). This is a painless inflammation of glans, sulcus, and corona, which starts as tiny blebs, eventually merging into a larger ring of inflammatory tissue that may completely circumscribe the glans. In addition, Reiter’s patients often have mucocutaneous lesions of the mouth, palms, and soles. Over the hands and feet, these tend to be scaly, sometimes pustular, and frequently resembling severe psoriasis (keratoderma blennorrhagica). Whether initial infection was sexually transmitted or enteric, there also may be urethritis with discharge. This is scanty, thin, and whitish—hence, quite different from the profuse, thicker, and more purulent discharge of gonorrhea. In fact, the discharge of Reiter’s resembles that of other nongonococcal urethritides (like chlamydia) insofar as it is usually clear. Acute Reiter’s also can present with systemic symptoms (fever, malaise, anorexia, and weight loss). Most cases resolve in 2–6 months with annual risk of recurrence of mucocutaneous manifestations around 15%, at intervals of months or years. The arthritis is usually persistent.

19 Who was Reiter?

Hans C. Reiter (1881–1969) was a German physician and the son of a rich Leipzig industrialist. He described his famous syndrome in 1916, while serving with the Hungarian Army in the Balkans during World War I. There, he encountered a young lieutenant affected by diarrhea, urethritis, arthritis, and conjunctivitis. Reiter first thought that the patient might have had syphilis but eventually changed his diagnosis and recognized the new syndrome. The same constellation of findings was described 2 years later by Sir Benjamin Brodie in his textbook, Diseases of the Bones and Joints. Reiter also is famous for having identified the spirochete causing Weil’s disease while being stationed on the Western front. He later became a member of the Nazi party, was appointed minister of health for Mecklenburg, and even signed an oath of allegiance to Adolf Hitler—hence the recent calls to remove his name from medical textbooks.

20 What about gonococcal urethritis?

It is the hallmark of gonorrhea, characterized in men by urethritis with thick and profuse discharge, urethral itch, dysuria, and epididymal pain (although more than one half of all men and women with gonorrhea are asymptomatic). If untreated, gonorrhea can lead to major sequelae, such as epididymo-orchitis and possibly infertility.

21 What kind of skin lesions can be seen on the penis?

The most common are classified on the basis of appearance (Table 16-1):

1. Ulcerating: Skin craters filled with serum, pus, or crust. They represent a full-thickness loss of epidermis and can be single or multiple.

2. Non-ulcerating: Further divided into:

Papules: Small (<1   cm in diameter) lesions, raised above the skin surface

Plaques: Larger (>1   cm in diameter) lesions, flat-topped

22 How do ulcerating lesions present?

As single or multiple. The single are more serious, since they reflect sexually transmitted diseases such as primary syphilis, chancroid, granuloma inguinale, and lymphogranuloma venereum. Penile cancer also can present as a painless, irregular, genital ulcer.

23 Describe the ulcerating lesion of primary syphilis

It is a single, round, nontender, and painless ulcer (often called a chancre) with bilateral lymphadenopathy.

24 Describe the ulcerating lesion of chancroid

It is a painful, single ulcer, at times multiple, with lymphadenopathy.

25 Describe the ulcerating lesion of granuloma inguinale

It is a single, painless ulcer without lymphadenopathy.

26 Describe the ulcerating lesion of lymphogranuloma venereum

It is a small, nontender ulcer with unilateral tender lymphadenopathy.

27 Which other dermatoses can be transmitted through sexual contact?

Definitely scabies and pediculosis. In both cases, itching is the prevalent symptom, and redness the predominant finding. Note that whereas scabies burrow under the skin to lay eggs, lice bite into the skin to draw blood. Hence, lice present with red and scaly areas of skin or hair where insects and eggs may be visible. Scabies, on the other hand, present with little bumps, blisters, and crusting in areas of pruritus.

28 What about multiple ulcerating lesions?

These are more common than single ulcers and may have less serious causes. Based on duration, they can be acute (<2-week course) or chronic (>2-week course).

29 What are the most important acute multiple ulcerating lesions?

30 Describe the multiple ulcerating lesions of secondary syphilis

Secondary syphilis is characterized by a papulosquamous rash involving not only the penis but also the palms and soles. Multiple, irregular, shallow, painless, and gray ulcers (often described as “serpiginous” since they move like a snail track along the penis) are usually present. There also may be a flu-like illness and a blotchy, red body rash.

31 What are aphthous ulcers?

Small, shallow, painful ulcers that most commonly appear in the mouth but also can affect the penis. Typically, they have a gray center surrounded by a bright red halo, occur in crops, and resolve without treatment. They can easily be confused with herpes simplex ulcers, so laboratory tests are necessary to reliably distinguish the two. They are not infectious, and their cause is unknown.

32 Describe the multiple ulcerating lesions of herpes simplex

They appear as small, multiple vesicular skin lesions that are painful, in clusters, and not associated with adenopathy. Note that chancroid lesions also can be multiple.

33 Are genital herpetic lesions due to HSV-1 or HSV-2?

Usually to herpes simplex virus type 2, the leading cause of infectious genital ulceration in the United States (HSV-1 is instead the most common cause of oral infections). Although one out of five American adults is seropositive for this virus, more than one half remain asymptomatic and yet capable of shedding and transmitting the virus. Lesions present as small, clustered vesicles on an erythematous base, rapidly progressing into pustules and painful ulcers, and eventually forming a crust. Since lesions follow the distribution of a sensory nerve, they tend to recur at (or near) the same site. Fever, malaise, and acute toxicity also may occur—especially in primary infections.

34 What are the most important chronic multiple ulcerating lesions?

35 And what about nonulcerating lesions?

They consist of papules and plaques.

36 Describe penile papules. What are the most important lesions of this sort?

Papules are usually benign, although a few are infectious and some are early and preulcerating cancers.

37 How does lichen planus present on the penis?

The most common form is classical papules and patches, mostly clustered in a circle on and around the glans. These are purple colored or white, ring shaped, and often resembling thrush. Unlike other patches of lichen planus (LP), they rarely itch. White streaks and erosive lesions are much less common presentations.

38 What are the characteristics of penile psoriasis?

Like lichen planus, psoriasis of the genital area may present with atypical features—usually because of moisture and maceration. The classic psoriatic scale, for example, is often rare (except in uncircumcised men). Instead, genital psoriasis presents as thickened red papules or plaques with well-defined edges and is rarely associated with irritation. Although psoriasis most commonly affects other parts of the body (especially the knees, elbows, and scalp), it can first appear on the penis, usually on the glans or inner surface of the foreskin. This may require differentiation from syphilis.

39 What is molluscum contagiosum?

A benign and common viral disease of skin and mucous membranes. In children, it is acquired through peer contact, whereas in adults, it may be sexually transmitted. Penile molluscum presents as multiple, small, soft, and spherical papules of penis or scrotum, often with a central depression or plug. If squeezed, lesions can express a curd-like discharge. Usually a marker for “unsafe” sexual practices (hence, test for HIV), molluscum lesions may disappear without treatment, although freezing or cautery is often curative.

40 And what about genital warts?

These also are quite common, and in fact increasing in prevalence, especially in young and sexually active people. Condylomata acuminata are arbor-like (acuminata) lesions caused by the human papillomavirus virus (the condylomata lata of syphilis are instead flat—see question 41). Usually more wart-like than ulcerating, condylomata acuminata usually occur in moist areas (such as the corona or sulcus), but also may affect the penis’s tip and shaft, plus scrotum, anus, and mouth. They appear as tiny and skin-colored genital warts, isolated or in clusters, and with a shiny surface. These may become fleshy and cauliflower-like. Highly infectious, genital warts can be latent, subclinical, and clinical—very much like herpes. Hence, asymptomatic infection (and shedding) is frequent. The most common agents are low-risk human papillomavirus (HPV) 6 and 11; high-risk HPV types 16 and 18 are less common but are associated with premalignant and malignant degeneration (i.e., squamous cell carcinoma of the penis, anus, and cervix). They may be confused with pearly penile papules.

41 What are condylomata lata?

They are flat (lata in Latin), multiple lesions of secondary syphilis. They present as flat-topped, soft, moist or macerated, reddish-brown to grayish genital papules or, more rarely, nodules. These may eventually coalesce into larger plaques, often cauliflower-like. Differential diagnosis includes the nonulcerating and papular lesions of psoriasis, lichen planus, scabies, squamous cell carcinoma (which usually presents as an indurated and nontender nodule, but at times may even ulcerate), and Reiter’s (which also may present with a nonulcerating penile lesion).

42 What about penile plaques?

They are usually benign (like psoriasis and Zoon’s plasma cell balanitis) and often infectious (balanitis and posthitis, see questions 15–17). Still, three of these lesions (erythroplasia of Queyrat, lichen sclerosus, and balanitis xerotica obliterans) are quite serious since they may degenerate into penile cancer. Finally, diffuse red plaques with a poorly defined edge and finely scaled surface (eczema-like) may be due to allergic contact dermatitis. Although often the result of lubricants, condoms, spermicides, and feminine deodorant sprays, they are more frequently caused by poor hygiene, with persistent moisture and maceration. They are quite irritating and usually respond to topical steroids.

43 What is Zoon’s balanitis?

A noninfectious condition characterized by a brightly red and shiny plaque on either the glans or inner foreskin. It is histologically characterized by a plasma cell infiltrate. Etiology is unknown and prognosis benign, even though it often prompts a differential diagnosis with the much more serious erythroplasia of Queyrat. Usually painless, it may be itchy and often recurrent, despite topical steroids. It always responds to circumcision.

44 What is the erythroplasia of Queyrat?

A sharply demarcated red plaque, bright, painless, and not itchy—often with a typical velvety surface. It is seen almost exclusively in uncircumcised men, and, unless excised, it eventually progresses to invasive cancer. Hence, it is an in situ form of squamous cell carcinoma. Queyrat lesions may be solitary or multiple, typically circumscribed, minimally raised, and with variegated erythematous plaques that may be smooth, scaly, crusty, or verrucous. It is typically located at the mucocutaneous junction of the penis or prepuce, but also can involve the mouth and vulva. Ulceration or distinct papillomatous papules within a plaque may indicate progression to invasive squamous cell carcinoma. Still, its nondescript look may lead to a lengthy period of misdiagnosis. Biopsy of any suspicious lesion is always the best approach. The lesion was originally described by Tarnovsky in 1891, and subsequently reported by Fournier and Darier as a penile disease in 1893. The French dermatologist Queyrat described in 1911 erythroplasia of the glans penis, and correctly identified it as precancerous. Hence, the eponym.

45 What about squamous cell carcinoma of the penis?

It is the most common penile cancer. Human papillomavirus, precancerous lesions, and poor hygiene from phimosis are all predisposing factors. Hence, it is almost absent in circumcised males. Rare before age 40, it presents with lymphonodal spread and proliferative glans lesions.

46 What is lichen sclerosus et atrophicus?

A lymphocyte-mediated chronic inflammation of the glans, foreskin, or shaft, presenting with atrophic white plaques that are usually asymptomatic, although irritation and burning also can occur. Its most severe form is balanitis xerotica obliterans (BXO), a condition affecting the prepuce of uncircumcised men, giving it a firm, whitish, and scarred appearance that may interfere with urination or sex. Indurated, flat, shiny, and white patches with an erythematous halo may eventually lead to foreskin depigmentation, atrophy, scarring, and eventually phimosis. Hence, the term of “obliterans.” BXO also may cause dysuria, progressive stenosis of the urethral meatus, stricture, and even penile cancer. Steroid creams may help, but the condition often recurs.

47 What is Peyronie’s disease (PD)?

A peculiar disease of unknown etiology, at times associated with Dupuytren’s contracture, and often referred to as penile fibromatosis—or van Buren’s disease, from the Philadelphia surgeon of Dutch descent, William Holme Van Buren (1819–1883). It presents with plaques (or strands) of dense fibrous tissue around the corpora cavernosa, possibly the result of trauma. These may be detectable by palpation and often cause penile deformity, with crooked and painful erections. Note that the penis of Peyronie patients is entirely normal at rest; only when erected does it appear bent and deformed. Although its major significance is psychologic, in some extreme cases the deformity is severe enough to interfere with erection, penetration, orgasm, and even fertility. Peyronie’s disease also was the condition rumored to affect the presidential penis of Bill Clinton, based on descriptions filed by Paula Jones in her lawsuit for sexual harassment.

48 Who was Peyronie?

François Gigot de La Peyronie (1678–1747) was a well-respected Montpellier surgeon and the personal physician to the Sun King, Louis XIV. He astutely used his connection to have the king pass a law banning barbers and wigmakers from practicing medicine, thus eliminating with the stroke of a pen the main competition to the surgical community. He subsequently founded the French Academy of Surgery and became one of the forces in the establishment of Paris as the world center of surgery. An immensely rich man, Peyronie described his eponymous lesion at the end of his life, in 1743, in a patient who had “rosary beads of scar tissue to cause an upward curvature of the penis during erection.”

49 Define hypospadias and epispadias

Both these congenital malformations (Fig. 16-4) may lead to fertility problems. They also represent a clue to other underlying abnormalities, such as undescended testis (cryptorchidism), Klinefelter’s syndrome, or other chromosomal disorders. Hypospadias may be induced by the mother’s ingestion of estrogens or progesterone or congenital adrenal hyperplasia.

Figure 16-4 A, Hypospadias. B, Epispadias.

(2) Scrotum

51 Which scrotal abnormalities can be identified through inspection?

Mostly skin abnormalities, including sexually transmitted or fungal lesions. Tinea cruris is especially common, presenting as large erythematous areas involving the scrotum and adjacent thighs. Lesions are often scaly and with ragged margins. Candidal infection also may cause scrotal lesions, particularly in grossly overweight and diabetic patients. Finally, lice (or sometimes even scabies) can be visualized in scrotal and pubic areas, often heralded by excoriations. Fordyce “lesions” and “spots” are also important and yet benign findings.

52 What are Fordyce lesions?

They are small, pin-sized (2–5   mm), bright red or purple papules that may occur on the scrotum, but occasionally on the glans and shaft, too, and even the inner thigh or lower abdomen. First described in 1896 by the American dermatologist John Addison Fordyce (on the scrotum of a 60-year-old man), they are still referred to as Fordyce’s angiokeratomas. They are not infectious but vascular. Hence, they should not be biopsied. In fact, they may even bleed after the minimal trauma of intercourse. At times solitary, they usually present as clusters of 50 to 100 asymptomatic lesions. They are benign and common, being present in as many as one of six men older than 50 (conversely, they are quite rare in men younger than 40). Since they reflect a congenital predisposition, they often occur in families, and yet remain primarily a by-product of age. Although often a cause of embarrassment or concern, they just represent abnormally dilated capillaries covered by thickened skin. They should not be confused with Fordyce spots (or granules).

53 What are Fordyce spots?

They are very common (80–95% of adults) yellowish/white papules, 1–3   mm in diameter, that occur on the shaft of the penis (or the labia of women), but also the tongue, vermillion border of the lips, and the inner surface of the cheeks. Usually clustered in 50 to 100, they are probably present at birth, even though they become bigger and more visible from puberty on. They represent enlarged ectopic sebaceous glands and are just of cosmetic concern.

54 What are the causes of scrotal swelling?

It depends on whether the swelling is bilateral or unilateral:

55 What is a varicocele?

A condition caused by incompetent valves in the internal spermatic veins, resulting in engorgement along the spermatic cord. Hence, a varicocele resembles a nest of worms, which only presents upon standing and resolves with either a supine position or scrotal elevation. Easily identifiable on exam, a varicocele is quite common, occurring in 15% of the general male population and 40% of men evaluated for infertility. It is, in fact, a common cause of reversible sterility (due to the increased testicular temperature of the affected testis). This was intuited by the first century A.D. Roman physician Celsus, who described the condition as “veins that are swollen and twisted over the testicle, which thus becomes smaller than its fellow inasmuch as its nutrition has become defective.” Note that because of the drainage characteristics of the testicular veins, a varicocele is much more common on the left than on the right. Accordingly, a right varicocele should prompt investigation to exclude either anatomic abnormalities or an alternative diagnosis. Other than a varicocele, localized and painless scrotal swelling usually reflects pathology of the testis or epididymis (see questions 63 and 64). Conversely, painful and tender scrotal swelling usually indicates a much more acute process, such as torsion of the spermatic cord, strangulated inguinal hernia, acute orchitis, or acute epididymitis.

56 What are the normal characteristics of testes and epididymides?

57 How should the testes and epididymides be examined?

With great care, since these organs (especially the testes) are exquisitely sensitive, not only to touch but also to temperature. In fact, in a cold room they may even retract toward the inguinal canal. Hence, to best palpate them, use your thumb plus index finger, or thumb plus index and medium fingers. This also allows you to gauge the length and thickness of each testicle, although for more accurate measurements, you will need a caliper. Note any discrepancy in consistency or size, and, if present, ask how long this has been so. If ruling out a congenitally undescended testis, examine the inguinal canal for localized swelling. Search for testicular lumps or bumps, which, if present, should be considered neoplastic until proven otherwise. Still, keep in mind that diffuse testicular enlargement usually reflects either a hydrocele (see question 59) or a varicocele (previously discussed, see question 55). Note that the left testis lies a bit lower in the scrotum than its counterpart (the reverse would suggests situs inversus). Also note that, although the testicles can be examined in either the standing or supine position, a search for hernias or varicoceles requires the patient to stand. Finally, move cephalad and gently assess the upper and posterior poles of the testes and adjacent heads of the epididymides. Examine the spermatic cord, which goes from the epididymis all the way up into the inguinal canal. This contains the vas deferens, the testicular artery/vein, the ilioinguinal nerve, plus lymphatic vessels and fat tissue. Of all these structures, only the vas can be easily recognized, based on its firm and wire-like feel and the location along the posterior aspect of the bundle. Identify any lumps or bumps in the cord, and then note their relationship to the testes and inguinal canal. Note that a varicocele will be palpable not only in the testes, but also throughout the length of the cord, since it represents a varicose dilation of the spermatic vein.

58 What is transillumination of a scrotal mass?

A good way to find out whether a localized scrotal swelling is solid or liquid. To do so, shut off the lights in the exam room, raise the penis (to better visualize the scrotum), and shine a penlight from behind the scrotal mass. Inability of the mass to transmit light suggests a solid lesion, whereas transmission of the light beam favors instead a fluid-filled lesion—like a hydrocele or spermatocele. Note, however, that a hematocele (a fluid-filled lesion caused by accumulation of blood) and a varicocele (varicose veins of the spermatic cord) are transillumination-negative because blood does not transmit light.

59 What is a hydrocele?

A collection of serous fluid in either the tunica vaginalis or in a separate pocket along the spermatic cord (literally, a water tumor in Greek). This presents as a unilateral and painless scrotal swelling. Since a hydrocele has different consistency from that of testicular tissue, it can be easily recognized by transillumination.

60 What is a spermatocele?

A spermatozoa-filled cyst of the epididymis (literally, a sperm tumor). It presents as a unilateral, painless, and movable scrotal mass, just above the testis and identifiable by transillumination. A true epididymal cyst is clinically similar but does not contain sperm.

61 What is cryptorchidism?

A condition characterized by failure of one or both testes to descend (literally, the invisible testis in Greek). The undescended testicle lies in the inguinal canal or abdomen and eventually atrophies from high surrounding temperatures. It may even undergo neoplastic degeneration. Yet, since the other testis remains fully functional, cryptorchidism does not affect fertility. It may, however, cause emotional repercussions. For example, it has been suggested that Adolf Hitler’s psychopathology could have been due to cryptorchidism, a condition documented by a urologist he consulted before rising to power (the Brits even wrote a song, titled “Hitler Has Only Got One Ball,” later set to the tune of Colonel Bogey March). Napoleon was cryptorchic, too. As a result, both men decided to screw the world.

62 What about small testes?

“Small” is a testis <3.5   cm in length. Its most common cause is atrophy. This may be either congenital (as in Klinefelter’s syndrome) or acquired (as in alcoholic cirrhosis). Klinefelter’s testicles tend to be small and firm, whereas those of cirrhosis are small and soft. Atrophy also may result from inflammatory or infectious processes (i.e., orchitis), often due to viruses (mumps), but also syphilis, filariasis, and even trauma.

63 What are the causes of an enlarged and solid testis?

Cancer for sure. Hence, an enlarged and firm testis should always be transilluminated to exclude a fluid-filled mass, such as a hydrocele, spermatocele, or epididymal cyst. A confirmed solid lesion increases the likelihood of testicular cancer, which is the most common tumor in men between the ages of 20 and 35. Solid testicular lesions should be actively sought out, not only by physicians but also by patients through self-examination.

64 What are the causes of a tender epididymis?

The most common is acute epididymitis, which may be associated with such a swelling that separation from the testis may be difficult to detect. In addition to edema, these patients also will have tenderness of the epididymal head and vas deferens. Occasionally, there is even swelling and redness of the overlying skin. Acute epididymitis is often the result of urinary tract infection (especially in men >35 years), whereas in younger men, it is usually due to sexually transmitted urethritis (by chlamydia or gonococcus) with prostatitis. Still, epididymitis occurs in less than 1% of all cases of identified sexually transmitted urethritis. Finally, an enlarged, nodular, beaded, and nontender epididymis should suggest tuberculous epididymitis, often the complication of renal tuberculosis.

65 What are the two possible sites of groin hernias?

Figure 16-5 Sites of hernias in the groin.

(Adapted from Swartz MH: Pocket Companion to Textbook of Physical Diagnosis. Philadelphia, WB Saunders, 1995.)

66 What is the best way to detect a hernia?

Start with inspection. Ask the patient to stand while you comfortably sit in a chair. Observe the external inguinal ring, looking for a localized bulge. If not visible, elicit the bulge by asking the patient to either cough or perform a Valsalva maneuver. After inspection, palpate the patient’s right inguinal region with your right index finger and the patient’s left inguinal region with your left index finger. Gently insert the finger along the spermatic cord, through the invaginated scrotum (Fig. 16-6), aiming for the external ring of the inguinal canal (from where the cord emerges). As your fingertip reaches into the external ring, put the fingers of your opposite hand over the inguinal canal, or over any noticeably swollen area. Ask the patient to cough or strain and see whether you can feel, with either hand, any bulging/impulse suggestive of hernia.

Figure 16-6 Examination of the inguinal floor by insertion of a finger through the invaginated upper scrotum.

(From James EC, Corry RJ, Perry JF: Basic Surgical Practice. Philadelphia, Hanley & Belfus, 1987.)

67 How do you separate indirect from direct inguinal hernias?

With great difficulty. Which is not a great loss, since both types usually need repair, treatment is the same, and identification is eventually carried out at surgery.

68 Should one auscultate over a hernia?

Yes, since presence of bowel sounds would confirm bowel herniation.

69 Should the patient always be standing?

Not necessarily. If the patient is unable to do so, examination can be definitely carried out in a supine position. This is preferable when evaluating the inguinal canal for an undescended testicle.

70 Are hernias painless?

Yes. In fact, pain and tenderness (plus evidence of local inflammation, such as skin edema or redness) always suggest an incarcerated/strangulated hernia—a surgical emergency.

71 How large are inguinal hernias?

Some are small enough to barely allow access to your fingertip; others are instead so massive to make it impossible to tell apart the structures of the spermatic cord (and testis) from the contents of the hernia (although the testis usually lies at the bottom of the scrotum).

72 What is Zieman’s tridigital examination for hernia?

A procedure used to identify both femoral and inguinal hernias (direct and indirect). The examiner stands at the right side of the patient (who also is standing) and places the palm of the right hand over the patient’s right lower abdomen, with fingertips near the right inguinal ligament: the tip of the long finger in the external inguinal ring; the tip of the index finger near the internal inguinal ring; and the tip of the ring finger in the femoral triangle. The patient then either strains or performs a Valsalva maneuver. The increase in intra-abdominal pressure will cause a hernia in any of these three sites to manifest itself as either a gliding motion of the walls of the empty sac or as an impulse caused by the protrusion of the viscus into the sac. The maneuver is then repeated for the other side.

73 What is the role of the digital rectal exam?

It is an essential part of any comprehensive examination. Not only in regard to genital/pelvic evaluation (i.e., prostate and gynecologic organs), but also for the assessment of many gastrointestinal, infectious, and oncologic problems.

74 Is it routinely performed?

Not really. Up to two thirds of patients presenting with anorectal and urogenital tract symptoms do not undergo a DRE before being referred to a specialist, and more than one half of all inpatients in a teaching hospital do not receive a DRE as part of their admission examination. Rates in community hospitals may be even lower: 25% in one study and 36% among elderly patients. This is concerning, since one third of all rectal cancers are palpable. Hence, lack of DRE may delay referral for resectable disease.

75 Is the rectal exam performed with the patient standing or in the lateral decubitus position?

Either. As for the rest of the genital exam, there are two schools of thought: one prefers a standing patient (and a seated physician), and the other opts instead for a standing physician and a recumbent patient (i.e., lying on one side, with knees tucked up toward the chest and body as close as possible to the table edge to facilitate the physician’s job). There are no data supporting one approach versus the other, and so it comes down to individual preference. Yet a lateral decubitus position is clearly a must in patients too weak to stand. Still, it is probably easier to perform a rectal exam (especially for its receiving end) with the patient lying down. Conversely, it is better to evaluate testes and inguinal hernias with the patient standing up. Hence, its choice for the genital exam.

76 What are the steps to follow in a rectal exam?

If you elect to have the patient standing, instruct him to turn around and rest his chest on the exam table. This will ease both the examiner’s and examinee’s job. Then sit down, put on gloves, and gently spread the patient’s buttocks. Evaluate the perianal area, and look for any skin abnormalities. Having done so, adequately lubricate your index finger and tell the patient that pretty soon you will be inserting it into his rectum. Place your finger against the anus and ask the patient to bear down as if he were having a bowel movement. This will relax the sphincter and allow you to insert the finger more easily. Aim your index finger toward the patient’s umbilicus, enter through the anus, and assess its sphincter tone. Palpate the prostate gland through the wall of the rectum. Using the palmar aspect of your index finger, you will be able to examine the posterior and lateral aspects of the gland, but not its anterior surface since this is inaccessible. Then, advance your index finger as far (and as gently) as you can toward the umbilicus, aiming for the seminal vesicles. These are usually not palpable, unless there is disease. Once you have done so, rotate your finger in order to reach upward, posteriorly, and laterally for rectal-based masses or lesions. Then withdraw and inspect the stool on your gloved finger for any evidence of mucus, blood, or tarry color (which would indicate a bleeding site above the ligament of Treitz, whereas obvious blood would point instead to rectal or anal sources). Afterwards, dab some of the stool on a guaiac card, and test it for occult blood. Finally, hand the patient a box of tissues for cleaning.

77 What perianal findings can be detected by rectal examination?

Skin lesions caused by sexually transmitted diseases (i.e., papillomavirus or herpes), parasitic infestations (pinworms), or fungi (Candida sp.). Fissures or fistulas also may be visualized (usually suggesting Crohn’s disease), and so are bleeding sites and tumors. Hemorrhoids are occasionally visible (especially if prolapsing), but usually require palpation.

78 How do you assess a reduced sphincter tone? What is its significance?

Look for degree of spontaneous resistance to your finger. Alternatively, ask the patient to contract the sphincter by trying to “hold on” to your finger. A reduced tone may reflect a central or peripheral nervous system compromise, disrupting sphincter innervation and causing rectal incontinence. For example, a neoplastic cord compression of sacral roots.

79 What characteristics of the prostate should you assess?

You should appreciate the two lobes and the longitudinal cleft between them. Assess size, symmetry, consistency, and surface characteristics, especially nodularities and tenderness (the latter usually indicates prostatic infection). A normal gland is small, rubbery, with symmetric and smooth lobes and a well-demarcated median cleft. A firm gland suggests instead malignancy, but also may indicate chronic prostatitis. A gland that has become fixed to the pelvis signals extension of tumor (and so does palpability of seminal vesicles).

80 What causes prostatic nodules?

A common cause is benign prostatic hyperplasia. Nodules also may reflect various inflammatory processes, and even infarct. Of course, a nodule should always raise concern about prostatic cancer. Since tumors often originate in the posterior lobe, which is accessible to the finger, they may indeed present as palpable hard nodules.

81 What causes a tender prostate?

The most common cause is infection (i.e., prostatitis and prostatic abscess). Patients with these conditions also may have palpable prostatic nodules.

82 What does the normal prostate look like?

It has the shape of a heart (which makes it especially endearing to those of us who are romantically inclined) and the size of a walnut. Enlargement does not necessarily indicate cancer but is instead a common sign of benign prostatic hypertrophy—a frequent by-product of aging. Nodules, on the other hand, are invariably suspicious and thus should always be biopsied. Still, only 50% of all nodules eventually turn out to be neoplastic, with the rest usually reflecting benign prostatic hypertrophy (hence, the low positive predictive value for cancer—see questions 83 and 84). Also, a localized area of induration is not necessarily typical of early cancer, but more of a late neoplastic process.

83 What is the diagnostic value of DRE in primary care screening for cancer?

Limited. In a meta-analysis of 14 studies, DRE had high specificity and negative predictive value for detecting prostate cancer (94% and 99%, respectively), but low sensitivity and positive predictive value (59% and 28%). Since false negative results are rare in the outpatient setting (given the small prevalence of cancer in an unselected population), DRE may have value for initial screening. Yet, given its moderate sensitivity (and very low positive predictive value), a positive DRE should not be used to rule in prostate cancer. Hence, further confirmation must be carried out. This includes measurement of serum prostatic specific antigen (PSA) and transrectal ultrasonography with possible biopsy. Still, DRE alone allows detection of almost one out of five cancers with “normal” PSA levels. These are usually small and confined.

84 What are the limitations of DRE for the screening of prostatic cancer?

In addition to examiner’s experience and interobserver variability on what constitutes an abnormal finding, the major limitation is access to only the posterior and lateral aspects of the gland. As a result, an overview of studies of screening suggests that DRE alone detects fewer than 60% of prostate cancers. Adding DRE to PSA does appear to increase the yield of screening; in a large study of volunteers, the combination of DRE and PSA detected 26% more cancers than PSA alone. However, combining DRE and PSA also increases the rate of false positive results. Note that in 2002 the U.S. Preventive Services Task Force (USPSTF) concluded that there was not enough evidence to recommend for, or against, routine screening for prostate cancer by DRE or PSA.

85 How about the effectiveness of DRE for the detection of colorectal cancer?

Questionable, since fewer than 10% of all colorectal cancers arise within reach of the examining finger (and some of these lesions will already be symptomatic). The same can be said for a single office-based fecal occult blood testing (FOBT) that relies on a stool sample obtained on DRE: the sensitivity of this test is substantially lower than that of screening protocols involving multiple cards (in one study the first test card would have missed 42% of cancers detected by multiple test cards). In addition to being a one-shot deal, FOBT on samples collected by DRE may be invalidated by inadequate amount of stool or trauma from the exam. Specificity, on the other hand, is usually high. Overall, sensitivity of a single test has been estimated at 40%, whereas specificity can be as high as 96–98%. Hence, in 2002, the USPSTF did recommend periodic fecal occult blood testing as a way to reduce mortality from colorectal cancer.

86 Should rectal exam be deferred in patients with a myocardial infarction?

No. Although conventional teaching suggests that a rectal examination may worsen ischemia (and even trigger arrhythmias in patients suffering an acute myocardial infarction), no scientific data support this assumption. In fact, a prospective study by Akhtar et al. of 480 intensive care unit and telemetry patients showed that none of the patients developed sustained arrhythmias during the test. There also was no change in vital signs. Conversely, DRE was able to detect significant clinical findings in 11% of all patients. Note that digital rectal exam may increase the acid prostatic phosphatase, but it will do so only in patients with prostatic cancer, not in patients with benign prostatic hypertrophy. Hence, when screening for cancer, you should obtain the serum acid phosphatase after a rectal exam, not before.