Year 2 MBChB Clinical Skills Sessin Male genitalia examinatin Reviewed & ratified by Miss R Hamm Cnsultant Urlgist Dr Paul Cllins Cnsultant Gastrenterlgist Mr Ben Hrsburgh SpR Urlgist Dr V Taylr Jnes & Ms C Tierney
Learning bjectives. T revise male genitalia examinatin including an understanding f the cmmn abnrmalities and examinatin f apprpriate lymph ndes Thery and backgrund. A male genitalia examinatin invlves; inspectin f the male external genitalia fllwed by palpatin f the penis, scrtum and the testes, tgether with the structures arising ff the testes. Testis is the singular Testes is the plural When dcumenting yu shuld use crrect terminlgy. As in all examinatins, effective cmmunicatin with yur patient is the basis f a safe and efficient examinatin. Therefre, make sure yu cmmunicate with yur patient apprpriately as yu prceed. Be familiar with the male genitalia and its structures, which are as fllws; Penis This cnsists f 3 parts which are the rt, the shaft and the glans penis. Bld supply is the pudendal artery. The rt is attached t the abdminal and pelvic wall. The shaft is the middle sectin cmpsed f three cylindrical spaces. The larger spaces are the crpra cavernsa with the smaller the crpus spngisum. These three layers encase the urethra. The glans penis is lcated distal t the shaft and is separated frm the shaft by the crna. The glans als mark the distal pint f the crpus spngisum. The glans may be cvered by the freskin therwise referred t as the prepuce. https://cmmns.wikimedia.rg/wiki/file:sb_1909_571.png Scrtum A thin skinned sac cntaining the testes. The cmpsitin f the scrtum is such that it can vary depending n the ambient temperature. This is fr the purpse f spermatgenesis. The testes require a slightly cler temperature relative t the rest f the bdy. Testes Tw vid shaped bdies, ne n the right and ne n the left (left usually lies lwer than the right). They have 2 principle functins; Prductin f sperm; Prductin f teststerne male sex hrmne. 2
Epididymis, Vas deferens & Seminal vesicles Fllwing the prductin f sperm, it travels thrugh a cllectin area referred t as the epididymis and then thrugh a tube like duct, called the vas deferens. This in turn jins the seminal vesicles which prvides nutrients fr the sperm. This tgether with ther fluids frms semen Urethra The urethra is surrunded by the crpus spngisum and has 2 purpses. T transprt urine frm the bladder T transprt semen frm the seminal vesicles ut the tip f the penis. Lymphatic drainage Deep and superficial lymph ndes fr the external genitalia and the anterir abdminal wall. The para artic ndes drain the testes. Indicatins fr a male genital examinatin. The histry the patient presents with determines why the examinatin is cnducted and what the anticipated findings may be. Therefre, take a full and cmprehensive histry prir t the examinatin. Examples f presenting cmplaints may include: Changes in size f the scrtum e.g. hydrcele accumulatin f serus fluid in the scrtum Penile discharge Tenderness f the penis r scrtum Penile grwths Skin discluratin Lump n the surface f the testis Trsin f the testes Health check up The abve list is nt exhaustive. Patient safety. On first meeting a patient intrduce yurself, cnfirm that yu have the crrect patient with the name and date f birth, if available please check this with the name band and written dcumentatin and the NHS/ hspital number/ first line f address. Check the patient s allergy status, being aware f the equipment yu will be using in yur examinatin. Ensure the prcedure is explained t the patient in terms that they understand, gain infrmed cnsent and ensure that yu are supervised, with a chaperne available as apprpriate. Dn persnal prtective equipment as required, especially if yu are likely t cme int cntact with bdily fluids. Be aware f hand hygiene and preventing the spread f disease, WHO (2018) http://www.wh.int/infectinpreventin/tls/hand-hygiene/en/ This prcedure will require the presence f a chaperne. That is smene wh is familiar with the examinatin and can ensure that nthing inapprpriate ccurs by either party. The chaperne can be a useful resurce, nt just being present t ensure the patient is treated apprpriately, but t help and supprt the patient. Fllwing yur intrductin, explain t the patient that they will need t remve their clthing frm the waist dwn, and when they are ready t lay supine n the examinatin cuch and cver ver with the sheet prvided. 3
Inspectin Yu are bserving fr; Are they in bservable pain? Observe fr any breast develpment gynaecmastia Observe fr any trauma Nte if they are circumcised Inspect the genitals fr any abnrmalities (swellings, discharge, grwths, rashes etc) Examinatin f the penis Inspect and palpate the ventral and drsal surfaces f the penis nting any abnrmalities t the shaft f the penis. Fllwing palpatin f the shaft f the penis, explain t the patient that yu are ging retract their freskin (if present), d s gently. Alternatively, yu may ask yur patient t d this themselves, especially if it is tender r they are sensitive t this being dne. The freskin under nrmal circumstances shuld retract easily and with n pain. Having retracted the freskin, inspect fr abnrmalities n the glans f the penis nt frgetting t inspect prximally t the crna. 4
Underlying the freskin yu may nte a curd like smegma, made up frm sebaceus secretins. This is ften durless and is nrmal. Fllwing the examinatin f the glans f the penis yu nw want t examine the external urethral meatus. Using yur thumb apply gentle pressure t the glans t gently pen the urethral meatus. This shuld expse a healthy glistening pink mucsa. If a discharge is present a swab shuld be taken. If the patient has cmplained f urethral discharge and n discharge is apparent the patient may be shwn hw t take a swab themselves next time the discharge is nticed. Examinatin f the scrtum Ask the patient t lift their penis up and hld it against their abdmen s that yu can clearly inspect the scrtum. Observe fr pubic hair n the scrtum; nte the darker pigmentatin f the scrtal skin. Other bservatins may include; The left testis usually lie lwer relative t the right testis Swelling f the scrtum The tne f the darts muscle. This muscle is temperature sensitive and alng with the cremaster muscle is respnsible fr temperature regulatin f the testes fr spermatgenesis. The appearance f the scrtum is affected by ambient temperature and that in turn can affect the ease f palpatin. A patient exhibiting a scrtal swelling can be divided int tw categries. 1 True scrtal swelling - This is a swelling riginating in the scrtum and when palpating yu will be able t feel abve the swelling e.g. Epididymal cyst fluid filled sac n the epididymis Hydrcele fluid accumulatin arund a testis as a cnsequence f trauma r inflammatin. Lump in the testes. 2 False scrtal swelling - This is where the swelling riginates utside f the scrtum and cnsequently when the patient is in a supine psitin the swelling may nt be palpable r if it is it will nly be partially palpable. An example f this wuld be an inguinal hernia, a lp f bwel that has extruded ut f the abdminal cavity and dwn the inguinal canal int the scrtum. This is accmpanied with pain when cughing, exercising and with bwel mvements. Examinatin f the testes Cmmnly the darts will cntract under stressful circumstances s t avid the testis retracting int the inguinal canal place yur left hand ver the inguinal canal t capture the testis in the scrtum. Apply gentle pressure t examine bth testis (ne at a time) using the thumb and first tw fingers. Nte the size and cnsistency f the testis. 5
Palpate the epididymis situated alng the psterlateral surface. This shuld feel smth and is bradest superirly, at its head. Finally rll with the finger and thumb t palpate the vas deferens. Examinatin f the scrtum & testes shuld be perfrmed with the patient supine unless indicated in histry e.g. hydrcele, hernia etc. in which case yu wuld examine the patient in the standing psitin as well. T size the testis yu may use an rchidmeter, this is a chart r a set f beads indicating the size / vlume f the testicle in millilitres (althugh this is nt standard practice). Inguinal lymph ndes The palpable lymph ndes assciated with a male genitalia examinatin are the superficial and deep inguinal lymph ndes. The later are lcated clse t the femral artery, vein and nerve. The superficial ndes drain; External genitalia Lwer limbs The deep ndes drain; The external genitalia Lwer anterir abdminal wall Lwer limbs Recrding yur findings Dn t frget when recrding yur findings t dcument the patient s identifier, date (and time), yur signature and t print yur name with yur rle r psitin. 6
When dcumenting r describing yur findings, remember t cmment n the penis, scrtum, palpatin f the scrtal cntents (testes, vas deferens and epididymis) and any abnrmal masses palpated. Remember t describe yur findings as fully as pssible; e.g. size, psitin, shape f a swelling etc a diagram may ften be useful in written ntes Further reading Anatmy f the male genitalia https://www.medicinebau.cm/uplads/7/9/0/4/79048958/anatmy histlgy_ug_ntes_6.pdf NICE guidelines n penile & testicular cancer pathways https://www.nice.rg.uk/guidance/cnditins-and-diseases/cancer/penile-and-testicular-cancer#panelpathways NICE guidelines n the management f scrtal swellings https://cks.nice.rg.uk/scrtal-swellings 7