Physical Examination

Physical examination should be carried out with the patient in both the supine and upright positions in a well-illuminated, warm room. If the scrotum is contracted despite proper room temperature, a warm towel placed over the genitalia permits the scrotum to relax and the testes to descend and be comfortably examined.

Examination should always begin with visual inspection. In uncircumcised males, the foreskin should be fully retracted to inspect the glans, coronal sulcus, and preputial areas for ulceration or malignant lesions. The location of the urethral meatus and presence of discharge should be noted. The penile shaft should be carefully palpated for plaques, cysts, or early abscesses.

The supine or modified lithotomy (frogleg) position is more comfortable for both the patient and the examiner and allows a more thorough examination of each testis, epididymis, the prostate, seminal vesicles, and rectal ampulla. During the critical evaluation of a scrotal mass, patient relaxation and cooperation in the supine position are paramount. Testicular nodularity or firmness should be considered carcinoma until proven otherwise. The epididymis usually lies on the posterolateral aspect of the testis and, if not inflamed or involved with other pathologic entities, has a soft, fleshy feel similar to that of the earlobe. Many males experience pain and tenderness with palpation of a normal globus major (head), body, and globus minor (tail) of the epididymis. All males experience some discomfort during palpation of a normal prostate. The supine position helps prevent an infrequent vasovagal response to the scrotal or prostate examination. The prostate has a heart-shaped contour with its apex located more distally, abutting the urogenital diaphragm (anatomic soft spot). The consistency of the normal prostate has the same resiliency as the cartilaginous tip of the nose, while suspicious carcinogenic areas feel more like the bony prominence of the chin. The posterior lobe is small and thin, allowing palpation of the median raphe that distinguishes the two lateral lobes. A normal rectal examination does not exclude bladder outlet obstruction secondary to an obstructing median bar or large intravesical prostate. The seminal vesicles, lying just superior to the prostate, cannot normally be distinguished unless there is inflammation, induration, or enlargement.

Examination of the inguinal canals for hernias and the scrotal spermatic cords for varicoceles is best done in the upright position, with the patient straining at the designated time. When the patient is upright, it should be determined whether the testes are aligned along a vertical or horizontal axis. Horizontally aligned testes are at greater risk for torsion.

Some genital disorders may require urine collection and analysis. The uncircumcised male should retract his foreskin and wash the glans penis with cleansing towels before collecting a midstream specimen. Failure to do so will result in preputial contamination. The often-described three-cup specimen used to localize male lower urinary tract infections is time-consuming and requires patient compliance, factors that tend to limit its usefulness in the emergency department.

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