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

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

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

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

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

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

Male Genitalia Penis Testicles Epididymis Scrotum Prostate gland Seminal vesicles 7

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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