11/13/24, 7\:10 PM Guide | Testicular examination

Testicular examination

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
y o u r g e n i t a l s , t h i s w i l l i n v o l v e m e e x a m i n i n g y o u r p e n i s , t e s t i c l e s a n d t h e s u r r o u n d i n g r e gi o n .
"
Explain the need for a chaperone\:
c h a p e r o n e , w o u l d t h a t b e o k ?”
“ O n e o f t h e w a r d s t a
Gain consent to proceed with the examination\:
h a p p y f o r m e t o c a r r y o u t t h e e x a m i n a t i o n ?”
“ D o y o u u n d e r s t a n d e v e r y t h i n g I’ v e s a i d ? D o y o u h a v e a n y q u e s t i o n s ? A r e y o u
Explain to the patient that they’ll need to remove their underwear and lie on the clinical examination couch, covering
themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room
before doing so.
Ask the patient if they have any pain before proceeding with the clinical examination.

Inspection

Penis, groin and abdomen

Inspect the patient's penis, groin and abdomen for relevant clinical signs\:
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Skin changes\: bruising, swelling, warts (human papillomavirus) and erythema.
Scars\: note any scars on the penis (e.g. circumcision) or in the inguinal region (e.g. inguinal hernia repair, orchidopexy).
Masses\: note any masses in the inguinal region (e.g. inguinal hernia, lymphadenopathy, undescended testicle) or on the
penis (e.g. chancre in primary syphilis).

Scrotum and perineum

Ask the patient to lift their penis out of the way to allow you to closely inspect the scrotum and perineum for relevant clinical
signs\:
Skin changes\: warts (human papillomavirus), erythema (e.g. cellulitis, fungal infection).
Scars\: may indicate previous surgery (e.g. vasectomy, testicular
Masses\: note any lumps associated with the scrotum (e.g. testicular cancer) or the perineum (e.g. abscess).
Swelling\: note any swelling of the scrotum (e.g. hydrocele, oedema) and look for associated erythema (e.g. cellulitis).
Bruising\: may indicate local trauma.
Necrotic tissue\: consider Fournier's gangrene (necrotising fasciitis of the external genitalia and/or perineum) which is often

Inspect the penis for skin changes

Palpation

Penis

Examine the penis for relevant clinical signs\:
Retract the foreskin (if the patient is not circumcised) and check for phimosis (narrowing of the foreskin). If you are unable to
retract the foreskin, ask the patient to try and do this themselves.
Open the urethral meatus to assess patency.
Inspect the glans for abnormalities (e.g. ulcers, warts, discharge, scarring).
Replace the foreskin once examined to prevent paraphimosis (a condition in which the retracted foreskin obstructs venous
return from the glans, resulting in painful swelling of the glans).

Testicles

If abnormalities have been identi
perform an examination of the 'normal' testicle
examination.
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Testicular palpation
Use both of your thumbs and index
behind the testicle to immobilise it.
Palpation of the testicle involves a gentle rubbing motion between your thumb and index
whole body of the testicle.
If you are unable to locate a testicle, palpate along the path of the inguinal ligament for an undescended testicle (if the
patient also has a scar in their inguinal region this would suggest a previous orchidectomy or orchidopexy).
Assessing a scrotal mass
If a scrotal mass is identi
Site\: assess the mass's location in relation to other anatomical structures. In particular, assess the mass's anatomical
relationship to the testicle (e.g. part of the testicle vs separate from it).
Size\: assess the size of the mass.
Shape\: assess the mass's borders to determine if they feel regular or irregular.
Consistency\: determine if the mass feels soft (e.g. cyst), hard (e.g. malignancy, epididymis, testicle) or 'like a bag of worms'
(e.g. varicocele).
Tenderness\: tenderness may indicate infective and/or in
Fluctuance\: hold the mass by its sides and then apply pressure to the centre of the mass with another

Transillumination\: apply a light source to the mass, if it is illuminated it suggests the mass is
hydrocele can sometimes be so large that you will not be able to palpate the testicle contained within it.
Cough impulse\: the presence of a cough impulse is suggestive of an underlying inguinal hernia or varicocele.
Ability to get above the lump\: the inability to get above the mass during palpation is suggestive of an inguinal hernia (you
should be able to get above a scrotal mass).

Epididymis

chlamydia).
Palpate the epididymis which is located at the posterior aspect of the testicle\: tenderness is indicative of epididymitis (e.g.

Spermatic cord

The spermatic cord is the cord-like structure in males formed by the vas deferens and surrounding tissue that runs from the
deep inguinal ring down to each testicle.
Begin palpation of the spermatic cord from the superior aspect of the testicle using your thumb and index
spermatic cord should be palpable connecting to the testicle at this region. Palpate along the cord assessing for masses (e.g.
spermatocele) and tenderness.
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Gently palpate the whole testicular body

Prehn's test

Prehn's test is used to di
The test involves elevating the testes to assess the impact on testicular pain. A reduction in testicular pain is associated with
epididymitis.
Although this test can provide some clinical value it is inferior to Doppler ultrasound when trying to rule out testicular torsion.
Prehn's test

Cremasteric re

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The cremasteric re
causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal. Loss of the cremasteric
re
Doppler ultrasound should always be performed).
Stroke the inner aspect of the thigh

Patient standing

At the end of the examination, ask the patient to stand to allow you to re-assess the scrotum.
Inspect and palpate the posterior scrotum for evidence of varicocele (a palpable mass that feels like a 'bag of worms') or a
hernia (a mass which you cannot get above).
Inspect the scrotum with the patient standing
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To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 6 4- y e a r-o l d m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t a n d
t h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
"
" O n i n s p e c t i o n , t h e r e w e r e n o a b n o r m a l i t i e s i d e n t i
i n t h e l e f t s i d e o f t h e s c r o t u m , s e p a r a t e f r o m t h e t e s t i c l e. T h e m a s s w a s
w a s a b l e t o g e t a b o v e t h e m a s s a n d t h e r e w a s n o c o u g h i m p u l s e.
"
" I n s u m m a r y, t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Suggest further assessments and investigations to the examiner\:
Full abdominal examination
Ultrasound scan of the testicles.

Urology overview

Hydrocele

Hydrocele involves an accumulation of
hydrocele is due to a patent processus vaginalis (PPV).
The testicle should be palpable within the hydrocele sac and the mass should transilluminate.
If the hydrocele is large, the testicle may be di

Epididymal cyst

epididymis.
An epididymal cyst is a benign, smooth, extra-testicular, spherical cyst that is most commonly located in the head of the
Typical clinical

Spermatocele

A spermatocele is a benign, smooth, extra-testicular, spherical cyst in the head of the epididymis or spermatic cord (there is
no way to clinically di
The cystic
Typical clinical
Spermatoceles most commonly develop in patients post-vasectomy.

Varicocele

A varicocele is an abnormal dilatation of the testicular veins in the pampiniform venous plexus, caused by venous re
Typical clinical
patient is standing. A cough impulse may also be present.
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If of recent onset on the left side a renal tract ultrasound should be performed to rule out renal cancer as the left gonadal
vein drains into the left renal vein.

Epididymitis

Epididymitis involves the progressive painful swelling of the epididymis +/- testicle (epididymo-orchitis).
If the patient is aged under 35, it is likely due to a sexually transmitted infection (e.g. chlamydia).
If the patient is aged over 35, urinary pathogens such as E. Coli are the most common cause.

Testicular torsion

Testicular torsion involves the twisting of the spermatic cord resulting in a sudden loss of testicular blood supply.
Typical clinical features include the sudden onset of severe testicular pain, scrotal erythema and a swollen retracted testicle.
If there is suspicion of testicular torsion a scrotal ultrasound should be considered if there is diagnostic uncertainty. Surgical
exploration is commonly warranted.

Testicular malignancy

Key points\:
Testicular malignancy most commonly a
In the early phase of the disease, there are few, if any, systemic symptoms with the only clinical feature being a solitary solid
testicular mass.
If there is suspicion of testicular malignancy patients should have an urgent ultrasound scan of the testicles, chest x-ray and
tumour markers checked (Beta-HCG, Alpha-fetoprotein and Lactate Dehydrogenase [LDH]).
Treatment is most commonly inguinal orchidectomy.

Orchidopexy

Key points\:
An orchidopexy is an operation performed in children for undescended testicles where the testicle is brought down from the
inguinal canal into the scrotum.
Undescended testicles can increase the risk of testicular malignancy if left untreated.

Unilateral testicular atrophy

Unilateral testicular atrophy involves the shrinkage of one testicle which may occur following mumps, vascular compromise
(e.g. missed testicular torsion) or surgery (e.g. orchidopexy or inguinal hernia repair).

Bilateral testicular atrophy

Bilateral testicular atrophy is suggestive of primary or secondary hypogonadism.
Further investigations involve assessment of secondary sexual characteristics and hormonal abnormalities as well as ruling
out anabolic steroid use.

Phimosis

Phimosis involves the narrowing of the distal foreskin leading to an inability to retract it.
It is most commonly associated with the chronic in
Phimosis is physiological in most children with only 1% of children having persisting phimosis by the age of 16.
If phimosis is severe, it may require circumcision.

Paraphimosis

Paraphimosis typically develops when a patient's foreskin is left retracted (typically after catheterisation) resulting in
impaired venous return, venous hypertension and eventually impaired arterial supply to the glans.
Typical clinical features involve a swollen, oedematous glans/foreskin and signi
Urgent correction by manually replacing the foreskin is required to restore normal venous drainage and arterial supply
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