Male Genital Examination
It is not uncommon for patients to feel uncomfortable during this portion of the exam. It can be embarrassing to have your genitals examined in a way that you probably wouldn't do yourself, and it may be uncomfortable to be in a position with your pants and underwear pulled down. As a physician I try to do this examination as quickly as possible to minimize exposure of the genitals, and I always wear gloves when examining patients. If your physician fails to wear gloves when examining your genitals, you should ask him to do so. This is similar to a dentist examining your mouth without a glove, or a gynecologist not wearing gloves. It is inappropriate.
When checking the groin I look for evidence of bulges that can indicate hernias. I then feel the spermatic cords. These are the structures that carry blood to and from the testes and that also contain the tube called the vas deferens.
I then examine the testicles. It is important to note their size and any adjacent structures. Testicles are roughly 4 cm in length and approximately the size of a small egg. They should be smooth and their examination should not be tremendously uncomfortable.
At this point I try to teach the patient what some of the other lumps and bumps of the scrotum are. This way, the patient can familiarize himself with what is a normal finding and what is abnormal. I always show the patient what a normal testicle examination should be like, and I strongly encourage monthly self-examinations.
I then examine the scrotum for evidence of rashes or infections. Scrotal skin is typically hair bearing, and depending upon the temperature of the room, may be contracted or relaxed. In some older men, the scrotum may be so relaxed that it almost hangs down to the level of the kneecaps. I recommend tighter underwear for men whose scrotums hang very low.
Long-term usage of boxer shorts tends to produce more problems with the scrotum with rubbing on the inner side of the thighs. The structures behind the testicles called the epididymis, a single coiled tube that carries sperm from the testicles to the vas deferens, are a frequent site of inflammation and enlargement. A cystic enlargement of this area in which fluid may be trapped and then stored is known as a spermatocele. Spermatoceles may become extremely large in size. I check the scrotum for the presence of small cystic structures called sebaceous cysts. These cysts have a waxy appearance, and they become inflamed and drain a cheesy material.
Additionally, fluid may collect around the testicle itself. This fluid collection is known as a hydrocele, which is distinct from the spermatocele. The difference lies in the position. A spermatocele usually sits above and behind a testicle, whereas a hydrocele lies in front of and encompasses the entire testicle. The hydrocele fluid collection can become massive, and its size alone can not only be a cause of embarrassment, but a physical impediment to intercourse by causing concealment of the penis.
If left untreated, fluid collections in the scrotum can come close to the size of basketballs and totally conceal the penis. I see this at least once or twice a month in my practice. These men, for a variety of reasons, will choose to live with this problem and avoid sexual intercourse. This condition is completely treatable by a simple surgical procedure, and it should not be an impediment to satisfactory sexual intercourse.
Testicles that are poorly developed or have been damaged may be a consequence of either testicle surgery or damage during vasectomy. More commonly this is the result of a mumps infection. Small testicles are termed atrophic. They can frequently be poor producers of testosterone.
If the penis is uncircumcised, I check whether the foreskin easily pulls up and back on the glans. If the skin is tight and it is not possible to pull the foreskin back, this is a condition called phimosis. Phimosis makes it extremely painful to get an erection and may be the cause of erectile dysfunction in some instances. I pull the foreskin back and examine the moist inner side of the foreskin for lesions, such as early cancers or venereal warts. Small firm bumps on the rim of the head of the penis, known as the corona, are hirsutoid papillomas. This upsets many men who believe that this is a venereal disease, but they are quite common. Men who examine their penis can identify the location and duration of many of the small bumps and whether they have been present their entire lives.
I inquire about any discoloration or small birthmarks on the penis itself and how long the mole or discoloration has been present. Any mole that changes color or consistency or bleeds easily needs to be biopsied.
I next examine the urethral meatus, the opening where the urine comes out at the tip of the penis. I check its size and evaluate to see if it has been narrowed or scarred. I always make sure that I can retract both edges and examine the inside of the urethra since this is a common site for venereal warts and discharges from sexually transmitted diseases.
An infection on the head of the penis is known as balanitis. The most common cause of balanitis is a yeast infection. This is prevalent in men with diabetes due to the high concentration of sugar in the urine that promotes the growth of yeast under the foreskin causing infection. Balanitis can also be transmitted from a sexual partner who has a yeast infection. It is generally painful and is treated with topical creams to prevent infection. If the creams do not get rid of the infection, then a procedure known as a circumcision is performed in which the outer foreskin that covers the head of the penis is cut. Circumcision was once a common operation in newborn babies, but it is being performed less often because of concerns that it is painful for the infant.
I also gently pull on the penis to see how mobile it is. Certain scarring conditions can cause the penis to be rigid and not allow it to be pulled in a gentle fashion. I feel the shaft of the penis for evidence of Peyronie's plaques and evaluate whether the superficial veins have become fibrotic or cordlike. These cords always run in a vertical fashion on the penis instead of around the penis. Any changes are usually the consequence of minor trauma during sexual intercourse.
An optional part of the physical examination is to test the sensation of the glans penis. The head of the penis has a number of receptors for increased sensation or sensitivity. Most men don't realize that the majority of sensation of their penis is actually on the glans. The shaft of the penis has relatively few receptors for sensation. The uncircumcised head of the penis is generally much more sensitive because the head is always covered by foreskin. This prevents it from chronic rubbing on clothing and dulling of the sensation.
The final part of the external exam is to feel the area between the rectum and the scrotum known as the perineum. In doing so, I am looking for infected cysts, lesions, or draining sinuses. A draining sinus is an area that drains from the rectum outside the anus to an area in the perineum. This is a condition that may be seen with certain inflammatory diseases of the bowel and can be an extremely painful situation.
E.B. was a twenty-nine-year-old man brought by his wife because of decreased sexual desire. History indicated that he had mumps as a teenager and that he had never really been sexually active or interested in sex. Upon examination, he was found to have sparse facial and body hair and a normal-sized penis, however, both testes were smaller than peas. In this situation, the diagnosis of mumps orchitis was made. Treatment with testosterone replacement showed dramatic results.
A digital rectal examination involves inserting a gloved lubricated finger in the rectum to check not only the tone of the rectum and anus but also the prostate and for the presence of any other rectal or anal lesions.
There should be sufficient tone in the rectum so that it is tight around the examiner's finger. Decreased tone indicates either a neurologic problem or a situation where the rectum is chronically dilated, a result of anal intercourse or chronic insertion of foreign bodies into the rectum. Sometimes the anal sphincter is so tight that digital penetration is not possible. This is either a consequence of being unable to relax during the examination or a result of a spinal condition or nerve damage. The reflex known as the bulbocavernosus reflex is elicited by squeezing the head of the penis briskly with the finger and causing the anal sphincter to contract suddenly around the finger in the rectum. It is generally quite noticeable. Hyperreflexia, or an abnormal bulbocavernosus reflex, generally occurs from certain nervous conditions such as multiple sclerosis. Hyperreflexia refers to reflexes that are much more vigorous than normal. For instance, if you tap your knee, your foot will reflexively kick outward. Hyperreflexia means that the foot kicks out much higher and faster than normal.
I also evaluate for the presence or absence of stool in the rectum. Chronic constipation can cause the rectum to be extremely dilated resulting in blockage, or fecal impaction. Hemorrhoids are also detectable at this point, both external and internal. Patients who have had prior surgery to the anus may have scarring or strictures that prevent rectal examination.
An examination of the prostate includes all areas of the prostate. In thin individuals, I am frequently able to feel the top of the prostate in the area called the seminal vesicles. If this area is inflamed, the ejaculate may be bloody, a condition known as seminal vesiculitis.
I then feel the blood vessels in the groin, including the major artery that runs from the groin to the legs called the femoral artery. A decreased pulse in this area may be an important clue that there is decreased blood flow to the bottom half of the body. This finding may also be an indication as to the cause of erectile dysfunction. Examination of the legs often reveals evidence of severe diabetes or decreased blood flow. These are also important clues in the workup of erectile dysfunction.
P.F. was brought by his wife for evaluation of potential erectile dysfunction. The patient's wife was a registered nurse who reported that her husband had good desire but difficulty completing the act of intercourse. Physical examination disclosed a congenital abnormality of the penis where the urinary opening actually opened toward the base of the penis, a condition called hypospadias. When he achieved an erection, it was so bent that it precluded adequate vaginal penetration. The situation was easily remedied by surgery. Interestingly, the patient's wife had seen numerous normal penises as a nurse. They had been married several years before this condition became a problem and vaginal penetration was not part of their lovemaking. Apparently, she was now interested in becoming pregnant, which was what precipitated the visit to the clinic.
Remember, the physical examination is extremely important and should complement the medical history. It is important that the physical examination be complete. If the physician fails to examine the prostate or does only a cursory examination, then obtain another opinion.
One of the most common questions patients ask me is, "What is a normal-sized penis?" There really is no consensus on how to measure the penis, but generally speaking, an adequate penis is defined as one that allows penetration of the vagina sufficient enough to permit fertilization and the ability to stand upright to urinate. When these two criteria are met, the penis is an adequate size.
A flaccid and an erect penis differ tremendously in length. Measurement of a flaccid penis is not a good predictor of the length of an erect penis. Actual penile length measurement should be made with a full erection with a rigid ruler starting at the top of the penis between the tip to the point where the penis anchors the body at the bone, called the symphysis pubis. It is extremely important not to include the foreskin, especially in men who have elongated droopy foreskin. It is also important to avoid as much of the superficial fat as possible.
Studies show that the typical erection is roughly 5 inches in length, and I would certainly concur with this in my own busy urologic practice. The amount of body fat dictates the length of the penis as well. A general rule of thumb is that for every 30 pounds over ideal body weight, one can generally expect to lose an inch of penis size. The penis does not actually shrink, but more of it is concealed under a layer of fat. The more fat that surrounds the base of the penis, the less that length is apparent. While it is unusual to see a very large penis on an obese man, it is also true that a short penis can look quite long on an extremely thin man.
I look at the physical examination as a "blue light special." It allows me the opportunity to do a complete physical examination of a man who probably otherwise would never get a complete physical.
A careful history and physical examination is essential in determining the etiology of the erectile dysfunction. Laboratory tests should only be performed when the history and physical examination determine the need for these.
A pelvic examination is a complete physical exam of a woman's pelvic
organs by a health professional. A pelvic exam helps a health professional
evaluate the size and position of the vagina, cervix, uterus, fallopian tubes,
and ovaries. It is an important part of preventive health care for all adult
women. A pelvic exam is done to help detect certain cancers in their early
stages, infections, sexually transmitted diseases (STDs), or other
reproductive system problems.
Why It Is Done
A pelvic exam may be done:
As part of a woman's regular physical checkup. A Pap smear may be done during the pelvic exam. For more information, see the medical test Pap Test.
To help determine the cause of abnormal uterine bleeding.
To evaluate abdominal or pelvic pain.
Before prescribing a method of birth control (contraception). Some methods of birth control, such as a diaphragm or intrauterine device, require a pelvic exam to make sure the device fits properly.
Collect evidence in cases of suspected sexual assault.
How To Prepare
Before a pelvic exam:
Try to schedule the exam when you are not having your period, since blood can interfere with the results of a Pap smear. However, if you have a new vaginal discharge or new or increasing pelvic pain, a pelvic exam may be done while you are having your period.
Do not use douches, tampons, vaginal medications, or vaginal sprays or powders for at least 24 hours before having a pelvic exam.
If you have an abnormal discharge, do not have sex for 24 hours before having a pelvic exam. Semen in your vagina may interfere with your exam.
At the beginning of your visit, tell your health professional:
If you are or might be pregnant.
If you have any reproductive or urinary tract symptoms such as itching, redness, sores, swelling, or an unusual odor or increased vaginal discharge. If you have been performing regular vaginal self-exams, discuss any changes you have noticed with your health professional. For more information, see the medical testVaginal Self-Examination (VSE).
If you are using a method of birth control.
If this is your first pelvic exam.
The first day of your last menstrual period and how long your period lasted.
If you have had surgery or other procedures, such as radiation therapy, to the vagina, cervix, or uterus.
If you have had problems with pelvic exams in the past or are a survivor of rape or sexual abuse, talk to your health professional about your concerns or fears before the exam.
No other special preparations are needed before having a pelvic exam. For your own comfort, you may want to empty your bladder before the exam.
Talk to your health professional about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results may indicate.
During a pelvic exam, you will:
Take off your clothes below the waist. You will have a paper or cloth covering around your waist.
Lie on your back on an exam table with your feet raised and supported by stirrups. This allows the health professional to examine your vulva, urethra, vagina, and other reproductive organs. You may want to wear socks to keep your feet warm while they are in the stirrups.
Have a drape across your body for privacy during the test. The health professional may use a lamp during the test, and you may ask for a mirror if you want to watch while the test is being done.
A female nurse or assistant may stay in the room with you during the exam. You may also request the presence of your partner or a friend.
During the external exam, the health professional will:
Check inside your vagina with his or her finger for any cysts or pus coming from the Bartholin glands.
Gently insert the speculum into your vagina. The speculum spreads apart the vaginal walls, allowing the inside of the vagina and the cervix to be examined. The speculum may be plastic or metal and may be warmed with water or lubricated with a vaginal lubricant (such as K-Y Jelly).
Check the walls of your vagina and your cervix for damage, growths, inflammation, unusual discharge, or discoloration.
If you are due for a Pap smear, your health professional will use a small brush or a wooden spatula to gently collect a sample of cervical cells. You may have some staining or bleeding after the sample is taken. A sample of the cervical mucus may also be obtained and tested for sexually transmitted infections such as gonorrhea or chlamydia.
This exam is usually done as part of a pelvic exam. Your health professional will insert one or two gloved fingers of one hand into your vagina while placing the other hand on your lower abdomen. By pressing down on the abdomen and moving the fingers around inside your vagina, your health professional can locate and determine the size, shape, and consistency of the uterus, ovaries, and fallopian tubes. Any unusual growths, tenderness, or pain can also be identified.
For this exam, your health professional will insert one finger into your rectum and one into your vagina. This helps your health professional evaluate your ovaries, fallopian tubes, and uterus ligaments. This exam is not always done as part of a pelvic exam.
The entire pelvic exam takes about 10 minutes. After the exam is finished,
you will be given a washcloth or tissue to wipe your vaginal area to remove any
discharge resulting from the exam, and you will then dress. Some test results
may be available immediately, but results from the Pap smear may take from
several days to a couple of weeks.
How It Feels
A pelvic exam is more comfortable if you and the health professional are relaxed during the procedure. Breathing deeply and having a light conversation with your health professional may help you relax. Try not to hold your breath or tense your muscles.
You may feel some pressure or mild discomfort when the speculum is inserted into your vagina. Try to relax your legs and hips as much as you can. You may experience pain or irritation, especially if you have a vaginal infection. If a metal speculum is used, the metal may feel cold and hard. The speculum may be warmed with water or lubricated with a vaginal lubricant, such as K-Y Jelly, before being inserted into the vagina.
During the bimanual part of the exam, you may feel an uncomfortable sensation of pressure or a slight twinge of pain as the health professional feels your ovaries; breathing deeply may help you relax. You may feel a brief pinch when the Pap smear is taken. Tell your health professional if any part of the exam is painful.
During the rectovaginal exam, you may feel as though you are about to have a
bowel movement as the health professional withdraws a finger from your rectum.
This is a normal sensation that lasts only a few seconds. You may have a small
amount of vaginal discharge or bleeding after the exam.
There are no risks associated with a pelvic exam.
A pelvic examination is a complete physical exam of a woman's pelvic organs by a health professional. A pelvic exam helps a health professional evaluate the size and position of the vagina, cervix, uterus, fallopian tubes, and ovaries.
The uterus, fallopian tubes, and ovaries are normal in size and location. The uterus can be moved slightly without causing pain.
The vulva, vagina, and cervix appear normal with no signs of infection, inflammation, or other abnormalities.
Glands around the opening of your vagina (Bartholin's glands) or urethra (Skene's glands) are not swollen or inflamed.
No masses (nodules) of abnormal tissue are felt in the area between the uterus and rectum (cul-de-sac) or in the strong bands of tissue (ligaments) that attach to the uterus to hold it in place. No fibroids are felt during the bimanual pelvic or rectal exams.
No pelvic pain or tenderness is present.
No hardening of tissue (induration) is felt.
Sores, signs of infection, inflammation, or abnormalities of the vulva, vagina, or cervix are present. Signs of a sexually transmitted disease (such as genital herpes, genital warts, or syphilis) may be present. Additional testing will be required to determine the cause.
The glands around the vagina (Bartholin's glands) or urethra (Skene's glands) are swollen or inflamed.
The uterus cannot be moved (even slightly) during the exam.
Pain or tenderness is felt when the uterus is moved slightly or when the area between the uterus and rectum (cul-de-sac) is touched. The uterus is pushed away from the midline of the abdomen.
The ovaries are painful when touched, enlarged, or not movable (fixed).
An ovarian mass is present or a mass that was detected during a previous gynecologic exam is still present or has grown larger.
Small masses (nodules) of abnormal tissue are felt near the uterus or in the cul-de-sac. Uterine fibroids are felt during the bimanual pelvic or rectal exam.
Hardening of tissue (induration) is felt.
An area of ulceration or a tear is found.
A mass can be felt near one or both ovaries.
Many conditions can change the results of your pelvic exam. Your health
professional will discuss any significant abnormal results with you in relation
to your symptoms and medical history.
What Affects the Test
Reasons you may not be able to have the test or why the results may not be helpful include:
Menstrual blood on the slide.
A vaginal infection.
The use of douches or vaginal creams or preparations within 24 hours of the exam.
What To Think About
You should begin having regular Pap tests within 3 years after becoming sexually active. For more information, see the medical testPap Test.
After you have had three or more consecutive, normal annual pelvic and Pap tests, these tests may be performed less frequently, depending on your risk factors for cervical problems and the advice of your health professional.
If a sexually transmitted disease (STD) is suspected, other specialized testing may be needed to confirm a diagnosis.
Pelvic ultrasound is another test used to evaluate a woman's pelvic organs. For more information, see the medical test Pelvic Ultrasound.
Vaginal self-exam (VSE) may help you better understand your body, know what is normal for you, and find early signs of infections or other abnormal conditions that might require medical attention. However, VSE should supplement but not replace a regular pelvic exam and Pap test done by a health professional. For more information, see the medical testVaginal Self-Examination (VSE).
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