The adolescent male genital examination: What's normal and what's not

The adolescent male genital examination:
What's normal and what's not

By William P. Adelman, MD, and Alain Joffe, MD, MPH

Do you do a genital exam on your male adolescentpatients? You should. These adolescent specialists demystify theprocess by teaching you where the landmarks are and what to lookfor.

Pediatricians know that a genital exam should be part of routinehealth care for adolescent boys, but many of them avoid the procedureunless the patient has a specific complaint. This is a mistake.A genital exam is an essential part of the routine health maintenancevisit: to gauge sexual development, identify common anomalies,and pick up early signs of potentially serious conditions. Inaddition, many acute complaints such as abdominal, back, or flankpain, gynecomastia, supraclavicular adenopathy, and genital discomfortrequire a thorough genital examination for diagnosis and management.

This article will familiarize the reader with the male genitalexamination through review of important anatomical structuresand landmarks, benign findings of the penis, and common nonpainfulmasses in the scrotum. A second ariticle will review the differentialdiagnosis of the painful scrotum in the adolescent.

Where and how to perform the exam

We have found that even the most modest adolescent will agreeto be examined if we explain why it is important and tell himwhat to expect. We explain that examination of the penis and testiclesis an important part of the physical examination, as it allowsus to ensure that development is proceeding normally and to identifyearly signs of potential problems. We point out that, in the rarecircumstances in which a teenage male gets cancer, testicularcancer is the most likely possibility, and only a thorough genitalexam can pick this up at an early, treatable stage.

We do the examination with a chaperone present--a nurse, nurse'saide, medical student, or any clinician who is available at thetime. We have found that most patients are equally comfortablewith a male or female examiner, and our experience has been corroboratedby other researchers.¹ We keep the exam room warm,which relaxes the scrotum and makes it easier to examine, andthe examiner warms his or her gloved hands before starting theexam. We ask the patient to remove his own undergarments and standfacing the seated examiner. We first inspect and then palpatethe pubic area, inguinal canals, penis, and scrotum .

The pubic area

The pubic hair and underlying skin should be inspected to evaluatesexual maturity (Tanner stage) and look for evidence of such conditionsas folliculitis, molluscum contagiosum, scabies, or genital warts.Examination of the penis should include inspection of the meatus,glans, corona, and shaft (Figure 1). The meatus should be inspectedfor discharge, erythema, warts, or hypospadias (urethral openingon the underside of the penis). If a discharge or other sign ofsexually transmitted disease is noted, a specimen is taken. Collectionof material for gram stain or culture requires insertion of theswab at least 2 cm past the meatus to reach the columnar epitheliumof the urethra (Figure 2). The prepuce should be evaluated forphimosis.

For uncircumcised males, the foreskin should be retracted toinspect the glans for erythema or evidence of Candida infection,balanitis, or contact dermatitis. Ulceration of the glans maybe present with herpes, syphilis, or trauma. The foreskin shouldthen be returned to its original position. Inspection of the coronamay reveal the common benign finding of pearly penile papules,which will be discussed in the next section. The shaft, includingits underside, should also be inspected for ulcers and warts.

Pearly penile papules

These uniform-sized papules arise at the time of maximum pubertalchanges, most commonly in Tanner stage II or III (Figure 3). Theyare found in approximately 15% of teenagers ² and arebenign. They typically appear along the corona and less frequentlyalong the sides of the frenulum and on the inner preputial skin.Pearly penile papules have distinct clinical and histologic featuresand are a variant of the normal epithelium of the glans and, lessfrequently, the frenulum and penile shaft. They should be differentiatedfrom warts caused by human papilloma virus (HPV). In a study lookingfor HPV DNA by polymerase chain reaction in biopsy-proven pearlypenile papules, no HPV was found.³ Therefore, treatmentis unnecessary and the patient and sexual partner may be reassured.

The scrotum and its contents

The scrotum and testis examination may be divided into fourparts: scrotum, spermatic cord, epididymis, and testis (Figure4).

Scrotum. The scrotum should be inspected for redness or otherlesions. Contraction of the dartos muscle of the scrotal wallproduces folds or rugae, most prominent in the younger adolescent.An underdevoped scrotum may indicate an ipsilateral undescendedtesticle. With a retractile testicle, the scrotum is normallydeveloped.

Spermatic cord. This fascial-covered structure contains bloodvessels, lymphatics, nerves, the vas deferens, and the cremastermuscle. To examine the spermatic cord, apply gentle traction onthe testis with one hand and palpate the structures of the cordwith the index or middle finger and thumb of the opposite hand.The vas deferens feels like a smooth, rubbery tube and is themost posterior structure in the spermatic cord. Normally, thevas deferens should be present on each side, nontender, and smooth.Absence of the vas deferens bilaterally is associated with cysticfibrosis. Unilateral absence of the vas deferens is associatedwith ipsilateral renal agenesis.⁴ Thickening and irregularityof the vas deferens may be caused by infection such as tuberculosis.The pampiniform plexus of veins lies within the spermatic cordand usually cannot be differentiated from other structures inthe cord except when abnormally dilated, forming a varicocelethat feels like a "bag of worms." Varicocele will bediscussed in greater detail below.

The epididymis. This structure lies along the posterolateralwall of the testicle. It anchors the testicle to the scrotal wall.The head of the epididymis lies at the superior pole of the testiswhile the tail lies at the inferior pole. The easiest way to findthe epididymis is to follow the vas deferens toward its junctionwith the tail of the epididymis. The appendix epididymis is astalked structure on the head of the epididymis, and may be multiplein some individuals. The epididymis consists of efferent ductsthat may be applied to the testis loosely or tightly, but shouldalways be differentiated from the testis itself. Acute inflammationof the epididymis (epididymitis) causes acute scrotal pain, tenderness,swelling, and induration of the epididymis. In contrast, a welllocalized, nontender, spherical enlargement of the epididymalhead is a spermatocele.

Testis. This firm, ovoid body is encased in the tunica albuginea,an inelastic white fascial sheath that maintains the testicle'sintegrity. Adult testes are usually 4 cm to 5 cm long and 3 cmwide but vary from one individual to another.⁵ Abouttwo thirds of the testicular volume is produced by the seminiferoustubules. For that reason, decreased testicular volume and firmnessare considered indicators of decreased spermatogenesis. The lefttesticle is usually lower than the right. To examine the testicle,stabilize it with one hand and use the other hand to palpate theentire surface. Examine each testis for size, shape, and consistency.The testes should be roughly the same size (within 2 mL in volumeof each other). Any induration within the testicle is testicularcancer until proven otherwise. The appendix testis, present in90% of males, can be palpated at the superior pole of the testicle.

Inguinal canals. Check the canals for hernia by sliding yourindex finger along the spermatic cord above the inguinal ligamentand palpating the opening of the external inguinal ring (Figure5). While your finger remains at the external ring or within thecanal, ask the patient to cough or perform a Valsalva maneuverto check on whether there is any herniation of abdominal contentsinto the scrotum.

Scrotal lumps and bumps

Pain, swelling, or masses are the most common presentationsof scrotal or testicular pathology in the adolescent. Many teenagersdelay seeking care for these conditions because they are embarrassed,afraid, or in denial. We try to circumvent that reaction by counselingteenagers at all routine health-care visits to call or come inwhenever they have questions or concerns about their genitals.And while we are examining the testes, we reinforce this anticipatoryguidance by telling the patient to let us know right away if hefeels pain or swelling in the testes or finds a lump. This sectionwill review three of the lumps and bumps that may be found inthe scrotal exam: hydrocele, spermatocele, and hernia (Figure6). Varicocele and tumors, which are more complex, will be reviewedin subsequent sections.

Hydrocele. This lump is actually a collection of fluid betweenthe parietal and visceral layers of the tunica vaginalis, whichlies along the anterior surface of the testicle and is a remnantof the processus vaginalis. The tunica vaginalis is importantanatomically as a potential space that may be involved in theformation of a hydrocele and in testicular torsion. A hydroceleis usually a soft, painless, fluctuant, fluid-filled mass thattransilluminates when you shine a flashlight behind the testicle.Occasionally, it may be tense. Commonly, hydroceles are anteriorto the testicle, but large ones may surround it, occupying thecomplete hemiscrotum.⁶ They occur in about 0.5% to1% of males and may appear at any age.⁷ In adults,the cause is believed to be an imbalance between the secretoryand absorptive properties of the tunica vaginalis. A congenitalhydrocele is due to a patent processus vaginalis. Most cases ofhydrocele are primary and idiopathic, but the examiner shouldalso suspect other processes, such as orchitis, epididymitis,or testis tumor. An acute hydrocele will transilluminate and iseasily diagnosed. A careful history and physical exam should excludean inguinal hernia, lymph blockage, or testicular torsion. Hydrocelesassociated with malignancy tend to be small. If the testicle canbe completely palpated and is of normal consistency, ultrasonographyis not mandatory. However, if the hydrocele prevents adequatepalpation of the testis, an ultrasound should be performed toassist with description of the testicle, differentiate a hydrocelefrom an inguinal hernia, and rule out testicular tumor, whichshows up on a sonogram as a heterogeneous mass. If a hydroceleis tense, painful, or associated with a hernia (in which caseit is called a communicating hydrocele), surgical interventionis advised. Otherwise, no treatment is necessary, as the hydrocelemay resolve spontaneously. Patients who feel discomfort afterexercise should be encouraged to use an athletic supporter. Mostsurgeons recommend elective removal of congenital hydroceles thatare still present in adolescence.

Spermatocele. This mass is a retention cyst of the epididymisthat contains spermatozoa. The incidence of spermatoceles is muchless than 1%. Microscopic examination of aspirated contents revealsspermatozoa, usually dead. Grossly the fluid is thin, white, andcloudy. The etiology of a spermatocele is not known, but may includecongenital weakness of the epididymis wall, epididymitis, epididymalobstruction, and scrotal trauma. Usually, a spermatocele is locatedat the head of the epididymis, above and behind the testis. Mostare small (less than 1 cm in diameter), freely movable, painless,and will transilluminate. Spermatoceles are usually discoveredduring routine examination. However, if the spermatocele is largeenough, the patient may come in complaining of a "third testicle."In the case of a large spermatocele, turbidity from increasedspermatozoa may prevent transillumination.

Occasionally, the spermatocele may be confused with a hydroceleor a solid tumor. The difference between a spermatocele and ahydrocele is that the hydrocele covers the entire anterior surfaceof the testicle, while the spermatocele is separate from, andabove, the testicle. On ultrasound examination, a spermatoceleappears as an echo-free collection above and behind the testis.A spermatocele may be firm, like a solid tumor, but­unlikea tumor--it feels separate from the testis when you palpate thescrotum. Epididymal tumors are extremely rare in the adolescent,but an adenomatoid tumor of the epididymis may mimic a spermatocele.A large spermatocele may also be confused with a hydrocele sonographically.

Discovery of a spermatocele requires no therapy unless it islarge enough to annoy the patient, in which case it may be excised.Excision should be approached with caution to avoid compromisingthe passage of spermatozoa through the epididymis and vas deferens.

Hernia. This mass is a sac-like protrusion of intestine throughthe inguinal ring into the scrotum. The incidence is about 1%to 2% (1% or less in teenage boys) and hernias may appear at anyage. A hernia may resemble a hydrocele but can be distinguishedby the following features: a hernia reduces when the patient isin the supine position, will not descend with traction on thetesticle, and may be associated with bowel sounds in the scrotum.The examiner can locate the top of a hydrocele within the scrotumbut cannot do so with a hernia. As mentioned previously, herniasand hydroceles may coexist. The treatment for hernia is surgicalcorrection.

Varicocele

The most common scrotal mass among teenagers is the varicocele,and its treatment is the most controversial. Varicoceles are elongated,dilated, tortuous veins of the pampiniform plexus within the spermaticcord, formed from incompetent and dilated internal and externalspermatic veins.

Varicoceles are rare before adolescence. Among 10- to 25-year-olds,incidence varies from 9.25% to 25.8%, with a weighted averageof 16%.⁸ Approximately 15% of adult males have a varicocele.⁹

Presentation. Most cases of varicocele are asymptomatic anddiscovered on routine physical examination. Occasionally, theyare associated with an ache or a "dragging" sensation,or patients complain of feeling a "bag of worms" alongthe spermatic cord. Characteristically, the "worms"are prominent when the patient is standing and less obvious whenhe lies down. A varicocele occurs most often on the left side(85% to 95% of cases), presumably as a consequence of retrogradeblood flow from the left renal vein. The condition may, however,be bilateral or, less commonly, right sided.¹⁰

Physical examination. Visual inspection of the scrotum shouldprecede any palpation. A visible varicocele is classified as aGrade 3 (large) varicocele. Palpation of the scrotum, testes,and spermatic cord structures comes next. A varicocele feels likea bag of worms or a "squishy tube." More subtle varicocelesmay feel like a thickened or asymmetric spermatic cord. A varicocelethat is palpable but not visible is classified as Grade 2 (moderate).If no varicocele is palpable, the patient may be asked to performa Valsalva maneuver. If a varicocele is present, this will distendthe intrascrotal veins. A varicocele discovered only with Valsalvais classified as Grade 1 (small). The benefit of identifying Grade1 varicoceles is unknown, and for that reason we do not routinelyhave our patients perform a valsalva maneuver if no varicoceleis palpable. If a varicocele is discovered, the patient shouldalso be examined in the supine position. This will help to confirmthe diagnosis, as varicoceles tend to decrease in size when thepatient is supine. In contrast, a thickened cord due to a lipomawill not change with position.

Evaluation. If a varicocele is present, the size of the testes(volume) should be compared. Volume assessment by ultrasound hasbeen shown to best represent true testes volume as determinedby weight and volume displacement. All other measurements aremore likely to overestimate small-volume testes and underestimatelarge-volume testes. Since two thirds of testicular volume isaccounted for by seminiferous tubules, decreased volume indicatesdecreased spermatogenesis--which is what we really care aboutin assessment of testicular damage. Decreased testicular volumeis one of the only clinical signs that suggest testicular damage.

Left testicular hypotrophy (growth arrest) in association withthe varicocele is the hallmark of testicular damage. During rapidpubertal growth, a volume discrepancy between the testes may becomeclinically apparent. The larger the varicocele, the more likelyhypotrophy will occur, and the greater the chance of correctionwith varicocele ligation.¹¹ Multiple methods have beenused to measure the size of the testis: visual comparison--rulers,calipers, Prader orchidometer (comparative ovoids), Takihara orchidometer(punched-out elliptical rings), and ultrasound. The most accurateand reproducible method is ultrasound.^12,13 Accuracyis important, as operative decisions may rest upon precise evaluationof discrepancies in testicular volume . Surgical repair is notconsidered unless the size variation is 3 mL or greater by ultrasound.

Treatment. Multiple lines of evidence suggest that Grade 2and Grade 3 varicoceles can have a negative effect on the growthand function of the ipsilateral testicle in some patients.^14­16For example, about 30% of males in infertility clinics havevaricoceles, compared with 15% in the general population. Also,some males with varicoceles have:

• abnormal follicle stimulating hormone/leutenizing hormone response to gonadotropin releasing hormone (GnRH) infusion, which suggests testicular damage
• abnormalities on testicular biopsy
• abnormal semen analysis.

Furthermore, testicular hypotrophy can be reversed and spermconcentration improved with varicocele ligation in adolescents.^17­19

However, over 80% of males with varicoceles are fertile, andno definitive studies show improved fertility following varicocelectomyin adolescence. So the challenge is to identify those patientswho may benefit from repair. Since GnRH testing and semen analysis,the best measures of testicular damage, are not widely availableand not easy to do, current recommendations for surgery are basedon the following abnormalities in testicular volume:

• a large varicocele associated with a small testicle or a testicle not growing as puberty progresses²⁰
• left testis at least 3 mL smaller than the right.
• bilateral or symptomatic varicoceles¹⁰
• a decrease of two standard deviations in testicular size when compared with normal testicular growth curves
• scrotal pain.¹⁴

When we discuss treatment with patients, we tell them thereis no guarantee that repairing the varicocele will assure fertility.Our current practice is to identify patients with varicoceles,follow testicular size through puberty, and refer those who meetthe criteria above to a urologist to discuss what should be done.

Testis tumor

Testicular cancer, predominantly of germ cell origin (95%),is the most common cancer of young men between 15 and 34. It accountsfor 3% of all cancer deaths in that age group, and may affectaround one in 10,000 teens.⁷ Six thousand to 8,000new cases are diagnosed annually in the United States, and approximately1,500 males in the US die each year from germ cell tumors. Fortyper cent of germ cell tumors are seminoma, making it the mostcommon testicular cancer of single cell type, but the incidenceof seminoma peaks in the 25- to 45-year age group while nonseminomapeaks in the 15 to 30-year-old group. Bilateral tumors occur in2% to 4 % of patients.²¹

Risk factors. Testicular cancer risk factors are largely unknown,although cryptorchidism, trauma, and atrophy are commonly associatedwith testicular cancer. Twelve percent of men with testicularcancer have a history of cryptorchidism, and the risk of developinggerm cell tumors is 10 to 40 times higher in a cryptorchid testis.From 1% to 5% of boys with a history of an undescended testiclewill later develop germ cell tumors, so any history of cryptorchidismshould prompt careful, long-term follow-up. If an undescendedtesticle is diagnosed after puberty, an orchiectomy is recommended,because the testicle can no longer produce sperm but is at riskfor malignant changes. We recommend regular testicular self-examinationfor such high-risk patients. It is important to keep the riskin perspective, however almost 90% of men with germ cell tumorsdo not have a history of cryptorchidism.

Clinical manifestations. Testis tumor most commonly appearsas a circumscribed, nontender area of induration within the testisthat does not transilluminate. Most tumors are painless and discoveredby the patient as a lump in the testis; when the patient is examined,however, physicians note swelling in up 73% of cases. Withouta high level of suspicion, testicular tumor may be missed on casualexamination. Patients with a testicular tumor may have a sensationof fullness or heaviness of the scrotum. Or the patient may comein with a history of recent trauma to the scrotum, which thendraws the physician's attention to a painless mass in the traumatizedtesticle. Testicular pain may be an early symptom in 18% to 46%of patients with germ cell tumors.²² Acute pain maybe associated with torsion of the neoplasm, infarction, or bleedinginto the tumor.

Signs and symptoms indistinguishable from acute epididymitishave been observed in up to one-fourth of patients with testicularneoplasms. Less commonly, patients with tumors may come to theoffice with gynecomastia from a tumor that secretes human chorionicgonadatropin (HCG), or with back or flank pain from metastaticdisease. In most cases of testicular tumor, the epididymis andcord feel normal. In more advanced tumors, the testis may be diffuselyenlarged and rock hard. Secondary hydroceles may occur. If a hydrocelemakes adequate palpation of the testis difficult, ultrasonographyis indicated to rule out a tumor. If the tumor is a seminoma,the testis may be uniformly enlarged to 10 times its normal sizewithout loss of normal shape.

Testicular cancer in the sexually active adolescent can easilybe mistaken for epididymitis, which is characterized by a swollen,tender testicle with occasional fever and pyuria. Treating patientsfor presumed epididymitis has caused delays of as long as ninemonths in the diagnosis of testicular cancer. Because of thispossibility, once a patient with an initial diagnosis of epididymitishas had an appropriate course of antibiotics, he should be reexaminedto be sure no residual mass is palpable. If the diagnosis is notclear cut, get an ultrasound.

Differential diagnosis. In an adolescent, the differentialdiagnosis of a testicular mass includes testicular torsion, hydrocele,varicocele, spermatocele, epididymitis (which can coexist withgerm cell tumors), and other malignancies, such as lymphoma. Rarely,genital tuberculosis, sarcoid, mumps, or inflammatory diseasecan also mimic cancer. Because 25% of patients with seminoma and60% to 70% of those with a nonseminomatous germ cell tumor havemetastatic disease at the time they seek medical attention,²¹any of the following symptoms should prompt examination of thetestis: back or abdominal pain, unexplained weight loss, dyspnea(pulmonary metastases), gynecomastia, supraclavicular adenopathy,urinary obstruction, or a "heavy" or "dragging"sensation in the groin.

Evaluation. Ultrasonography can discriminate between a testicularneoplasm and nonmalignant processes included in the differentialdiagnosis. Even if an obvious mass is palpated on physical examination,an ultrasound should be performed on both testicles to check forbilateral disease, which occurs in 2% to 4% of cases. Once a tumoris suspected, tumor serum markers such as lactate dehydrogenase,b human chorionic gonadatropin, and a fetoprotein are indicated.Further evaluation for staging, including a CT of the chest, abdomen,and pelvis, and other imaging as needed (imaging of the brainin choriocarcinoma, for example), should be performed in consultationwith an oncologist.

Prevention. Testicular self-examination (TSE) is a simple,potentially life-saving intervention that may detect cancer inan early, asymptomatic stage. Studies have shown that nearly 90%of young adults are not aware of testicular cancer and that lessthan 10% of men have been taught how to examine their testicles.²²However, no data show that testicular self-examination reducesmorbidity or mortality from testicular cancer, and its universalapplication remains controversial. We tend to reserve the discussionof TSE until patients have reached middle to late adolescence.For a comprehensive review of testicular self-examination, seeGoldenring J: A lifesaving exam for young men. Contemporary Pediatrics1992;9(4):63.

Am I normal?

All adolescents are concerned about whether they are "normal,"especially with regard to sexual development. Boys may be morereticent than girls about expressing this concern, but it takesup a lot of space in their psyches. The best way to reassure themis to make the genital examination a part of the routine healthcare you provide. This review of genital anatomy and common findingsis intended to make you more comfortable with providing this exam.By including it in your basic repertoire, you will be able tomonitor your patients' development, answer their questions, andspot rare but potentially serious anomalies early on, before damageis done. It's a skill worth acquiring.

DR. ADELMAN is a Fellow in Adolescent Medicine, Division ofGeneral Pediatrics and Adolescent Medicine, Johns Hopkins MedicalInstitutions, Baltimore, MD.

DR. JOFFE is Director, Adolescent Medicine, and AssociateProfessor of Pediatrics, Johns Hopkins Medical Institutions, Baltimore.

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