Male Repro

Question 1

When looking at a patient’s skin, what may a maculo popular rash in the palm of the hands and soles of the feet be an indicator of?

Answer 1

Secondary Syphilis

Question 2

When looking at a patient’s skin, what could you find in a patient’s finger webs?

Answer 2

Burrows of scabies mite

Question 3

When looking at a patient’s skin, what could you find when examining a patient hairline, fingernails and extensor surfaces of limbs?

Answer 3

Psoriasis

Question 4

What may general muscle wasting be a sign of?

Answer 4

Cachexia – Weight loss and deterioration of physical condition – Possibility of advanced cancer

Question 5

What is this sign?

Answer 5

Palmar erythema

Question 6

What is this sign?

Answer 6

Gynaecomastia

Question 7

What is this sign?

Answer 7

Axillary hair loss

Question 8

What is this sign?

Answer 8

Spider naevi (5+ significant)

Question 9

What are the signs of excessive oestrogen production?

Answer 9

Palmar erythema, Gynaecomastia, Axillary hair loss and Spider naevi

Question 10

What is this a sign of?

Answer 10

Cold sores indicate herpes simplex infection

Question 11

What is this a sign of?

Answer 11

Recurrent aphthous ulceration and oral candida may be present in HIV infection.

Question 12

What may generalised lymphadenopathy be suggestive of?

Answer 12

May be present in some infections.

Question 13

What may hepatosplenomegaly be secondary to?

Answer 13

Metastatic disease

Question 14

What may loin tenderness be secondary to?

Answer 14

Renal sepsis or stone

Question 15

What may the distribution of pubic hair may reflect?

Answer 15

Endocrine conditions such as androgen excess of adrenal or ovarian origin, or hypogonadism.

Question 16

What may an examination of the genital skin reveal?

Answer 16

Genital warts, molluscum contagiosum, ulcers (most commonly herpetic but also consider syphilis).

Question 17

What should you look carefully for in the hair of the pubic region, lower abdomen and upper thighs?

Answer 17

Pubic lice

Question 18

What is this a sign of?

Answer 18

A fungal rash which often has a scaley surface and well-defined border.

Question 19

What is this a sign of?

Answer 19

Skin sensitivity rashes can be from the use of products, especially antiseptic soap.

Question 20

Other examinations and tests that may be needed?

Answer 20

• Digital rectal examination
• Urine pregnancy test may be ordered if there is any doubt about possible pregnancy, intrauterine or ectopic.
• Urinalysis will be appropriate for suspected urinary tract infection.

Question 21

What does genital ulcer disease require?

Answer 21

Investigation for syphilis or other STIs

Question 22

How can we visualise pelvic organs?

Answer 22

Ultrasonography (transabdominal, transvaginal or transrectal) is very useful for visualisation of the pelvic organs.

Question 23

What is this a sign of?

Answer 23

Dupuytren’s contracture associated with Peyronie’s disease in males. Peyronie’s disease is a disorder in which scar link tissue, called plaque, forms under the skin of the penis—the male organ used for urination and sex. The plaque builds up inside the penis, in the thick elastic membrane called the tunica albuginea. The tunica albuginea helps keep the penis stiff during an erection.

Question 24

What areas of the male genital region should be examined ?

Answer 24

The skin of the shaft of the penis, the foreskin (or note circumcision) and glans, urethral meatus, scrotum, perineum, perianal area and inguinal region should be inspected. Most of the conditions mentioned above can also present in these areas.
The urethral meatus should be examined for any discharge or inflammation. Likewise, it is common to find inflammation of the foreskin or glans, referred to as posthitis or balanitis respectively or balanoposthitis if both are involved.

Question 25

If there is severe tenderness whilst palpating the scrotum what may this be suggestive of?

Answer 25

Severe tenderness whilst palpating can be suggestive of testicular torsion which is a medical emergency.

Question 26

What should you cover when palpating the male external genitalia?

Answer 26

Palpate the scrotum. Confirm the presence of both testicles in the scrotal sac. They should be approximately equal in size, smooth and fairly firm. Testes should be palpated between the examiner’s thumb and first two fingers checking for any lumps, hardness or tenderness. Lumps within the testes themselves are of much greater significance than lumps which are separate. If one of the testes is absent, ask about previous surgery or retractile/undescended testicles. On the superior pole of the testes the epididymis and surrounding structures should be palpated for lumps, thickening or tenderness. Epididymal cysts are a very common finding and are benign.

Question 27

What are Varicocoeles?

Answer 27

Distended veins that feel like “bag of worms”, are also relatively common and are more often found on the left side.

Question 28

What is hydrocoele and how would you test for it?

Answer 28

A hydrocele is a type of swelling in the scrotum. If hydrocele is suspected a bright pen torch should be pressed against the swelling to assess for transillumination, which lights up the scrotal sac, like water in a balloon. It may be necessary to darken the room to see this. The patient should then be asked to stand and the scrotum re-palpated systematically. If an inguinal hernia or varicocele is present, then this will usually increase the size of the swelling.

Question 29

If you felt a scrotal lump which you were unable to get above the lump and transmitted a cough impulse what would this be a sign of?

Answer 29

Inguinal hernia

Question 30

If you felt a scrotal lump which was fixed to testes and firm what would this be a sign of?

Answer 30

Testicular carcinoma

Question 31

If you felt a scrotal lump which was tender and usually on superior pole of testis
what would this be a sign of?

Answer 31

Epididymitis

Question 32

If you felt a scrotal lump which was cystic and on superior pole of testis what would this be a sign of?

Answer 32

Epididymal cyst

Question 33

If the posterior aspect was “like bag of worms” what would this be a sign of?

Answer 33

Varicocele

Question 34

If you felt a scrotal lump which was trans-illuminable what would this be a sign of?

Answer 34

Hydrocele

Question 35

If you felt a scrotal lump fixed to scrotum but not to the testes what would this be a sign of?

Answer 35

Scrotal lesion

Question 36

What would men with urethral discharge need to be investigated for?

Answer 36

Gonorrhoea, chlamydia and other STIs

Question 37

What are the different sections of this examination?

Answer 37

1. INTRODUCTION
2. GENERAL INSPECTION
3. CLOSE INSPECTION
4. PENIS
5. SCROTUM
6. OTHER AREAS
7. CONCLUSION

Question 38

What is involved in the Introduction?

Answer 38

A. Ensure adequate hygiene of hands and appropriate PPE
- Wearing PPE of mask, apron + gloves
B. Introduce self
C. Confirm patient’s name and DOB
D. Ask if patient in any discomfort
E. Explain procedure and seek permission to examine the genitourinary system
- Important to explain the examination as you go along and repeatedly check that you have consent to continue. Reassure the patient you can stop at any stage if they request.
F. Offer a chaperone
- Chaperone desirable in any intimate examination. Document clearly if patient declines.
G. Allow privacy for patient to undress. Provide a cover until examination starts
H. Position patient – initially lying on the bed as for an abdominal examination

Question 39

What is involved in the General Inspection?

Answer 39

A. Demeanour, weight change, skin conditions e.g. psoriasis
B. Hands – signs of anaemia, scabies, maculopapular rash of secondary syphilis
- Maculopapular rash of secondary syphilis typically seen on palms and soles
C. Face – mouth ulcers, cold sores NOT looking in mouth during Covid-19
- Cold sores indicate herpes simplex infection, typically but not always, type 1. Recurrent apthous ulceration
and oral candida may be present in HIV.

Question 40

What is involved in the Close Inspection?

Answer 40

A. Inspect skin – groin, skin creases, perineum and scrotal skin, hair distribution
- Look for genital warts, molluscum contagiosum, and pubic lice. There may be alopecia, infestation or ulcers (most commonly herpetic but also consider syphilis). Patients who shave may have dermatitis or folliculitis. Inertrigo (infected eczema) occurs in skin creases and check for fungal rash which often has a scaly surface and well defined border.
Scrotal oedema can be caused by systemic or local disease. Heart and liver dysfunction may cause significant
genital oedema, as may the nephrotic syndrome and lymphoedema due to para-aortic lymphadenopathy.

B. If any swellings in the groin – palpate and describe SPACESPIT
- Lymphadenopathy may be due to local or general causes. Tender inguinal lymph nodes are common in genital herpes simplex infection (usually bilateral in primary episodes and unilateral in recurrences.) Enlarged
nodes may be due to many causes of genital infection, particularly syphilis.
- SPACESPIT Size, Position, Attachment, Consistency, Edge, Surface and shape, Pulsation, thrills and
bruits, Inflammation, Transillumination

Question 41

What is involved in the Penis?

Answer 41

A. Inspect shaft
B. Palpate shaft for fibrous plaques (usually on dorsum)
C. Palpate any other lesions and define them
D. Retract the prepuce and inspect the glans for red patches or vesicles
E. ALWAYS DRAW THE FORESKIN FORWARD AFTER EXAMINATION TO AVOID A
PARAPHIMOSIS
F. (Take a urethral swab if indicated)

Inspect the skin of the shaft of the penis, foreskin and glans, urethral meatus. The rash of psoriasis may only be found in the genital area, typically scrotum and natal cleft. The urethral meatus should be examined for any discharge or inflammation. Inflammation of the foreskin (posthitis) or glans (balanitis) or both (balanoposthitis) is common. Enlarged follicles may mimic warts – numerous uniform pearly penile papules around the corona of the glans are normal.
Warts, sebaceous cysts or a hard plaque of Peyronies disease may occur on the shaft and phimosis, adhesions, inflammation or swellings on the foreskin or glans.

Question 42

What is involved in the Scrotum?

Answer 42

A. Ask if any genital pain

B. Inspect the scrotum
- Note the position of the testes and any paratesticular swellings or tenderness. Looking for redness, swelling, or ulcers, lifting it to inspect the posterior surface and the perineum. Sebaceous cysts are common in scrotal skin.

C. Gently palpate the scrotum
- Palpate the scrotum gently using both hands. Check that both testes are present: (The right testicle is usually closer to the inguinal canal than the left, but testes may be highly mobile/retractile.) If they are not, examine the inguinal canal and perineum for ectopic testes. Ask about previous excision surgery or retractile/undescended testes.
With each testis in turn, place the fingers of both your hands behind the testis to immobilise it and use your index finger and thumb to palpate the body of the testis methodically. Feel the anterior surface and medial border with your thumb and the lateral border with your index finger. Note size and consistency of the testis -they should be approx. equal in size (A normal testis is 5cm long), smooth and fairly firm. Note any nodules or irregularities. Measure the testicular size in cm from one to the other. Small firm testes suggest hypogonadism or testicular atrophy. Lumps within the testes themselves are of much greater significance than lumps which are separate.
The epididymis and surrounding structures should also be palpated for lumps, thickening or tenderness. Epididymal cysts are a common finding and benign. The normal epididymis is barely palpable except for its head which feels like a pea separate from the superior pole of the body of the testicle.

D. Palpate the spermatic cord
- Palpate the spermatic cord with your right hand. Gently pull the testis downward and place your fingers behind the neck of the scrotum. Feel the spermatic cord and within it the vas, like a thick piece of string.

E. Transluminate any scrotal swelling
- Transluminate to determine if a mass is solid or cystic. Place a torch against the swelling. Fluid filled cysts
allow light transmission and the scrotum glows bright red. This is an inconsistent sign which does not differentiate a hydrocele from other causes of intrascrotal fluid e.g. a large epididymal cyst. With thick walled cysts, transillumination may be absent.

F. Ask patient to stand and examine whether you can get above any swelling
- A varicocele feels like a ‘bag of worms’ in the cord and should disappear when the patient lies down. If it does not then consider a pelvic mass compressing the testicular veins. Decide whether a swelling arises from the scrotum or the inguinal canal. With the patient standing, if you can feel above the swelling it originates in the scrotum; if you can’t the swelling usually originates in the inguinal region, it may be a varicocele or inguinal hernia which has descended into the scrotum.
A bulky or painful mass in the scrotum when you cannot palpate the testis needs an ultrasound to clarify the nature of the intrascrotal structures.

A retracted testicle accompanied by acute pain and swelling occurs in testicular torsion, which is dealt with as an emergency.

Differentials:
- Attached to testis: Solid (non-translucent): testicular tumour
- Cystic (translucent): hydrocele
- Separate from testis: Solid (non-translucent): chronic epididymitis
- Cystic (translucent): epididymal cyst

Question 43

What is involved in the Other Areas?

Answer 43

A. Abdominal examination including examination for inguinal hernias
B. Prostate exam if indicated
C. Cervical/axillary and inguinal lymphadenopathy (generalised lymphadenopathy with HIV,
syphilis, malignancy)

Question 44

What is involved in the Conclusion?

Answer 44

A. Thank the patient, dispose of gloves / PPE and wash hands
B. Ensure patient has privacy to dress
C. Summarise and present findings