The adolescent male genital examination

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					The adolescent male genital examination: What's normal and what's notTop of Form
By William P. Adelman, MD, and Alain Joffe, MD, MPH Do you do a genital exam on your male adolescent patients? You should. These adolescent specialists demystify the process by teaching you where the landmarks are and what to look for.

Pediatricians know that a genital exam should be part of routine health care for adolescent boys, but many of them avoid the procedure unless the patient has a specific complaint. This is a mistake. A genital exam is an essential part of the routine health maintenance visit: to gauge sexual development, identify common anomalies, and pick up early signs of potentially serious conditions. In addition, many acute complaints such as abdominal, back, or flank pain, gynecomastia, supraclavicular adenopathy, and genital discomfort require a thorough genital examination for diagnosis and management. This article will familiarize the reader with the male genital examination through review of important anatomical structures and landmarks, benign findings of the penis, and common nonpainful masses in the scrotum. A second ariticle will review the differential diagnosis of the painful scrotum in the adolescent.

Where and how to perform the exam
We have found that even the most modest adolescent will agree to be examined if we explain why it is important and tell him what to expect. We explain that examination of the penis and testicles is an important part of the physical examination, as it allows us to ensure that development is proceeding normally and to identify early signs of potential problems. We point out that, in the rare circumstances in which a teenage male gets cancer, testicular cancer is the most likely possibility, and only a thorough genital exam can pick this up at an early, treatable stage. We do the examination with a chaperone present--a nurse, nurse's aide, medical student, or any clinician who is available at the time. We have found that most patients are equally comfortable with a male or female examiner, and our experience has been corroborated by other researchers.1 We keep the exam room warm, which relaxes the scrotum and makes it easier to examine, and the examiner warms his or her gloved hands before starting the exam. We ask the patient to remove his own undergarments and stand facing the seated examiner. We first inspect and then palpate the pubic area, inguinal canals, penis, and scrotum .

The pubic area
The pubic hair and underlying skin should be inspected to evaluate sexual maturity (Tanner stage) and look for evidence of such conditions as 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 inspected for discharge, erythema, warts, or hypospadias (urethral opening on the underside of the penis). If a discharge or other sign of sexually transmitted disease is noted, a specimen is taken. Collection of material for gram stain or culture requires insertion of the swab at least 2 cm past the

meatus to reach the columnar epithelium of the urethra . The prepuce should be evaluated for phimosis.

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

Pearly penile papules
These uniform-sized papules arise at the time of maximum pubertal changes, most commonly in Tanner stage II or III (Figure 3). They are found in approximately 15% of teenagers 2 and are benign. They typically appear along the corona and less frequently along the sides of the frenulum and on the inner preputial skin. Pearly penile papules have distinct clinical and histologic features and are a variant of the normal epithelium of the glans and, less frequently, the frenulum and penile shaft. They should be differentiated from warts caused by human papilloma virus (HPV). In a study looking for HPV DNA by polymerase chain reaction in biopsy-proven pearly penile papules, no HPV was found.3 Therefore, treatment is unnecessary and the patient and sexual partner may be reassured.

The scrotum and its contents
The scrotum and testis examination may be divided into four parts: scrotum, spermatic cord, epididymis, and testis (Figure 4).

Scrotum. The scrotum should be inspected for redness or other lesions. Contraction of the dartos muscle of the scrotal wall produces folds or rugae, most prominent in the younger adolescent. An underdevoped scrotum may indicate an ipsilateral undescended testicle. With a retractile testicle, the scrotum is normally developed.

Spermatic cord. This fascial-covered structure contains blood vessels, lymphatics, nerves, the vas deferens, and the cremaster muscle. To examine the spermatic cord, apply gentle traction on the testis with one hand and palpate the structures of the cord with the index or middle finger and thumb of the opposite hand. The vas deferens feels like a smooth, rubbery tube and is the most posterior structure in the spermatic cord. Normally, the vas deferens should be present on each side, nontender, and smooth. Absence of the vas deferens bilaterally is associated with cystic fibrosis. Unilateral absence of the vas deferens is associated with ipsilateral renal agenesis.4 Thickening and irregularity of the vas deferens may be caused by infection such as tuberculosis. The pampiniform plexus of veins lies within the spermatic cord and usually cannot be differentiated from other structures in the cord except when abnormally dilated, forming a varicocele that feels like a "bag of worms." Varicocele will be discussed in greater detail below. The epididymis. This structure lies along the posterolateral wall of the testicle. It anchors the testicle to the scrotal wall. The head of the epididymis lies at the superior pole of the testis while the tail lies at the inferior pole. The easiest way to find the epididymis is to follow the vas deferens toward its junction with the tail of the epididymis. The appendix epididymis is a stalked structure on the head of the epididymis, and may be multiple in some individuals. The epididymis consists of efferent ducts that may be applied to the testis loosely or tightly, but should always be differentiated from the testis itself. Acute inflammation of the epididymis (epididymitis) causes acute scrotal pain, tenderness, swelling, and induration of the epididymis. In contrast, a well localized, nontender, spherical enlargement of the epididymal head is a spermatocele. Testis. This firm, ovoid body is encased in the tunica albuginea, an inelastic white fascial sheath that maintains the testicle's integrity. Adult testes are usually 4 cm to 5 cm long and 3 cm wide but vary from one individual to another.5 About two thirds of the testicular volume is produced by the seminiferous tubules. For that reason, decreased testicular volume and firmness are considered indicators of decreased spermatogenesis. The left testicle is usually lower than the right. To examine the testicle, stabilize it with one hand and use the other hand to palpate the entire surface. Examine each testis for size, shape, and consistency. The testes should be roughly the same size (within 2 mL in volume of each other). Any induration within the testicle is testicular cancer until proven otherwise. The appendix testis, present in 90% of males, can be palpated at the superior pole of the testicle. Inguinal canals. Check the canals for hernia by sliding your index finger along the spermatic cord above the inguinal ligament and palpating the opening of the external inguinal ring (Figure 5). While your finger remains at the external ring or within the canal, ask the patient to cough or perform a Valsalva maneuver to check on whether there is any herniation of abdominal contents into the scrotum.

Scrotal lumps and bumps
Pain, swelling, or masses are the most common presentations of scrotal or testicular pathology in the adolescent. Many teenagers delay seeking care for these conditions because they are embarrassed, afraid, or in denial. We try to circumvent that reaction by counseling teenagers at all routine health-care visits to call or come in whenever they have questions or concerns about their genitals. And while we are examining the testes, we reinforce this anticipatory guidance by telling the patient to let us know right away if he feels pain or swelling in the testes or finds a lump. This section will review three of the lumps and bumps that may be found in the scrotal exam: hydrocele, spermatocele, and hernia (Figure 6). Varicocele and tumors, which are more complex, will be reviewed in subsequent sections.

Hydrocele. This lump is actually a collection of fluid between the parietal and visceral layers of the tunica vaginalis, which lies along the anterior surface of the testicle and is a remnant of the processus vaginalis. The tunica vaginalis is important anatomically as a potential space that may be involved in the formation of a hydrocele and in testicular torsion. A hydrocele is usually a soft, painless, fluctuant, fluid-filled mass that transilluminates when you shine a flashlight behind the testicle. Occasionally, it may be tense. Commonly, hydroceles are anterior to the testicle, but large ones may surround it, occupying the complete hemiscrotum.6 They occur in about 0.5% to 1% of males and may appear at any age.7 In adults, the cause is believed to be an imbalance between the secretory and absorptive properties of the tunica vaginalis. A congenital hydrocele is due to a patent processus vaginalis. Most cases of hydrocele are primary and idiopathic, but the examiner should also suspect other processes, such as orchitis, epididymitis, or testis tumor. An acute hydrocele will transilluminate and is easily diagnosed. A careful history and physical exam should exclude an inguinal hernia, lymph blockage, or testicular torsion. Hydroceles associated with malignancy tend to be small. If the testicle can be completely palpated and is of normal consistency, ultrasonography is not mandatory. However, if the hydrocele prevents adequate palpation of the testis, an ultrasound should be performed to assist with description of the testicle, differentiate a hydrocele from an inguinal hernia, and rule out testicular tumor, which shows up on a sonogram as a heterogeneous mass. If a hydrocele is tense, painful, or associated with a hernia (in which case it is called a communicating hydrocele), surgical intervention is advised. Otherwise, no treatment is necessary, as the hydrocele may resolve spontaneously. Patients who feel discomfort after exercise should be encouraged to use an athletic supporter. Most surgeons recommend elective removal of congenital hydroceles that are still present in adolescence. Spermatocele. This mass is a retention cyst of the epididymis that contains spermatozoa. The incidence of spermatoceles is much less than 1%. Microscopic examination of aspirated contents reveals spermatozoa, usually dead. Grossly the fluid is thin, white, and cloudy. The etiology of a spermatocele is not known, but

may include congenital weakness of the epididymis wall, epididymitis, epididymal obstruction, and scrotal trauma. Usually, a spermatocele is located at the head of the epididymis, above and behind the testis. Most are small (less than 1 cm in diameter), freely movable, painless, and will transilluminate. Spermatoceles are usually discovered during routine examination. However, if the spermatocele is large enough, the patient may come in complaining of a "third testicle." In the case of a large spermatocele, turbidity from increased spermatozoa may prevent transillumination. Occasionally, the spermatocele may be confused with a hydrocele or a solid tumor. The difference between a spermatocele and a hydrocele is that the hydrocele covers the entire anterior surface of the testicle, while the spermatocele is separate from, and above, the testicle. On ultrasound examination, a spermatocele appears as an echo-free collection above and behind the testis. A spermatocele may be firm, like a solid tumor, butunlike a tumor--it feels separate from the testis when you palpate the scrotum. 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 is large enough to annoy the patient, in which case it may be excised. Excision should be approached with caution to avoid compromising the passage of spermatozoa through the epididymis and vas deferens. Hernia. This mass is a sac-like protrusion of intestine through the inguinal ring into the scrotum. The incidence is about 1% to 2% (1% or less in teenage boys) and hernias may appear at any age. A hernia may resemble a hydrocele but can be distinguished by the following features: a hernia reduces when the patient is in the supine position, will not descend with traction on the testicle, and may be associated with bowel sounds in the scrotum. The examiner can locate the top of a hydrocele within the scrotum but cannot do so with a hernia. As mentioned previously, hernias and hydroceles may coexist. The treatment for hernia is surgical correction.

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 spermatic cord, formed from incompetent and dilated internal and external spermatic veins. Varicoceles are rare before adolescence. Among 10- to 25-year-olds, incidence varies from 9.25% to 25.8%, with a weighted average of 16%.8 Approximately 15% of adult males have a varicocele.9 Presentation. Most cases of varicocele are asymptomatic and discovered on routine physical examination. Occasionally, they are associated with an ache or a "dragging" sensation, or patients complain of feeling a "bag of worms" along the spermatic cord. Characteristically, the "worms" are prominent when the patient is standing and less obvious when he lies down. A varicocele occurs most often on the left side (85% to 95% of cases), presumably as a consequence of retrograde blood 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 should precede any palpation. A visible varicocele is classified as a Grade 3 (large) varicocele. Palpation of the scrotum, testes, and spermatic cord structures comes next. A varicocele feels like a bag of worms or a "squishy tube." More subtle varicoceles may feel

like a thickened or asymmetric spermatic cord. A varicocele that is palpable but not visible is classified as Grade 2 (moderate). If no varicocele is palpable, the patient may be asked to perform a Valsalva maneuver. If a varicocele is present, this will distend the intrascrotal veins. A varicocele discovered only with Valsalva is classified as Grade 1 (small). The benefit of identifying Grade 1 varicoceles is unknown, and for that reason we do not routinely have our patients perform a valsalva maneuver if no varicocele is palpable. If a varicocele is discovered, the patient should also be examined in the supine position. This will help to confirm the diagnosis, as varicoceles tend to decrease in size when the patient is supine. In contrast, a thickened cord due to a lipoma will not change with position. Evaluation. If a varicocele is present, the size of the testes (volume) should be compared. Volume assessment by ultrasound has been shown to best represent true testes volume as determined by weight and volume displacement. All other measurements are more likely to overestimate small-volume testes and underestimate large-volume testes. Since two thirds of testicular volume is accounted for by seminiferous tubules, decreased volume indicates decreased spermatogenesis--which is what we really care about in assessment of testicular damage. Decreased testicular volume is one of the only clinical signs that suggest testicular damage. Left testicular hypotrophy (growth arrest) in association with the varicocele is the hallmark of testicular damage. During rapid pubertal growth, a volume discrepancy between the testes may become clinically apparent. The larger the varicocele, the more likely hypotrophy will occur, and the greater the chance of correction with varicocele ligation.11 Multiple methods have been used 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 accurate and reproducible method is ultrasound.12,13 Accuracy is important, as operative decisions may rest upon precise evaluation of discrepancies in testicular volume . Surgical repair is not considered unless the size variation is 3 mL or greater by ultrasound. Treatment. Multiple lines of evidence suggest that Grade 2 and Grade 3 varicoceles can have a negative effect on the growth and function of the ipsilateral testicle in some patients.1416 For example, about 30% of males in infertility clinics have varicoceles, 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 sperm concentration improved with varicocele ligation in adolescents. 1719 However, over 80% of males with varicoceles are fertile, and no definitive studies show improved fertility following varicocelectomy in adolescence. So the challenge is to identify those patients who may benefit from repair. Since GnRH testing and semen analysis, the best measures of testicular damage, are not widely available and not easy to do, current recommendations for surgery are based on 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 there is 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 meet the 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 accounts for 3% of all cancer deaths in that age group, and may affect around one in 10,000 teens.7 Six thousand to 8,000 new cases are diagnosed annually in the United States, and approximately 1,500 males in the US die each year from germ cell tumors. Forty per cent of germ cell tumors are seminoma, making it the most common testicular cancer of single cell type, but the incidence of seminoma peaks in the 25- to 45-year age group while nonseminoma peaks in the 15 to 30-year-old group. Bilateral tumors occur in 2% to 4 % of patients.21 Risk factors. Testicular cancer risk factors are largely unknown, although cryptorchidism, trauma, and atrophy are commonly associated with testicular cancer. Twelve percent of men with testicular cancer have a history of cryptorchidism, and the risk of developing germ cell tumors is 10 to 40 times higher in a cryptorchid testis. From 1% to 5% of boys with a history of an undescended testicle will later develop germ cell tumors, so any history of cryptorchidism should prompt careful, long-term follow-up. If an undescended testicle is diagnosed after puberty, an orchiectomy is recommended, because the testicle can no longer produce sperm but is at risk for malignant changes. We recommend regular testicular selfexamination for such high-risk patients. It is important to keep the risk in perspective, however almost 90% of men with germ cell tumors do not have a history of cryptorchidism. Clinical manifestations. Testis tumor most commonly appears as a circumscribed, nontender area of induration within the testis that does not transilluminate. Most tumors are painless and discovered by the patient as a lump in the testis; when the patient is examined, however, physicians note swelling in up 73% of cases. Without a high level of suspicion, testicular tumor may be missed on casual examination. Patients with a testicular tumor may have a sensation of fullness or heaviness of the scrotum. Or the patient may come in with a history of recent trauma to the scrotum, which then draws the physician's attention to a painless mass in the traumatized testicle. Testicular pain may be an early symptom in 18% to 46% of patients with germ cell tumors.22 Acute pain may be associated with torsion of the neoplasm, infarction, or bleeding into the tumor. Signs and symptoms indistinguishable from acute epididymitis have been observed in up to one-fourth of patients with testicular neoplasms. Less commonly, patients with tumors may come to the office with gynecomastia from a tumor that secretes human chorionic gonadatropin (HCG), or with back or flank pain from metastatic disease. In most cases of testicular tumor, the epididymis and cord feel normal. In more advanced tumors, the testis may be diffusely enlarged and rock hard. Secondary hydroceles may occur. If

a hydrocele makes adequate palpation of the testis difficult, ultrasonography is indicated to rule out a tumor. If the tumor is a seminoma, the testis may be uniformly enlarged to 10 times its normal size without loss of normal shape. Testicular cancer in the sexually active adolescent can easily be mistaken for epididymitis, which is characterized by a swollen, tender testicle with occasional fever and pyuria. Treating patients for presumed epididymitis has caused delays of as long as nine months in the diagnosis of testicular cancer. Because of this possibility, once a patient with an initial diagnosis of epididymitis has had an appropriate course of antibiotics, he should be reexamined to be sure no residual mass is palpable. If the diagnosis is not clear cut, get an ultrasound. Differential diagnosis. In an adolescent, the differential diagnosis of a testicular mass includes testicular torsion, hydrocele, varicocele, spermatocele, epididymitis (which can coexist with germ cell tumors), and other malignancies, such as lymphoma. Rarely, genital tuberculosis, sarcoid, mumps, or inflammatory disease can also mimic cancer. Because 25% of patients with seminoma and 60% to 70% of those with a nonseminomatous germ cell tumor have metastatic disease at the time they seek medical attention, 21 any of the following symptoms should prompt examination of the testis: 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 testicular neoplasm and nonmalignant processes included in the differential diagnosis. Even if an obvious mass is palpated on physical examination, an ultrasound should be performed on both testicles to check for bilateral disease, which occurs in 2% to 4% of cases. Once a tumor is 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 brain in choriocarcinoma, for example), should be performed in consultation with an oncologist. Prevention. Testicular self-examination (TSE) is a simple, potentially life-saving intervention that may detect cancer in an early, asymptomatic stage. Studies have shown that nearly 90% of young adults are not aware of testicular cancer and that less than 10% of men have been taught how to examine their testicles.22 However, no data show that testicular self-examination reduces morbidity or mortality from testicular cancer, and its universal application remains controversial. We tend to reserve the discussion of TSE until patients have reached middle to late adolescence. For a comprehensive review of testicular selfexamination, see Goldenring J: A lifesaving exam for young men. Contemporary Pediatrics 1992;9(4):63.

Am I normal?
All adolescents are concerned about whether they are "normal," especially with regard to sexual development. Boys may be more reticent than girls about expressing this concern, but it takes up a lot of space in their psyches. The best way to reassure them is to make the genital examination a part of the routine health care you provide. This review of genital anatomy and common findings is intended to make you more comfortable with providing this exam. By including it in your basic repertoire, you will be able to monitor your patients' development, answer their questions, and spot rare but potentially serious anomalies early on, before damage is done. It's a skill worth acquiring

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