What other physical exams should be performed when evaluating a patient for gynecomastia?

Physical Examination Components for Gynecomastia Evaluation

When evaluating a patient for gynecomastia, a thorough physical examination should include assessment of the breast tissue, general body habitus, testicular examination, and evaluation for signs of underlying systemic conditions. 1, 2

Breast Examination

• Confirm the presence of palpable glandular tissue to differentiate true gynecomastia from pseudogynecomastia (fatty tissue deposition) 1, 2
• Assess if the enlargement is unilateral or bilateral (gynecomastia is bilateral in approximately 50% of patients) 1
• Evaluate for tenderness, which is often present in gynecomastia of less than 6 months duration 1
• Check for suspicious features that might suggest malignancy (skin changes, nipple discharge, fixed or hard masses) 1, 2

General Body Assessment

• Evaluate general body habitus and calculate body mass index (BMI) or measure waist circumference 3
• Assess virilization status by examining body hair patterns and amounts in androgen-dependent areas 3
• Look for signs of systemic diseases that may cause gynecomastia, such as liver disease, thyroid disorders, or renal dysfunction 4, 2
• Check for signs of under-virilization or systemic disease 2

Genital Examination

• Perform a complete testicular examination to:
  • Assess testicular size, consistency, and presence of masses 3, 2
  • Rule out testicular tumors that may secrete hormones causing gynecomastia 2
  • Check for testicular atrophy, which may indicate hypogonadism 2
• Consider testicular ultrasound, as detection of testicular tumors by palpation has low sensitivity 2
• Evaluate for the presence of varicocele 3

Prostate Examination

• Assess prostate size and morphology 3
• Look for abnormalities that might indicate prostate pathology 3

Additional Physical Assessments

• Examine for visual field changes (bitemporal hemianopsia) that might suggest pituitary disorders 3
• Check for gynecomastia, which may be a sign of testosterone deficiency 3
• Evaluate for signs of Klinefelter syndrome, which significantly increases the risk of gynecomastia 4

Important Considerations

• Distinguish true gynecomastia from pseudogynecomastia, especially in patients with elevated BMI 1, 4
• Be vigilant for signs of breast cancer, which is rare in males but should be ruled out, especially in older men 1
• Consider the possibility of medication-induced gynecomastia by correlating physical findings with medication history 4

Common Pitfalls to Avoid

• Failing to distinguish between true gynecomastia and pseudogynecomastia, especially in obese patients 4
• Overlooking the need for testicular ultrasound, as physical examination alone has limited sensitivity for detecting testicular tumors 2
• Ordering unnecessary imaging in clear cases of gynecomastia, which can lead to additional unnecessary benign biopsies 1, 4