Normal Physical Examination of Male Genitalia
A comprehensive male genital examination should systematically assess the penis (including urethral meatus location), measure and palpate both testes, verify presence and consistency of the vas deferens and epididymides, check for varicoceles, evaluate secondary sexual characteristics, and include digital rectal examination when clinically indicated. 1
Systematic Examination Components
Penis Examination
- Inspect the penile shaft for skin lesions, plaques, or deformities
- Verify urethral meatus location - should be at the tip of the glans (hypospadias if abnormally positioned) 1
- Palpate the stretched penis from pubic bone to coronal sulcus to detect occult plaques or deformities 2
- Document circumcision status 3
Testicular Assessment
- Measure testicular volume - normal adult testes are typically ≥12 mL 4
- Palpate each testis for size, consistency, and masses
- Normal testes should be firm, smooth, and symmetric
- Atrophic testes (<12 mL) warrant further evaluation 4
Spermatic Cord Structures
- Palpate vas deferens bilaterally - should be present and cord-like in consistency 1
- Check epididymides - should be palpable along posterior testis
- Congenital bilateral absence of vas deferens can be definitively diagnosed on physical examination 1
Varicocele Detection
- Examine with patient standing in warm room to relax dartos muscle
- Palpate spermatic cord for dilated veins (described as "bag of worms")
- Clinical varicoceles are palpable; routine ultrasound for non-palpable varicoceles is discouraged 5
- Left-sided varicoceles are most common; isolated right varicoceles don't routinely require abdominal imaging unless large, new-onset, or non-reducible 5
Secondary Sexual Characteristics
- Assess body habitus and fat distribution
- Evaluate hair distribution - pubic, axillary, facial, chest
- Examine for gynecomastia or breast development 1
- These findings help assess androgen status
Additional Components
- Inguinal examination - palpate for hernias or lymphadenopathy 1
- Digital rectal examination - not required for routine ED evaluation but may be indicated for prostate assessment in older men 2
- Scrotal transillumination - when masses detected, to differentiate solid from cystic lesions 6
Key Clinical Pearls
Privacy and consent are paramount - always explain the procedure, obtain informed consent, and offer a chaperone 6
Normal findings include:
- Urethral meatus at glans tip
- Bilateral descended testes in scrotum
- Testicular volume ≥12 mL in adults
- Palpable vas deferens and epididymides bilaterally
- No masses, hernias, or varicoceles
- Appropriate secondary sexual characteristics for age
Common pitfalls to avoid:
- Examining in cold room (causes cremasteric reflex and testicular retraction)
- Missing acquired cryptorchidism (previously descended testis that ascended) 7
- Over-relying on imaging for palpable findings 5
- Failing to examine under anesthesia when findings are equivocal 8
Red flags requiring further evaluation:
- Testicular masses or asymmetry
- Absent or non-palpable vas deferens (consider CFTR testing and renal ultrasound) 5
- Unilateral testicular atrophy
- New-onset or non-reducible varicocele
- Abnormal secondary sexual characteristics