Testicular exam

• Penis, groin and abdomen inspection:

  • Skin changes: bruising, swelling, warts (human papillomavirus) and erythema.
  • Scars: note any scars on the penis (e.g. circumcision) or in the inguinal region (e.g. inguinal hernia repair, orchidopexy).
  • Masses: note any masses in the inguinal region (e.g. inguinal hernia, lymphadenopathy, undescended testicle) or on the penis (e.g. chancre in primary syphilis).
• Scrotum and perineum inspection:

  • Skin changes: warts (human papillomavirus), erythema (e.g. cellulitis, fungal infection).
  • Scars: may indicate previous surgery (e.g. vasectomy, testicular fixation).
  • Masses: note any lumps associated with the scrotum (e.g. testicular cancer) or the perineum (e.g. abscess).
  • Swelling: note any swelling of the scrotum (e.g. hydrocele, oedema) and look for associated erythema (e.g. cellulitis).
  • Bruising: may indicate local trauma.
  • Necrotic tissue: consider Fournier’s gangrene
• Penis palpation:

  • Retract the foreskin (if the patient is not circumcised) and check for phimosis (narrowing of the foreskin). If you are unable to retract the foreskin, ask the patient to try and do this themselves.
  • Open the urethral meatus to assess patency.
  • Inspect the glans for abnormalities (e.g. ulcers, warts, discharge, scarring).
  • Replace the foreskin once examined to prevent paraphimosis
• Testicular palpation:

  • Start on asymptomatic side
  • If you are unable to locate a testicle, palpate along the path of the inguinal ligament for an undescended testicle
  • Palpate the epididymis which is located at the posterior aspect of the testicle: tenderness is indicative of epididymitis
  • Palpate spermatic cord - assessing for masses (e.g. spermatocele) and tenderness
• Assessing a scrotal mass:

  • Site - part of the testicle vs separate
  • Size
  • Shape - irregular or regular
  • Consistency - soft, hard or bag of worms
  • Tenderness
  • Fluctuance
  • Transillumination - e.g. hydrocele
  • Cough impulse - hernia or varicocele
  • Ability to get above the lump - inability to get above suggests inguinal hernia
• Prehn's tests:

  • Prehn’s test is used to differentiate testicular pain caused by acute epididymitis and testicular torsion.
  • The test involves elevating the testes to assess the impact on testicular pain. A reduction in testicular pain is associated with epididymitis.
• Cremasteric reflex:

  • The cremasteric reflex is a superficial reflex which is elicited when the inner part of the thigh is stroked. 
  • Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal. 
  • Loss of the cremasteric reflex is associated with testicular torsion, but it should not be relied upon in isolation for ruling the condition in or out
• At the end of the examination, ask the patient to stand to allow you to re-assess the scrotum.

  Inspect and palpate the posterior scrotum for evidence of varicocele (a palpable mass that feels like a ‘bag of worms’) or a hernia (a mass which you cannot get above).