In surgical practice examination of theexternal genitalia is usually confined to examination of the male genitalia, since females with disorders of this region are managed by gynaecologists. The examination is best performed with the sick man in the supine position. Phimosis (narrowing of the preputial orifice such that the prepuce cannot be retracted over the glans) is common in uncircumcised males, often causes infection (balanitis) and meatal stricture. The majority of penile tumours are confined to the glans penis and this region should always be inspected in patients with a history of bloodstained discharge.
Initially one should establish that the patient has two palpable testes. If only one testis is palpable, palpation of the groin may reveal an ectopic testis (usually in infants). The impalpable testis may of course be in the inguinal canal or the abdominal cavity (undescended testis).
Scrotal swellings may originate from disease of the testis, epididymis and their coverings or result from a swelling (an indirect inguinal hernia) that descends to, and in time occupies, the scrotum. Thus the first objective with any scrotal swelling is to determine whether one can get above it by approximating the tips of the two hands above the upper limit of the swelling. If the examiner is unable to establish this, the swelling is inguinoscrotal and caused by a large indirect inguinal hernia.
The common swellings encountered in the scrotum are hydrocele, inflammation of the testis, epididymis (epididymo-orchitis), and tumours of the testis (seminomas and teratomas). Torsion of the testis presents acutely with a very painful tender swelling and may be very difficult to distinguish from epididymo-orchitis.
A hydrocele is a collection of fluid in the tunica vaginalis and therefore surrounds the testis, which thus becomes difficult to palpate. The swelling caused by a hydrocele is smooth and uniform, fluctuates and is brilliantly transilluminable. Cysts of the epididymis (multiloculated epididymal cyst, spermatocele) are not surrounded by fluid and for this reason are felt as swellings above, behind the testis, which is also easily palpable in this situation. Because of the septation, multiloculated epididymal cysts have a characteristic ‘Chinese lantern’ appearance on transillumination. Testicular tumours form heavy painless swellings of the testis, may be surrounded by a lax secondary hydrocele that does not, however, obscure their presence. When suspected, palpation of testicular tumours should be gentle to minimize the risk of dissemination of these malignant tumours. As the lymphatic spread from these tumours goes straight to the para-aortic lymph nodes, palpation of the abdomen for masses on either side of the umbilicus should be conducted.