Introduction 

 Greet patient and introduce yourself 

 Briefly explain the procedure and reason for a chaperone ✍ 

 Get consent ✅ 

 Wash hands ✋ 

 Don gloves ✋ 

 Ask patient to remove underwear and lie down whilst you leave room  

 Check the patient is not in any pain 

Inspection  

Inspect the penis, groin and abdomen, identifying any clinically relevant signs: 

 Scars: on penis indicate circumcision, in inguinal region indicate hernia repair or orchidopexy 🏨 

 Abnormalities of skin: swelling, warts, bruises, erythema 

 Masses: on penis indicate chancre in primary syphilis, in inguinal region indicate hernia, undecended testicle or lymphadenopathy 

Inspect the scrotum and perineum, identifying any clinically relevant signs: 

 Scars: indicate prior surgery 🏨

 Abnormalities of skin: erythema or warts 

 Masses: lumps on scrotum can indicate testicular cancer, on perineum can indicate abscess 

 Bruises: indicate local trauma 

 Swelling: of scrotum can indicate oedema or hydrocoele, when erythema is also present it can indicate cellulitis 

 Necrotic tissue: may indicate Fournier’s gangrene 

Palpation 

Inspect the penis: 

 Check for phimosis: by retracting foreskin (phimosis is the narrowing of foreskin) 

 Assess patency of urethra: by opening urethral meatus 

 Identify abnormalities of glans: inspect for scars, warts, ulcers or discharge 💧

 Prevent paraphimosis: by replacing foreskin (paraphimosis is when venous return from the glans is prevented causing them to swell) 

Palpate the testicles: 

 Palpate the entire testicle by gently rubbing the testicle between index finger and thumb of both hands, holding it still with your other fingers 👉

 If you cannot identify testicle: palpate along inguinal ligament to assess for an undescended testicle, or a scar which indicates orchidectomy/orchidopexy 

If a scrotal mass is identified, assess it: 

 Position: especially in relation to the testicle 

 Size 📏

 Shape: regular or irregular 

 Consistency: soft like a cyst, hard like malignancy/epididymis, or varicocele like a ‘bag of worms’ 

 Motility: if you can ‘get above’ it, it indicates the mass is probably an inguinal hernia 

 Fluctuance: holding the mass on each side, press the centre of it, observing whether it bulges out, meaning it is filled with fluid, like a cyst 

 Expands upon coughing: indicates inguinal hernia or varicocele  

 Tenderness: indicates infection/inflammation 🔥

 Transillumination: shine a light on the lump, if it illuminates it indicates it is fluid filled (hydrocele) 🔦

Palpate epididymis:  

 Curved structure on back of testicles  

 Tenderness indicates epididymitis (chlamydia) 

Palpate spermatic cord: 

 Cord like structure, running from deep inguinal ring to both testicles 

 Using thumb and index finger, start palpating from above the testicle, identifying the cord and palpate along it to identify masses/tenderness 👉

Phren’s test: 

 Distinguishes testicular pain caused by testicular torsion and acute epididymitis 

1. Elevate testes 
2. Assess testicular pain now 😪
3. Less pain indicates epididymitis 

 Doppler ultrasound is a more effective method for confirming the pain is not caused by testicular torsion 

Cremasteric reflex: 

 Stroking the inner thigh causes contraction of cremaster muscle, which pulls the ipsilateral testicle upwards towards the inguinal canal 

 No cremasteric reflex indicates testicular torsion ❌ 

Assess scrotum with patient standing up 

 Assess and palpate the back of the scrotum to identify varicocele or hernia evidence 

Completion 

1. Tell patient the examination is complete ✅ 
2. Allow them to get dressed in privacy 
3. Thank patient 
4. Wash hands ✋ 
5. Summarise what the examination revealed ✍ 

Glossary 

Hydrocele:  

 Fluid in tunica vaginalis 

 Palpable 

 Transilluminates 🔦

Epididymal cyst:  

 Benign smooth 

 Spherical cyst in epididymis head ⭕ 

 Independent from testicle 

 Transilluminates 🔦

 Mass fluctuates 

Spermatocele:  

 Benign 

 Smooth 

 Spherical cyst in epididymis or spermatic cord head ⭕ 

 Sperm in fluid 

 Independent from testicle 

 Transilluminates 🔦

 Mass fluctuates 

Varicocele: 

 Enlargement of testicular veins in pampiniform venous plexus 

 ‘Bag of worms’ texture 

 Cough impulse 

 If newly developed, perform renal tract ultrasound to rule out renal cancer 

Epididymitis: 

 Progressive painful swelling of epididymis 

 <35, likely due to STI 

 >35, likely die to urinary pathogens e.g. E. coli 

Testicular torsion: 

 Twisted spermatic cord causing sudden blood supply loss 

 Sudden severe pain in testicles 

 Scrotal erythema 

 Swollen testicle 

 Scrotal ultrasound and surgical exploration required 

Testicular malignancy:  

 20-40 y/o males 👨

 Mostly asymptomatic early on 

 Testicular ultrasound required 

 Treatment is usually inguinal orchidectomy 

Orchidopexy: 

 Undescended testicles, increases malignancy risk 

 Operation to descend them from inguinal canal into scrotum 

Unilateral testicular atrophy: 

 Decrease in size of one testicle 📏

 Due to mumps/vascular compromise/surgery 

Bilateral testicular atrophy: 

 Decrease in size of both testicles 📏

 Can indicate hypogonadism 

Phimosis:  

 Foreskin narrowing preventing its retractability 

 Severe phimosis may require circumcision 

Summary:

1. Greet the patient and explain the procedure
2. Inspect the penis, groin and abdomen and then the scrotum and perineum
3. Inspect the penis to identify abnormalities
4. Palpate the testicle
5. If a scrotal mass is identified, assess it
6. Palpate the epididymis to identify tenderness indicative of chlamydia
7. Palpate the spermatic cord to identify masses/tenderness
8. Perform Phren's test to distinguish between testicular pain caused by testicular torsion and acute epididymitis 
9. Assess the cremasteric reflex - absence indicates testicular torsion
10. Assess the scrotum with the patient standing up to identify varicocele or hernia evidence
11. Complete the examination by thanking the patient and giving them privacy to get dressed