Male Genitalia, Hernias, and Rectal Exam

Describe the anatomy of the penis.

The penis consists of a shaft , formed by three juxtaposed columns of spongy and vascular tissue: the corpora cavernosa . These can be temporarily filled with blood, thus providing a unique erectile capacity to the organ. The distal tip of the penis consists of a cone-shaped structure called the glans (“acorn” in Latin), which contains the vertical slit-like opening of the urethra (urethral meatus) . The glans is separated from the shaft by a circular sulcus called the corona (“crown” in Latin), which, in uncircumcised men, is covered in a hood-like fashion by the prepuce or foreskin , a fold surgically removed during circumcision. All areas must be examined ( Fig. 14.2 ).

What steps should I take to properly examine the penis?

The first, of course, is precautionary: put on a pair of gloves because some sexually transmitted diseases (including syphilis) can be acquired through simple skin abrasions. With gloves on, examine the penis by first palpating the shaft, and then by carefully looking for areas of induration or tenderness. Then, look for unusual curvatures ( see Peyronie’s disease [PD], Question 46). Retract the prepuce to gain access to the glans and inspect it for abnormalities. After completing the exam, return the foreskin to its original position since failure to do so may cause severe edema in unconscious patients. Finally, gently compress the glans between your thumb and forefinger to visualize the urethral meatus, and possibly express secretions. Note that this maneuver may be unyielding even in patients with a history of penile discharge . In this case, milk the shaft of the penis (from its base to the glans), since this may produce a few precious drops for analysis. Finally, examine the base of the penis for hair or skin abnormalities.

What is priapism?

A fancy term for a protracted erection, usually associated with pain. The term “priapism” is actually rooted in Greek mythology, specifically in Priapus, one of the many illegitimate sons of Zeus, King of the Gods (which confirms our suspicion that power and sex may be linked, at least among American presidents and Greek deities). According to tradition, Hera (Zeus’ unfortunate wife) found out about this umpteenth illicit affair of her husband and decided to attend the child’s birth, to cast a mortal spell on the baby. Things, however, did not go as expected, since Priapus was born so well endowed that Hera, taken by surprise, completely missed her chance. Hence, the baby was rushed to safety, and a new medical term was born. Priapism eventually came to signify a condition characterized by chronic, protracted, and painful erections. Still, Priapus also prompted great respect for the penis, which became a symbol not only of fertility but also of luck, since it had literally saved his owner’s life. From that time on, Romans developed a penchant for wearing little phalluses around their neck, usually made in coral (because of its apotropaic virtue [i.e., the ability to ward off the evil eye]), but occasionally also in gold. They also carved phalluses on buildings – as hopeful lucky charms. For example, the great Roman wall erected (no pun intended) in England by Emperor Hadrian during the 1st century ad was riddled with various penile carvings, still visible today and accurately catalogued in local museums by serious British archeologists. Stone phalluses were supposed to bring good luck to the wall’s defenders but unfortunately fell short of expectations; Hadrian’s wall was pierced by raiding Scots and Picts and eventually abandoned. The reverence for the penis, however, continued unabated throughout the Mediterranean basin. Indeed, in some parts of Italy and Greece (not to mention South Philadelphia) it is still possible to see golden pricklets hanging from people’s necks, a reminder of the long-lasting value of Greek mythology and penile lore.

What is the pathophysiology of priapism?

It is a persistent erection of the corpora cavernosa of the penis, due to disturbances in the mechanisms controlling penile detumescence.

Does priapism involve all erectile tissue?

No. Only the corpora cavernosa of the penis. The one surrounding the urethra and the corpus spongiosum of the glans remains instead flaccid.

What is the cause of priapism?

Often idiopathic. Yet, priapism also may reflect systemic or local abnormalities:

• Local conditions are usually neoplastic or inflammatory diseases of the shaft, but also thrombotic and/or hemorrhagic processes of the penile vasculature (i.e., arterial high-flow priapism).

• Systemic conditions are instead either neurologic lesions (spinal cord injury and spinal anesthesia) or various hematologic disorders that predispose to thrombosis, like leukemia or sickle cell anemia (which are therefore responsible for veno-occlusive priapism). In one study, close to one-half of sickle cell patients reported at least one episode of priapism. Finally, the condition also has been reported after recent infection by Mycoplasma pneumoniae , possibly because of secondary hypercoagulability.

And what about drugs?

Many drugs can cause priapism. In addition to the various products that release nitric oxide into the corpora cavernosa (e.g., sildenafil [Viagra]) or the intracavernosal injection of medications for impotence, drugs that can induce priapism include:

• Psychotropics (chlorpromazine, trazodone, and thioridazine, and even serotonin reuptake inhibitors such as citalopram)

• Calcium channel blockers

• Anticoagulants (both warfarin and heparin)

• Vasodilators (hydralazine and prazosin, especially in patients with renal failure)

• Various others (metoclopramide, omeprazole, hydroxyzine, tamoxifen, testosterone, and androstenedione in athletes)

• “Recreational” drugs such as cocaine, marijuana, ecstasy, and alcohol (which should instead be called destructive drugs, since they kill you, make you destitute, or both)

What is phimosis?

From the Greek phimos (muzzle or snout), this is a narrowed opening of the prepuce, so that the foreskin cannot be retracted over the glans penis ( Fig. 14.3 ). Usually congenital (from membranes binding the prepuce to the glans), phimosis also may result from acquired adhesions, often the sequela of poor hygiene, previous infections (chronic balanoposthitis), or a too forceful retraction of a congenital phimosis. If untreated, it can degenerate into squamous intraepithelial cancer of the penis.

Is a phimosis always pathologic?

No. A congenital phimosis can be quite physiologic in children, in fact well into the teenage years. In a recent study from Japan (where circumcision is not routinely done), a congenital phimosis was seen in 88.5% of children aged 1–3 months, and 35% of those aged 3 years. In fact, only 39.7% of these children had foreskins fully retractable by 3 years of age. Other studies have shown persistence of congenital phimoses in 6% of boys aged 8–11, and 3% of those aged 12–13. Only 20% of 200 boys aged 5–13 years had fully retractable foreskins.

What is paraphimosis?

A condition related to, but actually different from, a phimosis. Once a phimotic prepuce is forcibly retracted over the glans, the edematous foreskin cannot be brought forward again, thus resulting in paraphimosis , a tight band of retracted foreskin behind the coronal sulcus ( see Fig. 14.3 ). This is a very painful condition, which, if unrelieved, can cause urinary tract obstruction, venous engorgement, edema, and even necrosis of the foreskin and glans.

What are the causes of paraphimosis?

The same as those of phimosis: an uncircumcised or incorrectly circumcised penis. In fact, both conditions are often indication for circumcision to prevent vascular or infectious complications. In children, the narrowed preputial opening of a congenital phimosis often results in paraphimosis, especially if parents forcibly retract the foreskin while attempting to clean the glans. In adults, there is often a history of catheterization (without allowing the foreskin to return over the glans) or poor hygiene (with balanoposthitis eventually leading to phimosis and then to paraphimosis). Vigorous sexual activity can predispose to paraphimosis, too. Finally, body piercing with penile rings that prevent the reduction of a retracted foreskin can be a unique, but not too uncommon, cause.

What is balanoposthitis?

It is the inflammation of the glans ( balanos is Greek for acorn) and prepuce ( posthe is Greek for foreskin) due to a wide variety of organisms. This is often seen in uncircumcised males because of poor local hygiene, with accumulation of (and irritation by) smegma – a mix of desquamated epithelial cells, sweat, debris, and transudate oils (from the Greek term for “soap”). Examination of the prepuce and the glans reveals a red, moist, and macular lesion, at times with areas of yellow-to-black discoloration. Irregular borders and lichenification suggest instead human papillomavirus (HPV) or a chronic bacterial process, eventually leading to phimosis. Ulceration and deep erosion occur only with fungal infection in immunocompromised hosts.

What are the causes of balanoposthitis?

The most common is infection, either by bacteria (staphylococci and streptococci, but also anaerobes, Gardnerella sp., and S. pyogenes sp.) or yeasts (usually candidal). This is usually facilitated by poor hygiene and poorly retractile foreskin. Contact dermatitis also may cause it, and in one-third of cases no specific etiologies are established. Associations with ulcerative colitis and Crohn’s disease also have been reported. Refractory or recurrent forms may benefit from circumcision. Still, do not confuse balanoposthitis with balanitis .

What is balanitis?

An inflammation of the glans , usually in uncircumcised men with poor personal hygiene. It is common, affecting 11% of American men in a urology clinic. Irritation from smegma causes edema and inflammation of the glans, with eventual adherence of the foreskin to the penis (i.e., phimosis). Local burning and a red rash also are common. The skin may appear to peel off, as if scalded. Predisposing conditions include diabetes, but also morbid obesity, edema (nephrosis, cirrhosis, and heart failure), and old age. Seborrheic and contact dermatitis can do it, too. Given its frequent infectious nature, it may be sexually transmitted.

What is reactive arthritis? What are its manifestations?

Reactive arthritis is usually triggered by an infection. This may be sexually transmitted ( Chlamydia , genital mycoplasmas, and, to a lesser degree, gonococci) or enteric ( Shigella, Salmonella, Yersinia , and Campylobacter spp.). Its clinical manifestations include acute arthritis/arthralgia, lower urogenital tract inflammation, mucocutaneous lesions, and conjunctivitis/iridocyclitis. One-quarter of affected men have small, ulcerated plaques around the glans and foreskin. In fact, the most common mucocutaneous lesion involves the penis and is called circinate balanitis ( circinata means round in Latin, and balanitis is the Greek term for inflammation of the glans). This is a painless inflammation of glans, sulcus, and corona, which starts as tiny blebs, eventually merging into a larger ring of inflammatory tissue that may completely circumscribe the glans. In addition, patients often have mucocutaneous lesions of the mouth, palms, and soles. Over the hands and feet, these tend to be scaly, sometimes pustular, and frequently resembling severe psoriasis ( keratoderma blennorrhagica ). Whether initial infection was sexually transmitted or enteric, there also may be urethritis with discharge. This is scanty, thin, and whitish – hence, quite different from the profuse, thicker, and more purulent discharge of gonorrhea. In fact, the discharge of reactive arthritis resembles that of other nongonococcal urethritides (like chlamydia) insofar as it is usually clear. Acute reactive arthritis also can present with systemic symptoms (fever, malaise, anorexia, and weight loss). Most cases resolve in 2–6 months with annual risk of recurrence of mucocutaneous manifestations around 15%, at intervals of months or years. The arthritis is usually persistent.

What about gonococcal urethritis?

It is the hallmark of gonorrhea, characterized in men by urethritis with thick and profuse discharge, urethral itch, dysuria, and epididymal pain (although more than one-half of all men and women with gonorrhea are asymptomatic). If untreated, gonorrhea can lead to major sequelae, such as epididymo-orchitis and possibly infertility.

What kind of skin lesions can be seen on the penis?

The most common are classified on the basis of appearance ( Table 14.1 ):

• Ulcerating: skin craters filled with serum, pus, or crust. They represent a full-thickness loss of epidermis and can be single or multiple.

• Nonulcerating: further divided into:

  • Papules : small (<1 cm in diameter) lesions, raised above the skin surface

  • Plaques : larger (>1 cm in diameter) lesions, flat-topped

How do ulcerating lesions present?

As single or multiple. The single are more serious, since they reflect sexually transmitted diseases such as primary syphilis, chancroid, granuloma inguinale, and lymphogranuloma venereum. Penile cancer also can present as a painless, irregular, genital ulcer.

Describe the ulcerating lesion of primary syphilis.

It is a single, round, nontender, and painless ulcer (often called a chancre) with bilateral lymphadenopathy.

Describe the ulcerating lesion of chancroid.

It is a painful, single ulcer, at times multiple, with lymphadenopathy.

Describe the ulcerating lesion of granuloma inguinale.

It is a single, painless ulcer without lymphadenopathy.

Describe the ulcerating lesion of lymphogranuloma venereum.

It is a small, nontender ulcer with unilateral tender lymphadenopathy.

Which other dermatoses can be transmitted through sexual contact?

Definitely scabies and pediculosis. In both cases, itching is the prevalent symptom, and redness the predominant finding. Note that whereas scabies burrow under the skin to lay eggs, lice bite into the skin to draw blood. Hence, lice present with red and scaly areas of skin or hair where insects and eggs may be visible. Scabies, on the other hand, present with little bumps, blisters, and crusting in areas of pruritus.

What about multiple ulcerating lesions?

These are more common than single ulcers and may have less serious causes. Based on duration, they can be acute (<2-week course) or chronic (>2-week course).

What are the most important acute multiple ulcerating lesions?

• Secondary syphilis

• Aphthous ulcers

• Herpes simplex

Describe the multiple ulcerating lesions of secondary syphilis.

Secondary syphilis is characterized by a papulosquamous rash involving not only the penis but also the palms and soles. Multiple, irregular, shallow, painless , and gray ulcers (often described as “serpiginous”, since they move like a snail track along the penis) are usually present. There also may be a flu-like illness and a blotchy, red body rash.

What are aphthous ulcers?

Small, shallow, painful ulcers that most commonly appear in the mouth but also can affect the penis. Typically, they have a gray center surrounded by a bright red halo, occur in crops, and resolve without treatment. They can easily be confused with herpes simplex ulcers, so laboratory tests are necessary to reliably distinguish the two. They are not infectious, and their cause is unknown.

Describe the multiple ulcerating lesions of herpes simplex.

They appear as small, multiple vesicular skin lesions that are painful , in clusters, and not associated with adenopathy. Note that chancroid lesions also can be multiple.

Are genital herpetic lesions due to herpes simplex virus type 1 (HSV-1) or herpes simplex virus type 2 (HSV-2)?

Usually to HSV-2, the leading cause of infectious genital ulceration in the United States (HSV-1 is instead the most common cause of oral infections). Although one out of five American adults is seropositive for this virus, more than one-half remain asymptomatic and yet capable of shedding and transmitting the virus. Lesions present as small, clustered vesicles on an erythematous base, rapidly progressing into pustules and painful ulcers, and eventually forming a crust. Since lesions follow the distribution of a sensory nerve, they tend to recur at (or near) the same site. Fever, malaise, and acute toxicity also may occur – especially in primary infections.

What are the most important chronic multiple ulcerating lesions?

• Pemphigus: these are fragile, thin-walled blisters that eventually break down to form ulcers. Often painful and itchy. Note that pemphigus usually affects other parts of the body (frequently starting in the mouth) but also may involve only the penis.

• Behçet’s disease : an inflammatory and noninfectious multisystem disease that involves the skin, joints, nerves, and eyes. Genital lesions present as large, deep, and painful penile/scrotal ulcers, always accompanied by mouth ulcers.

• Reactive arthritis (circinate balanitis)

And what about non ulcerating lesions?

They consist of papules and plaques .

Describe penile papules . What are the most important lesions of this sort?

Papules are usually benign, although a few are infectious, and some are early and preulcerating cancers.

• Hair follicles and sebaceous glands are completely normal and frequently found on the penile shaft, particularly its ventral surface. Sebaceous glands can be either seen (as small and yellowish nodules, homogenous, and rather symmetrically distributed) or palpated (as small skin lumps). They are often referred to as Fordyce spots (see Question 52). Hair follicles, on the other hand, typically contain hair. Neither should be confused with genital warts (which are asymmetric and heterogeneous, with a cauliflower-like presentation) or molluscum contagiosum (which presents as fleshy, rounded, and umbilicated lesions).

• Pearly penile papules are multiple, tiny (1–3 mm), pearly appearing, and skin-colored papules around the circumference of the glans’ crown. They typically develop in men ages 20 to 40, with 10% of all subjects being affected, especially if uncircumcised. Although often mistaken for warts (which instead are asymmetric, heterogeneous, and with a cauliflower-like presentation), pearly papules are neither infectious nor symptomatic. Hence, their only “treatment” is reassurance. They are still referred to as preputial or Tyson’s glands , since initially they were believed to be smegma -producing glands.

• Fordyce spots (see also question 52)

• Lichen planus (LP) and psoriasis

• Molluscum contagiosum

• Genital warts

• Secondary syphilis

How does lichen planus present on the penis?

The most common form is classical papules and patches, mostly clustered in a circle on and around the glans. These are purple colored or white, ring shaped, and often resembling thrush. Unlike other patches of LP, they rarely itch. White streaks and erosive lesions are much less common presentations.

What are the characteristics of penile psoriasis?

Like LP, psoriasis of the genital area may present with atypical features – usually because of moisture and maceration. The classic psoriatic scale , for example, is often rare (except in uncircumcised men). Instead, genital psoriasis presents as thickened red papules or plaques with well-defined edges and is rarely associated with irritation. Although psoriasis most commonly affects other parts of the body (especially the knees, elbows, and scalp), it can first appear on the penis, usually on the glans or inner surface of the foreskin. This may require differentiation from syphilis.

What is molluscum contagiosum?

A benign and common viral disease of skin and mucous membranes. In children, it is acquired through peer contact, whereas in adults, it may be sexually transmitted. Penile molluscum presents as multiple, small, soft, and spherical papules of penis or scrotum, often with a central depression or plug. If squeezed, lesions can express a curd-like discharge. Usually a marker for “unsafe” sexual practices (hence, test for HIV), molluscum lesions may disappear without treatment, although freezing or cautery is often curative.

And what about genital warts ?

These also are quite common, and in fact increasing in prevalence, especially in young and sexually active people. Condylomata acuminata are arbor-like (acuminata) lesions caused by the HPV (the condylomata lata of syphilis are instead flat – see Question 40). Usually more wart-like than ulcerating, condylomata acuminata usually occur in moist areas (such as the corona or sulcus), but also may affect the penis’ tip and shaft, plus scrotum, anus, and mouth. They appear as tiny and skin-colored genital warts, isolated or in clusters, and with a shiny surface. These may become fleshy and cauliflower-like. Highly infectious, genital warts can be latent, subclinical, and clinical – very much like herpes. Hence, asymptomatic infection (and shedding) is frequent. The most common agents are low-risk HPV types 6 and 11; high-risk HPV types 16 and 18 are less common but are associated with premalignant and malignant degeneration (i.e., squamous cell carcinoma of the penis, anus, and cervix). They may be confused with pearly penile papules.

What are condylomata lata?

They are flat ( lata in Latin), multiple lesions of secondary syphilis. They present as flat-topped, soft, moist or macerated, reddish-brown to grayish genital papules or, more rarely, nodules. These may eventually coalesce into larger plaques, often cauliflower-like. Differential diagnosis includes the nonulcerating and papular lesions of psoriasis, LP, scabies, squamous cell carcinoma (which usually presents as an indurated and nontender nodule , but at times may even ulcerate), and reactive arthritis (which also may present with a nonulcerating penile lesion).

What about penile plaques ?

They are usually benign (like psoriasis and Zoon’s plasma cell balanitis ) and often infectious ( balanitis and posthitis , see Questions 17 and 18). Still, three of these lesions (erythroplasia of Queyrat, lichen sclerosus, and balanitis xerotica obliterans [BXO]) are quite serious since they may degenerate into penile cancer. Finally, diffuse red plaques with a poorly defined edge and finely scaled surface (eczema-like) may be due to allergic contact dermatitis. Although often the result of lubricants, condoms, spermicides, and feminine deodorant sprays, they are more frequently caused by poor hygiene, with persistent moisture and maceration. They are quite irritating and usually respond to topical steroids.

What is Zoon’s balanitis?

A noninfectious condition characterized by a brightly red and shiny plaque on either the glans or inner foreskin. It is histologically characterized by a plasma cell infiltrate. Etiology is unknown and prognosis benign, even though it often prompts a differential diagnosis with the much more serious erythroplasia of Queyrat . Usually painless, it may be itchy and often recurrent, despite topical steroids. It always responds to circumcision.

What is the erythroplasia of Queyrat?

A sharply demarcated red plaque, bright, painless, and not itchy – often with a typical velvety surface. It is seen almost exclusively in uncircumcised men, and, unless excised, it eventually progresses to invasive cancer. Hence, it is an in situ form of squamous cell carcinoma. Queyrat lesions may be solitary or multiple, typically circumscribed, minimally raised, and with variegated erythematous plaques that may be smooth, scaly, crusty, or verrucous. It is typically located at the mucocutaneous junction of the penis or prepuce, but also can involve the mouth and vulva. Ulceration or distinct papillomatous papules within a plaque may indicate progression to invasive squamous cell carcinoma. Still, its nondescript look may lead to a lengthy period of misdiagnosis. Biopsy of any suspicious lesion is always the best approach. The lesion was originally described by Tarnovsky in 1891, and subsequently reported by Fournier and Darier as a penile disease in 1893. The French dermatologist Queyrat described in 1911 erythroplasia of the glans penis, and correctly identified it as precancerous. Hence, the eponym.

What about squamous cell carcinoma of the penis?

It is the most common penile cancer. HPV, precancerous lesions, and poor hygiene from phimosis are all predisposing factors. Hence, it is almost absent in circumcised males. Rare before age 40, it presents with lymphonodal spread and proliferative glans lesions.

What is lichen sclerosus et atrophicus?

A lymphocyte-mediated chronic inflammation of the glans, foreskin, or shaft, presenting with atrophic white plaques that are usually asymptomatic, although irritation and burning also can occur. Its most severe form is BXO , a condition affecting the prepuce of uncircumcised men, giving it a firm, whitish, and scarred appearance that may interfere with urination or sex. Indurated, flat, shiny, and white patches with an erythematous halo may eventually lead to foreskin depigmentation, atrophy, scarring, and eventually phimosis. Hence, the term “obliterans.” BXO also may cause dysuria, progressive stenosis of the urethral meatus, stricture, and even penile cancer. Steroid creams may help, but the condition often recurs.

What is Peyronie’s disease (PD)?

A peculiar disease of unknown etiology, at times associated with Dupuytren’s contracture, and often referred to as penile fibromatosis – or van Buren’s disease, from the Philadelphia surgeon of Dutch descent, William Holme Van Buren (1819–1883). It presents with plaques (or strands) of dense fibrous tissue around the corpora cavernosa, possibly the result of trauma. These may be detectable by palpation and often cause penile deformity, with crooked and painful erections. Note that the penis of Peyronie patients is entirely normal at rest; only when erected does it appear bent and deformed. Although its major significance is psychologic, in some extreme cases the deformity is severe enough to interfere with erection, penetration, orgasm, and even fertility. PD also was the condition rumored to affect the presidential penis of Bill Clinton, based on descriptions filed by Paula Jones in her lawsuit for sexual harassment.

Who was Peyronie?

François Gigot de La Peyronie (1678–1747) was a well-respected Montpellier surgeon and the personal physician to the Sun King, Louis XIV. He astutely used his connection to have the king pass a law banning barbers and wigmakers from practicing medicine, thus eliminating with the stroke of a pen the main competition to the surgical community. He subsequently founded the French Academy of Surgery and became one of the forces in the establishment of Paris as the world center of surgery. An immensely rich man, Peyronie described his eponymous lesion at the end of his life, in 1743, in a patient who had “rosary beads of scar tissue to cause an upward curvature of the penis during erection.”

Define hypospadias and epispadias.

• Hypospadias is a developmental anomaly characterized by a defect on the lower (ventral) surface of the penis. Consequently, the urethral meatus is more proximal than normal, opening on the ventral aspect of the penis rather than on the glans.

• Epispadias is a defect on the upper (dorsal) surface of the penis. Hence, the urethral meatus opens dorsally .

Both these congenital malformations ( Fig. 14.4 ) may lead to fertility problems. They also represent a clue to other underlying abnormalities, such as undescended testis (cryptorchidism), Klinefelter’s syndrome, or other chromosomal disorders. Hypospadias may be induced by the mother’s ingestion of estrogens or progesterone or congenital adrenal hyperplasia.

Describe the anatomy of the scrotum.

The scrotum consists of a skin pouch, divided in the midline by a raphe extending from the ventral surface of the penis to the perineum. It is internally subdivided into right and left compartments, housing, respectively, the testes, epididymis, and the various spermatic cord structures (vas deferens with its vascular and nervous supply).

Which scrotal abnormalities can be identified through inspection?

Mostly skin abnormalities, including sexually transmitted or fungal lesions. Tinea cruris is especially common, presenting as large erythematous areas involving the scrotum and adjacent thighs. Lesions are often scaly and with ragged margins. Candidal infection also may cause scrotal lesions, particularly in grossly overweight and diabetic patients. Finally, lice (or sometimes even scabies ) can be visualized in scrotal and pubic areas, often heralded by excoriations. Fordyce “lesions” and “spots” are also important and yet benign findings.

What are Fordyce lesions ?

They are small, pin-sized (2–5 mm), bright red or purple papules that may occur on the scrotum, but occasionally on the glans and shaft, too, and even the inner thigh or lower abdomen. First described in 1896 by the American dermatologist John Addison Fordyce (on the scrotum of a 60-year-old man), they are still referred to as Fordyce’s angiokeratomas. They are not infectious but vascular. Hence, they should not be biopsied. In fact, they may even bleed after the minimal trauma of intercourse. At times solitary, they usually present as clusters of 50 to 100 asymptomatic lesions. They are benign and common, being present in as many as one of six men older than 50 (conversely, they are quite rare in men younger than 40). Since they reflect a congenital predisposition, they often occur in families, and yet remain primarily a byproduct of age. Although often a cause of embarrassment or concern, they just represent abnormally dilated capillaries covered by thickened skin. They should not be confused with Fordyce spots (or granules) .

What are Fordyce spots ?

They are very common (80%–95% of adults) yellowish/white papules, 1–3 mm in diameter, that occur on the shaft of the penis (or the labia of women), but also the tongue, vermillion border of the lips, and the inner surface of the cheeks. Usually clustered in 50 to 100, they are probably present at birth, even though they become bigger and more visible from puberty on. They represent enlarged ectopic sebaceous glands and are just of cosmetic concern.

What are the causes of scrotal swelling?

It depends on whether the swelling is bilateral or unilateral:

• Bilateral scrotal edema, diffuse and painless, is usually a feature of systemic disease, most commonly anasarca. Ascites, pleural effusion, and scrotal edema are commonly seen in severe congestive heart failure, nephrotic syndrome, or cirrhosis.

• Unilateral scrotal edema, on the other hand, is a sign of local pathology. The most common is a varicocele , from the Latin varix (dilated vein) and Greek kele (tumor).

What is a varicocele?

A condition caused by incompetent valves in the internal spermatic veins, resulting in engorgement along the spermatic cord . Hence, a varicocele resembles a nest of worms, which only presents upon standing and resolves with either a supine position or scrotal elevation. Easily identifiable on exam, a varicocele is quite common, occurring in 15% of the general male population and 40% of men evaluated for infertility. It is, in fact, a common cause of reversible sterility (due to the increased testicular temperature of the affected testis). This was intuited by the 1st century AD Roman physician Celsus, who described the condition as “veins that are swollen and twisted over the testicle, which thus becomes smaller than its fellow inasmuch as its nutrition has become defective.” Note that because of the drainage characteristics of the testicular veins, a varicocele is much more common on the left than on the right. Accordingly, a right varicocele should prompt investigation to exclude either anatomic abnormalities or an alternative diagnosis. Other than a varicocele, localized and painless scrotal swelling usually reflects pathology of the testis or epididymis (see Questions 62 and 63). Conversely, painful and tender scrotal swelling usually indicates a much more acute process, such as torsion of the spermatic cord, strangulated inguinal hernia, acute orchitis, or acute epididymitis.

What are the normal characteristics of testes and epididymides?

• Testes are paired organs, 2–3 cm in thickness, and 3.5–5.5 cm in length. They have the shape of an egg, with the vertical axis being the longest. All but the posterior surfaces are wrapped by a folded serous sheath with a potential cavity: the tunica vaginalis .

• Epididymides (in Greek, “the ones on top of the testicles”) are two elongated structures attached to the posterior surface of the testes (even though in 7%–10% of normal adults the epididymides are located anteriorly to the testicles). Each structure consists of a head (caput epididymidis), body (corpus epididymidis), and tail (cauda epididymidis). The tail turns sharply upon itself to become the ductus (or vas ) deferens . Both the tail and the beginning of the ductus deferens serve as reservoir for spermatozoa. Secretions from the ductus deferens, seminal vesicles, and prostate form the semen.

How should the testes and epididymides be examined?

With great care, since these organs (especially the testes) are exquisitely sensitive, not only to touch but also to temperature. In fact, in a cold room they may even retract toward the inguinal canal. Hence, to best palpate them, use your thumb plus index finger, or thumb plus index and medium fingers. This also allows you to gauge the length and thickness of each testicle, although for more accurate measurements, you will need a caliper. Note any discrepancy in consistency or size, and, if present, ask how long this has been so. If ruling out a congenitally undescended testis, examine the inguinal canal for localized swelling. Search for testicular lumps or bumps, which, if present, should be considered neoplastic until proven otherwise. Still, keep in mind that diffuse testicular enlargement usually reflects either a hydrocele (see Question 58) or a varicocele (previously discussed, see Question 54). Note that the left testis lies a bit lower in the scrotum than its counterpart (the reverse would suggest situs inversus ). Also note that, although the testicles can be examined in either the standing or supine position, a search for hernias or varicoceles requires the patient to stand . Finally, move cephalad and gently assess the upper and posterior poles of the testes and adjacent heads of the epididymides. Examine the spermatic cord , which goes from the epididymis all the way up into the inguinal canal. This contains the vas deferens, the testicular artery/vein, the ilioinguinal nerve, plus lymphatic vessels and fat tissue. Of all these structures, only the vas can be easily recognized, based on its firm and wire-like feel and the location along the posterior aspect of the bundle. Identify any lumps or bumps in the cord, and then note their relationship to the testes and inguinal canal. Note that a varicocele will be palpable not only in the testes but also throughout the length of the cord, since it represents a varicose dilation of the spermatic vein.

What is transillumination of a scrotal mass?

A good way to find out whether a localized scrotal swelling is solid or liquid. To do so, shut off the lights in the exam room, raise the penis (to better visualize the scrotum), and shine a penlight from behind the scrotal mass. Inability of the mass to transmit light suggests a solid lesion, whereas transmission of the light beam favors instead a fluid-filled lesion – like a hydrocele or spermatocele . Note, however, that a hematocele (a fluid-filled lesion caused by accumulation of blood) and a varicocele (varicose veins of the spermatic cord) are transillumination-negative because blood does not transmit light.

What is a hydrocele?

A collection of serous fluid in either the tunica vaginalis or in a separate pocket along the spermatic cord (literally, a water tumor in Greek). This presents as a unilateral and painless scrotal swelling. Since a hydrocele has different consistency from that of testicular tissue, it can be easily recognized by transillumination.

What is a spermatocele?

A spermatozoa-filled cyst of the epididymis (literally, a sperm tumor ). It presents as a unilateral, painless, and movable scrotal mass, just above the testis and identifiable by transillumination. A true epididymal cyst is clinically similar but does not contain sperm.

What is cryptorchidism?

A condition characterized by failure of one or both testes to descend (literally, the invisible testis in Greek). The undescended testicle lies in the inguinal canal or abdomen and eventually atrophies from high surrounding temperatures. It may even undergo neoplastic degeneration. Yet, since the other testis remains fully functional, cryptorchidism does not affect fertility. It may, however, cause emotional repercussions. For example, it has been suggested that Adolf Hitler’s psychopathology could have been due to cryptorchidism, a condition documented by a urologist he consulted before rising to power (the Brits even wrote a song, titled “Hitler Has Only Got One Ball,” later set to the tune of Colonel Bogey March ). Napoleon was cryptorchic, too. As a result, both men decided to screw the world.

What about small testes?

“Small” is a testis <3.5 cm in length. Its most common cause is atrophy . This may be either congenital (as in Klinefelter’s syndrome) or acquired (as in alcoholic cirrhosis). Klinefelter’s testicles tend to be small and firm, whereas those of cirrhosis are small and soft . Atrophy also may result from inflammatory or infectious processes (i.e., orchitis), often due to viruses (mumps), but also syphilis, filariasis, and even trauma.

What are the causes of an enlarged and solid testis?

Cancer for sure. Hence, an enlarged and firm testis should always be transilluminated to exclude a fluid-filled mass, such as a hydrocele, spermatocele, or epididymal cyst. A confirmed solid lesion increases the likelihood of testicular cancer, which is the most common tumor in men between the ages of 20 and 35. Solid testicular lesions should be actively sought out, not only by physicians but also by patients through self-examination.

What are the causes of a tender epididymis?

The most common is acute epididymitis , which may be associated with such a swelling that separation from the testis may be difficult to detect. In addition to edema, these patients also will have tenderness of the epididymal head and vas deferens . Occasionally, there is even swelling and redness of the overlying skin. Acute epididymitis is often the result of urinary tract infection (especially in men >35 years), whereas in younger men, it is usually due to sexually transmitted urethritis (by chlamydia or gonococcus) with prostatitis. Still, epididymitis occurs in less than 1% of all cases of identified sexually transmitted urethritis. Finally, an enlarged, nodular, beaded, and nontender epididymis should suggest tuberculous epididymitis , often the complication of renal tuberculosis.