Advertisement

The Male Genital Examination: A Position Paper of the Society for Adolescent Health and Medicine

  • Society for Adolescent Health and Medicine

      Abstract

      The male genital examination is a simple and quick clinical assessment and is important for screening and diagnostic purposes beyond the need to screen for testicular cancer. Despite the lack of evidence supporting screening for testicular cancer, the genital examination should be included as part of a male's routine physical examination, as well as when a male patient presents with genital complaints.

      Positions

      The Society for Adolescent Health and Medicine (SAHM) supports the following positions:
      • 1
        A complete examination of the male genitals, including inspection of skin and hair and palpation of inguinal nodes, scrotal contents, and penis, and inspection of perianal area (as indicated), should be performed annually as part of a comprehensive physical examination.
      • 2
        A complete genital examination should be performed as part of the diagnostic assessment when a male presents with genital symptoms.
      • 3
        A complete male genital examination should be included as an evaluation competency for health care providers in training.
      • 4
        Clinicians should use the male genital examination as an opportunity to promote young men's sexual/reproductive health (SRH) and educate about male anatomy, function, and SRH matters.
      SAHM does not have a recommendation on whether providers should teach patients to perform regular testicular self-examinations (TSE). Appropriate resources should be available to share with patients at risk for testicular cancer. Individual providers can decide whether to use these resources in the context of their practice.

      Background

      Screening for testicular cancer is no longer recommended for male adolescents and young adults. SAHM believes it is important to update clinicians and to address any possible misperceptions that the male genital examination is no longer an important part of the male physical examination. The recently updated Bright Futures Guidelines supports yearly male genital examinations [
      • Hagan Jr., J.F.
      • Shaw J.S.
      • Duncan P.
      • et al.
      Bright futures: Guidelines for health supervision of infants, children, and adolescents.
      ]. Other organizations, such as the U.S. Preventive Services Task Force (USPSTF), do not comment on the male genital examination apart from screening for testicular cancer.

      Health Maintenance

      The male genital examination is an important part of the physical examination beyond the need to screen for testicular cancer. During adolescence, performing the genital examination allows the health care provider to assess progress of sexual development by documenting sexual maturity ratings (e.g., Tanner stages) of pubic hair and testicular size. This process can reassure the male patient regarding progress of puberty or identify problems with development. The examination also allows the clinician to reassure the male patient about normal genital findings, such as penile pearly papules and sebaceous cysts, and to review normal anatomy and function.

      Genital Findings

      It is not uncommon to discover structural anomalies (e.g., varicocele, spermatocele, or hydrocele), meatal abnormalities (e.g., hypospadias), issues related to an uncircumcised penis (e.g., phimosis, paraphimosis, or inadequate hygiene), and hair and skin problems (e.g., folliculitis or tinea cruris) in the course of a male genital examination [
      • Mansbach J.M.
      • Forbes P.
      • Peters C.
      Testicular torsion and risk factors for orchiectomy.
      ,
      • Feber K.M.
      • Kass E.J.
      Varicocelectomy in adolescent boys: Long-term experience with the Palomo procedure.
      ]. Less common but more serious issues may be uncovered, including findings of genetic disease (e.g., Klinefelter's syndrome, incomplete 21-congenital adrenal hyperplasia, or fragile X syndrome), testicular atrophy secondary to central causes or abuse of anabolic steroids, and absent or undescended testes due to cryptorchidism or another etiology [
      • Bojesen A.
      • Juul S.
      • Gravholt C.H.
      Prenatal and postnatal prevalence of Klinefelter syndrome: A national registry study.
      ,
      • O'Donnell W.T.
      • Warren S.T.
      A decade of molecular studies of fragile X syndrome.
      ,
      • Sijstermans K.
      • Hack W.W.
      • Meijer R.W.
      • et al.
      The frequency of undescended testis from birth to adulthood: A review.
      ]. Abnormal changes associated with sexually transmitted infections that may have gone unnoticed by the male patient (e.g., genital warts, syphilitic ulcers or condylomata, herpes lesions, or evidence of discharge) or other genital-related concerns can also be found.
      A male genital examination is an essential step in evaluating a male patient when he presents with genital symptoms (e.g., discharge, dysuria, or “bumps” on the penis). For example, a teenaged male presenting with dysuria is more likely to be diagnosed with a sexually transmitted infection than a urinary tract infection, as fewer than .01% of adult men are diagnosed with UTIs [
      • Foxman B.
      Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs.
      ]. Clinicians' ability to properly evaluate males presenting with genital complaints is based on their knowledge and skills of performing a male genital examination and the health issues that affect this population.

      Testicular Cancer

      Although testicular cancer is uncommon, with just over 8,000 new cases diagnosed in the United States each year, it is one of the most common cancers in young men. Testicular cancer is treatable and often curable, especially when it is found at early stages. Risk factors for testicular cancer include Caucasian race, cryptorchidism, testicular atrophy, family history, and HIV infection.

      Screening examination for testicular cancer

      Recommendations to screen for testicular cancer differ by health organizations with respect to the clinical examination. Since 2006, the American Cancer Society recommends “a testicular exam [to screen for testicular cancer] should be part of a routine cancer-related checkup”[
      American Cancer Society
      Detailed guide: Testicular cancer: Can testicular cancer be found early?.
      ], whereas in 2010, the USPSTF found no new evidence that screening for testicular cancer during clinical examination is effective in reducing mortality from testicular cancer [
      • Lin K.
      • Sharangpani R.
      Screening for testicular cancer: An evidence review for the U.S. preventive services task force.
      ]. The USPSTF's guidelines have evolved to a recommendation “against routine screening for testicular cancer in asymptomatic adolescent and adult males” because of a change in methodology in reviewing the evidence that was reaffirmed in 2011 [
      U.S. Preventive Services Task Force
      Screening for testicular cancer: U.S. preventive services task force reaffirmation recommendation statement.
      ]. The methodology takes into account the certainty of the evidence and the magnitude of the benefits and harms of screening [
      • Sawaya G.F.
      • Guirguis-Blake J.
      • LeFevre M.
      • et al.
      Update on the methods of the U.S. preventive services task force: Estimating certainty and magnitude of net benefit.
      ]. The USPSTF concluded that the magnitude of the net benefit of screening for testicular cancer (e.g., zero/negative) exceeds any potential benefits of screening given the low prevalence of testicular cancer, limited accuracy of screening tests, and no new evidence for the incremental benefits of screening. However, the USPSTF notes clinicians should be aware that patients who present with symptoms of testicular cancer are frequently misdiagnosed as having other genital complaints, such as epididymitis, testicular trauma, hydrocele, or other benign disorders. A recent Cochrane review on the topic noted a lack of randomized controlled trials evaluating the effectiveness of screening for testicular cancer [
      • Ilic D.
      • Misso M.L.
      Screening for testicular cancer.
      ]. In the absence of high-quality evidence, male patients with an increased risk of developing testicular cancer should be informed of the potential benefits and harms associated with screening [
      • Ilic D.
      • Misso M.L.
      Screening for testicular cancer.
      ].

      Testicular self-examination

      The USPSTF states that there is “no evidence that teaching young men how to examine themselves for testicular cancer would improve health outcomes, even among men at high risk, including men with a history of undescended testes or testicular atrophy” [
      • Lin K.
      • Sharangpani R.
      Screening for testicular cancer: An evidence review for the U.S. preventive services task force.
      ]. The American Cancer Society states that it “does not have a recommendation on regular testicular self-exams for all men” [
      American Cancer Society
      Detailed guide: Testicular cancer: Can testicular cancer be found early?.
      ]. Resources for TSE are readily available to share with patients at risk, and clinicians can decide for themselves whether to use these in their practice.

      Conclusion

      Despite the lack of evidence supporting testicular cancer screening, the male genital examination should be included as part of a routine physical examination, as well as when a patient presents with genital complaints. The male genital examination should be included as an evaluation competency for health professionals in training and used as an opportunity to promote young men's SRH and to educate about male anatomy, function, and SRH matters. SAHM does not have a recommendation on regular TSE but recommends that resources be readily available to share with patients at risk. Clinicians can decide for themselves whether to use these resources within the context of their own practice.
      Prepared by: Arik V. Marcell, M.D., M.P.H. Division of General Pediatrics and Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
      David L. Bell, M.D., M.P.H. Department of Pediatrics, Department of Population and Family Health, Columbia University Medical Center, New York, New York
      Alain Joffe, M.D., M.P.H. Student Health and Wellness Center, The Johns Hopkins University, Baltimore, Maryland
      and the SAHM Male Health Special Interest Group

      References

        • Hagan Jr., J.F.
        • Shaw J.S.
        • Duncan P.
        • et al.
        Bright futures: Guidelines for health supervision of infants, children, and adolescents.
        3rd edition. American Academy of Pediatrics, Elk Grove Village, IL2008
        • Mansbach J.M.
        • Forbes P.
        • Peters C.
        Testicular torsion and risk factors for orchiectomy.
        Arch Pediatr Adolesc Med. 2005; 159: 1167-1171
        • Feber K.M.
        • Kass E.J.
        Varicocelectomy in adolescent boys: Long-term experience with the Palomo procedure.
        J Urol. 2008; 180 (discussion:1659–60): 1657-1659
        • Bojesen A.
        • Juul S.
        • Gravholt C.H.
        Prenatal and postnatal prevalence of Klinefelter syndrome: A national registry study.
        J Clin Endocrinol Metab. 2003; 88: 622-626
        • O'Donnell W.T.
        • Warren S.T.
        A decade of molecular studies of fragile X syndrome.
        Annu Rev Neurosci. 2002; 25: 315-338
        • Sijstermans K.
        • Hack W.W.
        • Meijer R.W.
        • et al.
        The frequency of undescended testis from birth to adulthood: A review.
        Int J Androl. 2008; 31: 1-11
        • Foxman B.
        Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs.
        Am J Med. 2002; 113: S5-S13
        • American Cancer Society
        Detailed guide: Testicular cancer: Can testicular cancer be found early?.
        (2011 Revised: 01/19/2011 [cited 2011 23 Jan])
        • Lin K.
        • Sharangpani R.
        Screening for testicular cancer: An evidence review for the U.S. preventive services task force.
        Ann Intern Med. 2010; 153: 396-399
        • U.S. Preventive Services Task Force
        Screening for testicular cancer: U.S. preventive services task force reaffirmation recommendation statement.
        Ann Intern Med. 2011; 154: 483-486
        • Sawaya G.F.
        • Guirguis-Blake J.
        • LeFevre M.
        • et al.
        Update on the methods of the U.S. preventive services task force: Estimating certainty and magnitude of net benefit.
        Ann Intern Med. 2007; 147: 871-875
        • Ilic D.
        • Misso M.L.
        Screening for testicular cancer.
        Cochrane Database Syst Rev. 2011; 16 (CD007853)