Genital problems ●

Essential skills of scrotal

examination: a step-by-step
technique
Helen Please, Junior Surgical Clinical Fellow (CT3);1 Vanessa Savopoulos, Endourology Fellow;1 Chandra Shekhar Biyani,
Consultant Urologist1 and Co-Director Cadaveric Simulation Programme2
1. Department of Urology, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, UK; 2. Anatomy Department, School of Medicine,
University of Leeds, UK

Examination of the scrotum

Transversus Peritoneum
is an essential skill for abdominis muscle
emergency, surgical and Internal abdominal Obliterated tract of
general practice (GP) oblique muscle processes vaginalis
clinicians. However, the Transversalis fascia
examination poses a number External abdominal
of challenges due to its oblique muscle

intimate nature and wide Ductus deferens

range of potential pathologies, External
resulting in many UK trainees spermatic fascia
feeling uncomfortable and
underconfident in this skill. Cremasteric fascia Scrotum
and muscle
This article aims to address Testes
this issue by training clinicians Epididymis
Tunica vaginalis
in a stepwise, structured
Internal spermatic fascia
approach. Gubernaculum

S crotal examination is notoriously

difficult due to its intimate nature
and wide range of potential
Figure 1. Scrotal anatomy. Adapted, with permission, from Dr Pasindu
Suriapperuma, Pasindu’s Archives5

pathologies. Furthermore, a common testicular assessment1 and 62% of their clinical confidence in scrotal
scenario faced by GPs, surgical primary care providers have little/no examination. We hope it facilitates
trainees and emergency clinicians is formal training in scrotal examination. clinicians’ confidence and
having to rely on their examination However, structured training can competency in examination and
skills to assess whether an acute significantly increase confidence in diagnosis of serious and common
scrotum is caused by testicular scrotal examination,2 and can be scrotal pathologies. It includes an
torsion, therefore requiring facilitated by simulation models. outline of the pertinent anatomy and
exploration and fixation. Several robust models exist indications of this examination,
Most scrotal complaints present (exemplified by the ‘Limbs and followed by a step-by-step
first to GPs and emergency Things’ model CMPT Mk 2 in our examination approach aided by
departments, making initial images), with low-fidelity alternatives photographs using simulation
examination crucial for appropriate also available.3,4 models. The standardised structure is
onward referral versus reassurance. This article is especially useful for used: preparation, inspection,
Studies show that 28% of UK GP doctors in GP, emergency, and core palpation, auscultation, special tests,
trainees feel uncomfortable in surgical training who want to build followed by a list of important

wchh.onlinelibrary.wiley.com Trends in Urology & Men’s Health ❘ March/April 2022 ❙ 9

● Genital problems

questions to be asked in cases of Step 2: inspection

scrotal masses. Finally, the examination First perform a general inspection,
findings for common and concerning noting whether the patient is unwell
scrotal pathologies are described, or in pain. Next, assess the
supported by clinical images. inguinoscrotal region for colour,
testicular lie, size, shape, symmetry,
Anatomy presence of lesions/lumps/oedema/
A detailed anatomical understanding scars. Continue inspection throughout
underpins the quality of any clinical steps 3–5 as some signs, such as the
examination. The scrotum is a ‘blue dot sign’, may become visible
cutaneous sac beneath the penis, only when the skin is stretched
containing several important (Figure 2).
structures (Figure 1). The testes are
ovoid structures suspended by the Step 3: palpation
spermatic cord, separated by the Ask the patient about pain before
scrotal septum. The epididymis lies palpating and begin with the normal
on their posterior aspect, consisting Figure 2. Blue dot sign. Image side to allow comparison when
of a head, body and tail. The reproduced with permission from examining the abnormal side. Palpation
spermatic cord contains the vas Eleni Papageorgiou, Abraham is easiest in the supine position,
deferens, arteries (testicular, Cherian and Pankaj Mishra6 although some findings are best
cremasteric, artery to vas deferens), appreciated with the patient standing
veins (pampiniform plexus), nerves confirming identity, explaining the (for example, varicocele/hernia).
(genital branch of genitofemoral, examination and its indication, Due to testicular mobility, it is
sympathetic, parasympathetic) and ensuring privacy, and assessing for recommended to ‘fix’ each testicle
lymphatics. It is covered by multiple pain. When any intimate region is between both thumbs and index/
layers, from internal to external: examined, clear verbal consent and middle fingers (Figure 3a). In this
tunica vaginalis, internal spermatic a chaperone are critical to patient position, feel the size, texture and
fascia, cremaster muscle, external comfort. This also protects the contour, and attempt to localise any
spermatic fascia, dartos muscle clinician from medicolegal allegations tenderness to the testicle or other
and skin. or unwelcome behaviour. These structures (Figure 3b). Characterise
preparatory steps cannot be any lumps and determine if they are
Indications overemphasised, as they provide separate from the testis. Figure 3c
Scrotal examination is required in reassurance and build rapport, which demonstrates palpation of a
patients presenting with scrotal/ optimise a relaxed examination. In simulated malignant lump.
inguinal pain, lump(s) or trauma, the paediatric population this can Next, palpate the epididymis
and in comprehensive abdominal be facilitated by involving parents/ systematically including the head
examinations for males with guardians or play specialists to (Figure 3d), body and tail. Palpate the
abdominal pain. provide distraction. spermatic cord at the scrotal neck by
The examiner should wash their rolling it between thumb and index
Examination steps hands, ensure hands are warm and finger (Figure 3e); the vas deferens is
All clinical examinations should follow consider exposure/positioning. appreciated as a rubbery, cord-like
a structured approach, including Ideally, the patient should be structure slipping between the
preparation, inspection, palpation, exposed from the waist down and fingers. A varicocele, if present, will
auscultation and special tests. An the scrotum examined with the be felt in this region (Figure 3f
opportunistic approach may be patient first standing, then supine, demonstrates a simulated varicocele).
required in paediatric examinations, although paediatric patients may be Finally, palpate the groin lymph
allowing flexibility to rearrange best in their carer’s lap. An nodes (Figure 3g), particularly if
this order. abdominal examination should also infection/neoplasm are suspected.
be performed, as abdominal pain
Step 1: preparation can radiate to the scrotum and vice Step 4: special tests
Good communication skills are versa. Continue verbal communication Auscultation
essential in any examination. These and awareness of facial cues Listen over masses for bowel
include greeting the patient, throughout the examination to sounds. Positive findings suggest
introduction by name and role, ensure patient comfort. inguinoscrotal hernia.

10 ❙ Trends in Urology & Men’s Health ❘ March/April 2022 wchh.onlinelibrary.wiley.com

 Genital problems ●

a b c d e

f g h i j

Figure 3. Scrotal examination demonstrated on a simulated model. Image

reproduced with permission from Chandra Shekhar Biyani

Figure 4. Hydrocele. Original image

source from Shields L, White J, Peppas
D, 20198
Figure 5. Cremasteric reflex demonstrated on a simulated model. The black arrow
demonstrates the movement of finger stroking skin from position 1 to 2. The blue Step 5: questions about masses
arrow demonstrates the resulting retraction of the ipsilateral testis in normal If a scrotal mass/swelling is present,
physiology. Image reproduced with permission from Chandra Shekhar Biyani ask yourself the following:
1. Is it possible to get above the
Cough impulse between masses being fluid-filled mass (technique demonstrated in
Palpate masses with the patient (presence of a red glow) or solid Figure 3j)? If not, consider hernia
standing and ask them to cough. (no transmitted light), ie hydrocoele or infantile hydrocoele (Figure 4).
An impulse felt under the fingers (Figure 3h and Figure 4) versus 2. Is it possible to identify the testis and
suggests inguinoscrotal hernia epididymal cyst (Figure 3i). epididymis? If not, consider vaginal
or varicocele. hydrocoele, haematocele, tumour,
Cremasteric reflex torsion or epididymo-orchitis.
Transillumination Stroke the inner thigh to induce 3. Is the swelling translucent? If yes,
Darken the room and use a pen torch cremaster muscle contraction consider hydrocoele or epididymal
to shine light from behind any (Figure 5). This is positive if the cyst.
swelling/mass while inspecting ipsilateral testis elevates and is 4. Is the swelling tender? If yes,
anteriorly. This allows differentiation typically absent in torsion. consider torsion or epididymo-orchitis.

wchh.onlinelibrary.wiley.com Trends in Urology & Men’s Health ❘ March/April 2022 ❙ 11

● Genital problems

Pathologies • Questions about masses (see Step 5).

The following section lists several Tender, able to get above swelling,
common and concerning scrotal testis and epididymis definable.
pathologies, describing their expected
findings when using the examination Fournier’s gangrene
steps described below. • Clinical inspection (see Step 2).
Stepwise progression of oedema,
Torsion erythema, duskiness, necrosis and
• Clinical inspection (see Step 2). gangrene (Figure 6).
Erythematous or dark hemiscrotum. • Palpation findings (see Step 3).
• Palpation findings (see Step 3). Oedema, tender skin, may have
Abnormal lie (horizontal, high), subcutaneous crepitation or
firm and tender testicle purulent discharge.
(generalised). • Relevant special tests (see Step 4).
• Relevant special tests (see Step 4). Exquisite tenderness or pain out Figure 7. Frog-legged position
to inspect the scrotum. Image
Absent cremasteric reflex, no of proportion to examination is a
reproduced with permission from
transillumination. cardinal finding. Presence of crepitus Mau EE, Leonard MP10
• Questions about masses (see and subcutaneous gas is very
Step 5). Tender (sudden onset in specific for gas-forming organisms. • Palpation findings (see Step 3).
history), able to get above swelling, • Questions about masses (see Step 5). Tenderness localised to epididymis,
testis and epididymis may or may Tender (intense), testis and bulky epididymis, not reducible.
not be definable. epididymis definable. • Relevant special tests (see Step 4).
No transillumination, no cough
Torted testicular appendage Hydrocoele impulse.
• Clinical inspection (see Step 2). • Clinical inspection (see Step 2). • Questions about masses (see
Blue dot sign (Figure 2). Asymmetrical swelling (Figure 4). Step 5). Tender (gradual onset),
• Palpation findings (see Step 3). • Palpation findings (see Step 3). able to get above mass. Testis and
Normal lie, soft testicle with Fluctuant swelling, not reducible. epididymis may or may not be
pinpoint tenderness. • Relevant special tests (see Step 4). definable (depending on severity).
• Relevant special tests (see Step 4). Translucent, no cough impulse.
Cremasteric reflex present, no • Questions about masses (see Inguinoscrotal hernia
transillumination. Step 5). Depending on type of • Clinical inspection (see Step 2).
hydrocoele: may or may not be able Unilateral swelling, abdomen may
to get above mass. Testis and be distended.
epididymis may not be definable, • Palpation findings (see Step 3). May
generally non-tender. be soft and reducible, or firm and
irreducible.
Varicocele • Relevant special tests (see Step 4).
• Clinical inspection (see Step 2). Presence of bowel sounds on
‘Bag of worms’ swelling. auscultation; cough impulse may
• Palpation findings (see Step 3). be present.
Asymmetrical soft swelling, not • Questions about masses (see
reducible. Step 5). Unable to get above mass,
• Relevant special tests (see Step 4). testis and epididymis definable,
No transillumination, cough impulse may be tender (if irreducible/
may be present. strangulated, or non-tender).
• Questions about masses (see
Step 5). Able to get above mass, Scrotal examination in infants
testis and epididymis definable, and children
generally non-tender. Scrotal examination in infants and
adolescent boys is challenging, with
Figure 6. Fournier’s gangrene. Image Epididymo-orchitis adolescent boys being especially
reproduced with permission from • Clinical inspection (see Step 2). reserved about having their genitals
Nadiah Parry9 Erythematous unilateral swelling. examined. It is therefore important

12 ❙ Trends in Urology & Men’s Health ❘ March/April 2022 wchh.onlinelibrary.wiley.com

 Genital problems ●

the training received in urology on

the GP training scheme. Ir J Med Sci
2016;185:165–9.
2. Sarmah PB, Sarmah BD, Ibrahim H,
Panting J. Making models to simulate
testicular swellings. Clin Teach
2017;14:432–6.
3. Sharma D, Sohn JK, Zillioux JM, et al.
a b c Identifying and addressing training
deficiencies in the examination of
cryptorchidism – a quality improvement
study. J Pediatr Urol 2020;16:61.e1–61.e8.
4. Kailavasan M, Abdul-Rahman A,
Hanchanale V, et al. The validation
of the Clinical Male Pelvic Trainer
Mk 2 – advanced models for scrotal
examination simulation. J Surg Educ
d e f 2017;74:423–30.
Figure 8. Scrotal examination in the paediatric age group. Reproduced with 5. Suriapperuma P. Embryology and
permission from The Royal Australian College of General Practitioners from: surgical anatomy of testis and scrotum –
Yeap E, Nataraja RM, Pacilli M. Undescended testes: what general practitioners overview. Pasindu’s Archives April 2020
need to know. Aust J Gen Pract 2019;48:33–36. Available at: www.racgp.org.au/ (www.pasindusarchives.com/2020/04/
ajgp/2019/january–february/undescended-testes embryology-and-surgical-anatomy-of-
testis-and-scrotum-overview.html;
to collect maximum information prior position or flexing of both thighs accessed 8 December 2021).
to examination. GPs are most likely towards the abdomen may push the 6. Papageorgiou E, Cherian A, Mishra P.
to see children presenting with retractile testis into the scrotal sac. Testes congenital and childhood anomalies
absent testis. Once again, a ‘two- (https://abdominalkey.com/testes-
hand’ approach is recommended. In Acknowledgements congenital-and-childhood-anomalies;
neonates and infants, the inspection We would like to thank the Medical accessed 8 December 2021).
can be carried out in supine, frog- Education Department, Leeds 7. Davis JE. Scrotal Pain. In: Mahadevan SV,
legged position (Figure 7). Teaching Hospitals NHS Trust for the Garmel GM. An introduction to clinical
In a child with undescended use of their facilities, and thanks to emergency medicine. Cambridge:
testis, an inspection of the scrotum Limbs and Things for their scrotal Cambridge University Press, 2005;461–72.
may show a hypoplastic hemiscrotum examination model. 8. Shields L, White J, Peppas D. Scrotal
(Figure 8a). To locate the testis, the ultrasound is not routinely indicated in
the management of cryptorchidism,
deep ring should be occluded with a Declaration of interests
retractile testes, and hydrocele in
finger (Figure 8b–d), then gently milk Chandra Shekhar Biyani has received
children. Glob Pediatr Health 2019.
along the inguinal canal towards the a scrotal examination model from
doi:10.1177/2333794X19890772.
scrotum (Figure 8e–f). A testis may Limbs & Things on behalf of the 9. Parry N. Fournier gangrene. Clin Case
feel like movable ‘soft marble’ under Urology Simulation Boot Camp. Rep 2015;3:198–9.
the skin. An undescended testis 10. Mau EE, Leonard MP. Practical
may not reach the scrotal base; in References approach to evaluating testicular status in
contrast, a retractile testis will touch 1. Redmond EJ, Kelly NP, McCarthy C, infants and children. Can Fam Physician
the scrotal base. The squatting et al. Attitudes of GP trainees towards 2017;63:432–5.

wchh.onlinelibrary.wiley.com Trends in Urology & Men’s Health ❘ March/April 2022 ❙ 13