Male Urogenital Physical Examination
A reconstructive examination documents the patient's current anatomy, tissue quality, symptoms and functional goals. Combine it with the history, prior operative records and appropriately selected investigations. Palpation cannot establish the full length or obliteration of a urethral stricture, exclude microscopic skin disease, or predict an operation's continence and sexual outcomes.[1]
For symptom instruments, diaries and the standing cough test, see Assessment Tools. This page covers examination; disease-specific treatment belongs in the linked clinical and operative articles.
Preparation and Positioning
Explain the purpose and sequence, obtain consent, offer a chaperone and preserve privacy. Ask about pain, prior traumatic examinations, positioning limitations and any preference that would make the examination easier. Examine only what is indicated; record a declined or deferred component without assuming a normal result.
| Setting | Practical preparation |
|---|---|
| Routine genital examination | Good lighting, gloves, drape, lubricant and a ruler when measurements are relevant |
| Standing examination | Inspect the groin, assess a suspected hernia or varicocele, or perform a standardized stress test when indicated |
| Supine examination | Abdominal, penile and scrotal examination; adapt leg position for comfort |
| Rectal or detailed perineal examination | Use a tolerable position providing adequate exposure; assess hip mobility before planning operative lithotomy |
| Endoscopy, calibration or biopsy | A separately indicated procedure with suitable consent, equipment, infection precautions and analgesia; not a compulsory part of every visit |
Before reconstruction, document abdominal scars, stomas or suprapubic access, skin problems and positioning restrictions. If oral mucosal harvest is being considered, assess oral health, prior harvest scars and mouth opening.[1]
Penis — Meatal and Glans Inspection
Meatal Position and Appearance
Describe the meatus, glans, frenulum, foreskin and shaft skin. Record discharge, fissures, ulceration, induration, visible narrowing and scars. For hypospadias or epispadias, describe the actual anatomy, curvature, fistulae and prior repairs; meatal position alone does not select a one-stage or staged operation.
Use complications after hypospadias repair when describing these patients. Obtain prior operative reports when possible: the current meatus may not reflect the original anomaly, and previous flaps, grafts and incisions affect subsequent options.
Meatal Caliber
Record visible narrowing and associated spraying, weak stream, dysuria or retention. A visually small meatus does not measure the proximal urethra. If instrumentation is clinically needed, document the actual instrument, its caliber and whether it passed without force. Avoid converting an examination into unintended dilation.[1][2]
There is no universal French-size table that maps the appearance of a meatus to DVIU, urethroplasty or urgent meatotomy. The relevant questions are the patient's symptoms and emptying, the location and extent of disease, prior treatment and goals.
Lichen Sclerosus
Look for pallor, sclerosis, fissuring, adhesions, a scarred preputial ring and meatal involvement. In males, common sites are the glans, coronal sulcus, foreskin, meatus and perifrenular area; the vulval/perianal “figure-of-eight” pattern should not be presented as the usual male distribution.[3]
Typical LS can be diagnosed clinically. Biopsy is important when the diagnosis is uncertain, treatment fails, or neoplasia is suspected. A new persistent ulcer, hyperkeratotic focus or indurated lesion warrants prompt assessment and biopsy when neoplasia is suspected; a reassuring examination elsewhere does not exclude malignancy.[3][4]
Topical corticosteroids are central to genital LS treatment. Persistent LS-related phimosis may require circumcision; the removed foreskin should undergo histology. Meatal and urethral obstruction need their own assessment. Avoid genital skin grafts or flaps for LS-related urethral reconstruction; oral mucosa and perineal urethrostomy are among the options selected according to disease extent and patient priorities. Neither a small meatus nor any visible LS automatically mandates complete urethral excision.[3][5]
See Lichen Sclerosus for treatment and surveillance.
Foreskin and Penile Skin
Retract the foreskin gently only as tolerated, inspect the concealed glans and return the foreskin to its normal position afterwards. Document whether exposure is limited by phimosis, buried penis, pain or adhesions. Do not record an unexamined glans as normal. A trapped retracted foreskin with swelling requires prompt assessment and treatment.
For reconstruction, describe skin availability, mobility, scarring, hair distribution and prior incisions. Circumcision alone does not prove that all remaining penile skin is unusable. Tunica vaginalis is a separate tissue flap, not a type of scrotal skin graft.
Urethral Calibration and Instrumentation
Routine blind passage of curved sounds or Hegar dilators is not a screening examination. Calibration can itself dilate a narrowing and change subsequent assessment. If needed to answer a specific distal-caliber question, use appropriate technique and stop at resistance; do not force a larger instrument through to establish “normal” caliber.[2]
For suspected stricture, combine symptoms and examination with uroflowmetry, residual urine and anatomic testing as indicated. RUG maps strictures before reconstruction; add VCUG when the proximal extent is poorly shown, including near-obliterative disease. Small-caliber endoscopy can answer selected questions without deliberately dilating the narrowing.[1]
In acute pelvic or perineal trauma, blood at the meatus, inability to void and swelling raise concern for urethral injury. Absent meatal blood does not exclude injury. Follow the trauma pathway, including RUG when indicated after stabilization; repeated blind instrumentation can worsen an injury.[6]
Penile Shaft, Urethra and Perineum
Inspect before palpating. Gently assess focal tenderness, induration, scars, fluctuance, skin fixation and palpable abnormalities along the ventral shaft and accessible perineum. Document location and whether pressure reproduces the patient's symptoms.
| Finding | Interpretation and next step |
|---|---|
| Firm tissue after urethral surgery | May represent postoperative fibrosis; establish recurrent narrowing with symptoms, flow and anatomic testing when indicated |
| Draining opening or urine-like discharge | Describe its position, surrounding skin and relation to voiding; determine the tract with directed evaluation |
| Tender swelling, erythema or fluctuance | Assess infection and possible abscess, urinary obstruction and systemic illness; arrange imaging or drainage according to the clinical situation |
| Perineal bruising after trauma | Supports concern for injury but does not by itself identify the injured urethral segment or prove complete disruption |
| Prior fistula repair, radiation or extensive scars | Anticipate altered tissue quality and operative planes; examination alone cannot establish the available dissection plane |
Avoid routine blind probing of fistulae or forceful occluded-urethral dye injection. Further evaluation may involve urethrography, endoscopy, imaging or examination under anesthesia, depending on the suspected communication.[1][7]
Record the condition of the perineal skin and relevant scars. Do not use an unvalidated male “perineal body length” cutoff to select posterior urethroplasty or fistula repair.
Acute urinary retention, systemic illness with genital/perineal infection, rapidly progressive swelling or crepitus, sudden severe scrotal pain, or new saddle sensory loss with bladder/bowel or limb symptoms require urgent assessment. Complete an emergency evaluation rather than delaying care for the remainder of an elective examination.
Peyronie's Disease Examination
Record onset, recent change, pain, erectile function, intercourse difficulty and distress. With the penis gently stretched, describe plaque location and palpable extent, deformity and baseline length using a reproducible method. A flaccid examination cannot fully characterize an erect deformity.[8]
Objective erection assessment may use suitable home photographs, vacuum-assisted erection or an in-office pharmacologically induced erection. Document curvature direction and angle, indentation/hourglass deformity, hinge instability and erection quality. Use ultrasound selectively to assess calcification or vascular function; plaque calcification does not establish disease stability.[8]
Stability depends on the clinical course, including no recent change in deformity for at least three months. Treatment selection considers intercourse function, erectile response to treatment, penile length, complexity and patient preference. A fixed 60° threshold is not a validated universal boundary between plication and grafting, and an IIEF-5 cutoff alone does not mandate a prosthesis.[8]
Measure length consistently and record the method; a single value below 10 cm does not diagnose acquired shortening. See Peyronie's Disease for management.
Scrotum and Contents
Inspect the skin and palpate each testis, epididymis and spermatic cord separately. Record side, tenderness, consistency, asymmetry, focal masses, scars, swelling and any difficulty distinguishing structures. If estimating testicular volume, identify the method; an orchidometer estimate is not interchangeable with ultrasound volume.
Transillumination is an adjunct. Failure to transilluminate does not diagnose cancer, and apparent fluid does not exclude an underlying testicular lesion. A suspected intratesticular mass requires ultrasound and the appropriate oncologic assessment.[9]
For suspected varicocele, examine standing at rest and with Valsalva, then assess decompression supine. Grade I is palpable only with Valsalva, grade II palpable at rest, and grade III visible; use Doppler when examination is inconclusive.[10] An isolated small or moderate right varicocele does not automatically require abdominal imaging under AUA/ASRM guidance. New onset, large size or non-reducibility should prompt further consideration of abdominal or retroperitoneal disease.[11]
Sudden severe scrotal pain requires urgent torsion assessment. An intact cremasteric reflex, relief with elevation, or preserved Doppler arterial flow cannot safely exclude torsion when the presentation remains concerning; imaging must not create an inappropriate delay to exploration.[12][13]
Digital Rectal Examination
Perform DRE when it addresses the presentation, after consent and with appropriate positioning. Inspect the perianal region first, then gently assess tenderness, a mass, prostate findings when relevant, resting anal tone and voluntary squeeze. Describe these findings rather than assigning a urinary continence prognosis from anal tone alone.
DRE gives only a rough estimate of prostate size and may underestimate enlargement. A large or smooth prostate does not demonstrate bladder outlet obstruction; interpret it with symptoms and relevant testing.[14] After pelvic trauma, a “high-riding prostate” is unreliable; concern for associated rectal injury is a separate reason to examine.[6]
Suspected Rectourethral Fistula
Ask about pneumaturia, fecaluria and urine per rectum, previous prostate treatment, radiation, infection and baseline continence. A reachable rectal opening is typically on the anterior rectal wall. Describe actual anatomy rather than an unqualified clock-face position, which depends on patient orientation.[7]
Cystoscopy and rectal endoscopy, RUG/VCUG and selected cross-sectional imaging define the communication, outlet and tissue condition; biopsy is considered when malignancy is suspected. Do not routinely pass a finger or sound through a tract. Radiation, stricture and tissue damage influence multidisciplinary repair planning; a fixed plane does not automatically require York–Mason repair or permanent colostomy. Transperineal repair with vascularized tissue interposition is an important option for complex cases.[7]
Focused Neurological Examination
Use a targeted examination when neurological disease, pelvic trauma, altered sensation or sphincter dysfunction is relevant. Record bilateral findings and compare them with the history and prior neurological baseline.[15]
| Component | Documentation |
|---|---|
| Sensation | Perineal, perianal and genital sensation; distribution and symmetry of reduction, plus relevant limb findings |
| Anal function | Resting tone and voluntary contraction, including whether the maneuver was understood and limited by pain |
| Sacral reflexes | Anal reflex and bulbocavernosus reflex when indicated; method, presence and symmetry |
| Broader neurological findings | Limb power/reflexes, gait or other findings relevant to the suspected lesion |
The bulbocavernosus reflex is a sacral reflex assessed using appropriate stimulation, such as gentle glans compression with observation or palpation of the response. Do not pull firmly on an inflated catheter balloon to elicit it. An isolated absent or brisk reflex does not diagnose detrusor overactivity, establish continence potential or predict erectile recovery. Combine findings with specialist neurological assessment and urodynamics when indicated.[15]
New saddle sensory loss with urinary retention, bowel dysfunction or progressive limb symptoms warrants urgent evaluation for spinal compression. In a patient susceptible to autonomic dysreflexia, genital, bladder and bowel procedures may provoke an episode; plan monitoring and prompt management.[15]
Post-Urethroplasty Assessment
Follow-up assesses symptoms and bother, flow, emptying, complications, sexual function and urethral patency. Scheduled dilation from 16 to 22 Fr is not a surveillance test. If calibration is used for a particular question, it should not become unplanned treatment.[2]
EAU recommends at least one year of follow-up and proposes risk-adjusted protocols, with an early anatomic assessment around three months. Subsequent cystoscopy or urethrography depends on recurrence risk, baseline findings and deterioration in symptoms or flow. Penile, graft/flap, LS, radiation and complex repairs may need longer surveillance. Explain how to seek reassessment for late recurrence.[2]
Compare postoperative erectile and ejaculatory symptoms with their preoperative baseline, including the effects of the original injury and other comorbidities. Neither a palpable scar nor a symptom score alone proves anatomic recurrence. Manage sexual symptoms individually; do not promise a fixed operation-specific erectile recovery rate or prescribe a universal rehabilitation regimen from the examination alone.
Concise Documentation Checklist
Record findings actually assessed, with important limitations:
- Reason for examination, consent, chaperone and positioning limitations.
- Meatus, glans, foreskin, penile skin and prior repair anatomy; lesions needing investigation.
- Relevant plaque/deformity findings, erection-assessment method and length-measurement method.
- Testes, epididymides, cords, scrotal skin and any groin findings.
- Perineal scars, tenderness, drainage and suspected fistula location.
- DRE and focused neurological findings when indicated; distinguish untested from normal.
- Relationship to symptoms, objective tests and baseline function; required next investigation or urgent action.
References
1. European Association of Urology. Urethral Strictures: Diagnostic Evaluation. 2026. Guideline chapter.
2. European Association of Urology. Urethral Strictures: Follow-up. 2026. Guideline chapter.
3. Kirtschig G, Woelber L, Günthert A, et al. Evidence- and consensus-based guideline on lichen sclerosus. J Dtsch Dermatol Ges. 2026;24:566–584. doi:10.1111/ddg.70000. Full text.
4. EuroGuiDerm. Guideline on Lichen Sclerosus. 2023 full guideline; journal publications 2024. Full guideline.
5. European Association of Urology. Urethral Strictures: Disease Management in Males. 2026. Section 6.3.1.e, LS-related penile urethral strictures. Guideline chapter.
6. European Association of Urology. Urological Trauma. 2026. Urethral trauma evaluation. Guideline chapter.
7. Chen S, Gao R, Li H, Wang K. Management of acquired rectourethral fistulas in adults. Asian J Urol. 2018;5:149–154. doi:10.1016/j.ajur.2018.01.003. Full text.
8. European Association of Urology. Sexual and Reproductive Health: Penile Curvature. 2026. Guideline chapter.
9. European Association of Urology. Testicular Cancer: Diagnostic Evaluation. 2026. Sections 5.1–5.2.1. Guideline chapter.
10. European Association of Urology. Sexual and Reproductive Health: Male Infertility. 2026. Varicocele diagnosis. Guideline chapter.
11. American Urological Association / American Society for Reproductive Medicine. Diagnosis and Treatment of Infertility in Men. Amended 2024. Statement 24 and discussion. Guideline.
12. European Association of Urology. Paediatric Urology: Acute Scrotum. 2026. Guideline chapter.
13. Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg. 2003;38:1248–1249. doi:10.1016/S0022-3468(03)00280-X. PubMed.
14. European Association of Urology. Management of Non-neurogenic Male LUTS: Diagnostic Evaluation. 2026. Sections 4.1–4.6. Guideline chapter.
15. European Association of Urology. Neuro-urology: The Guideline. 2026. Section 3.3.6 and autonomic dysreflexia assessment. Guideline chapter.