Testicular examination – OSCE guide

Testicular examination can occasionally appear in OSCEs and if it does you need to have practiced the routine to look slick and professional. This testicular examination OSCE guide provides a structured approach to examining the testicles. This is an intimate examination and therefore extra attention should be paid to the communication aspect to ensure the patient feels as comfortable as possible. Check out the testicular examination OSCE mark scheme here.

Introduction

Wash hands

Introduce yourself – name / role

Confirm patient details – name / DOB

Explain examination:

“I need to carry out an examination of your testicles, this will involve firstly inspecting the testicles and surrounding area, then I will examine the testicles“

“I’m required to have a chaperone present, this will most likely be a nurse from the ward, are you ok with that?“

Gain consent :

“Do you understand everything I’ve said?“  

“Are you happy for me to examine you?“

Get a chaperone – this is absolutely essential and often carries significant marks in the OSCE

Position patient – examination of the testicles is best performed with the patient standing

Expose patient – exposure should be from the waist down

Don gloves 

Inspection

General inspection

Inspect the patient’s genital region and the surrounding areas (i.e. penis / groin / lower abdomen):

• Skin changes – rash / bruising / swelling
• Scars
• Obvious masses

Inspection of the scrotum

Ask the patient to hold their penis out of the way to allow easier inspection of the scrotum.

Inspect the scrotum from the front, sides and the posterior aspect by lifting the scrotum.

Inspect the scrotum for the following…

• Skin changes – rash / ulcers / erythema (e.g. cellulitis / fungal infection)
• Scars – may provide clues as to previous operations (e.g. vasectomy)
• Masses – note any obvious lumps, these will require examination later
• Swelling – unilateral or bilateral? / associated with erythema? 
• Bruising
• Necrotic looking tissue – Fournier’s gangrene is a diagnosis not to be missed!

Palpation

Examine each testicle individually.

If abnormalities have been identified on inspection or the patient is concerned about a particular testicle, start examination on the other testicle.

Ask the patient to report any pain or discomfort they experience during the examination.

Testes

Use your thumb and index finger to gently palpate the whole testicle.

If you are unable to locate a testicle, palpate along the path of the inguinal ligament for an undescended testicle (if the patient also has a scar this would suggest a previous orchidectomy)

If a mass is found assess the following…

• Size / shape
• Regularity – regular vs irregular
• Consistency – hard (solid) / soft (cystic) / “Bag of worms” (varicocele) 
• Discomfort – try to identify the specific area causing pain
• Are you able to get above the mass?- No = inguinal scrotal hernia

Is the mass fixed to the testicle or separate?

• Separate + hard (solid) = epididymitis / orchitis
• Separate + cystic (soft / fluctuant) = epidermal cyst / spermatocele

Is there a cough impulse? – presence of a cough impulse suggests hernia / varicocele

Does the mass transilluminate? – transillumination suggests the mass is fluid filled – e.g. hydrocele

Epididymis

Palpate the epididymis (located at the posterior aspect of the testicle).

Pain in the epididymis may suggest epididymitis.

Phren’s test

If testicular pain is relieved by elevating the testes this is strongly suggestive of epididymitis.

Spermatic cord

Start palpation at the superior aspect of the testicle using your thumb and index finger.

The spermatic cord should be palpable connecting to the testicle at this region.

Palpate along the cord assessing for masses and tenderness.

Lymph nodes

Assess the local lymph nodes in the inguinal region for evidence of lymphadenopathy (scrotal infection).

To complete the examination

Thank patient

Allow patient time to get dressed

Dispose of gloves

Wash hands

Summarise findings 

“Today I performed a testicular examination on John Doe, a 42 year old gentleman. On inspection there were no abnormalities identified, however on palpation there was a 1cm smooth solid mass noted on the left testicle. The mass was non tender and fixed to the underlying testicle. I was able to get above the mass and there was no cough impulse or transillumination.  Some lymphadenopathy was noted in the left inguinal region“

Suggest further assessments and investigations

• Full abdominal examination
• Ultrasound scan of the testicles