Performing a physical examination on male children and adolescents can help detect conditions such as testicular cancer, Klinefelter syndrome, and penile and hormonal abnormalities.
This article covers what you need to know to conduct this clinical assessment with young people. This includes the types of testicular and penile examinations you may need, as well as the relevant signs and medical history to look out for.
For a step-by-step guide to performing a male genital examination, refer to our clinical summary guide.
How to approach an examination with children and adolescents
Young people — and their parents — may feel uncomfortable, embarrassed or anxious about a genital examination.
Good communication can help the examination go smoothly for everyone:
-
Talk to both the patient and their parents, using simple language and visual aids if available
-
Explain why you need to perform the examination and ask for permission to proceed
-
Allow the patient to ask questions and express any discomfort they may feel before and during the examination
-
If it seems appropriate, use humour to reduce anxiety, foster rapport and improve cooperation before or during the examination. This approach can be particularly helpful with children
-
If you refer the patient to another specialist, take the time to explain why, and what may be involved.
Do not perform the examination if the child is restrained by a parent. Always wear gloves unless there is a specific reason not to, for example, it’s a neonatal examination or you need to detect a small scrotal mass.
When to perform a genital examination
A genital examination should be part of a standard health check-up with new or existing patients.
Also perform an examination if a patient presents with symptoms or risk factors for any of the disorders below.
-
Testicular cancer
• Undescended testes as an infant
• Gynaecomastia
• History of testicular cancer
• Acute testicular or groin pain.
-
Androgen deficiency
• Delayed puberty
• Gynaecomastia.
-
Klinefelter syndrome
• Gynaecomastia.
-
Testicular torsion
• Testicular pain or lumps.
What to check for when examining children
Pain
If a patient presents with acute testicular pain, they may have testicular torsion. This is a medical emergency and you will need to refer the patient immediately for evaluation as surgery may be required. A follow up review should be done with the patient to check for other causes or consequences, for example epididymo–orchitis.
Medical history
-
Undescended testes — this can be a risk factor for testicular cancer, and is associated with inguinal hernia
-
Prior inguinal-scrotal surgery or hypospadias.
Testes
When examining the testes, check for:
-
Undescended testes
-
Whether testicular volume is in the normal childhood (pre-pubertal) range of less than 3 mL.
Penis
-
Hypospadias
-
Micropenis
-
Phimosis (physiological or pathological).
What to check for when examining adolescents
Pain
As with children, acute testicular pain in adolescents should be treated as a medical emergency. Refer the patient for evaluation immediately and conduct a follow up review.
Medical history
-
Undescended testes
-
Pubertal development
-
Testicular trauma, lumps and/or cancer
-
Gynaecomastia
-
Prior inguinal-scrotal surgery or hypospadias.
Testes
When examining the testes, check that testicular volume is in the normal pubertal range of 4-14 mL. A volume less than 4 mL by 14 years indicates delayed or incomplete puberty, and may also suggest Klinefelter syndrome. If puberty is complete, assess whether testes are of adult size.
You should also check the scrotal and testicular contents for abnormalities in texture or a hard lump, which could indicate a tumour or cyst.
Penis
When examining the penis, check for:
-
Hypospadias
-
Micropenis
-
Sexually transmitted infections (STIs) or inflammation
-
Phimosis (physiological or pathological)
-
Balanitis.
Secondary sexual characteristics
-
Gynaecomastia – excessive and/or persistent breast development
-
Indicators of delayed puberty, outlined in next section. The average onset of puberty is 12-13 years.
Delayed onset or poor progression of puberty
-
Indicators:
• Short stature compared to family
• Absent, slow or delayed genital development
• Anxiety, depression, school refusal and/or behaviour change.
-
These indicators might be accompanied by the following (and potential causes):
• Headache or changes to vision (CNS lesions)
• Inability to smell (Kallmann’s syndrome)
• Behavioural or learning difficulty (47,XXY)
• Unusual features (rare syndromes).
Investigations and treatment
-
Primary investigations:
• Growth chart in the context of mid-parental expectation (velocity, absolute height)
• Penile size (using a standard growth chart)
• Testicular volume (if >4 mL, puberty is likely imminent)
• Bone age.
-
Specific investigations:
• LH/FSH (these may be undetectable in early puberty but if they are elevated it may be informative).
• Total testosterone level (this rises with the onset of puberty).
• Karyotype (if there is suspicion of 47,XXY).
-
General investigations:
• U&E, FBE & ESR, coeliac screen, TFT.
-
Treatment and specialist referral:
• If all tests and assessments are normal for prepubertal age, observe for six months.
• Refer the patient to a paediatric endocrinologist if they are over 14.5 years without pubertal onset and/or they have a specific abnormality.
Klinefelter syndrome (47,XXY)
The way Klinefelter syndrome presents varies with age and is often subtle.
-
Signs to look for:
• Small testes (less than 4 mL from mid puberty)
• Behavioural and learning difficulties
• Gynaecomastia
• Poor pubertal progression.
-
Investigations (and findings in Klinefelter syndrome):
• Total testosterone level (androgen deficiency)
• LH/FSH level (both elevated)
• Karyotype.
-
Treatment and specialist referral:
• Refer the patient to a paediatric endocrinologist.
• Refer for educational and allied health assistance if needed.
See our clinical summary guide on Klinefelter syndrome for further information.
Testicular mass
Patients with testicular mass may present with a painless lump. It may be reported by the patient or discovered through an examination.
Check for a history of undescended testes, which can be a risk factor for cancer. The lump may also be an epididymal cyst.
-
Primary investigations:
• Testicular ultrasound.
-
Treatment and specialist referral:
• Refer the patient to a uro-oncologist
• Offer pre-treatment sperm cryostorage.
Refer to our clinical summary guide on testicular cancer for further information.
Penile abnormality
-
Abnormalities of the penis can present as:
• Hypospadias
• Micropenis
• Phimosis.
-
Treatment and specialist referral:
• Refer the patient to a urologist for investigation and a treatment plan.
• To investigate a micropenis, refer the patient to a paediatric endocrinologist.
Gynaecomastia
Gynaecomastia presents as excessive and/or persistent breast development. It appears in adolescence and is more prominent in patients who are overweight. It’s often normal and resolves over a couple of months.
There can be rare secondary causes. These include hypothalamic pituitary lesions and adrenal or testis lesions (resulting in oestrogen excess).
-
Treatment and specialist referral:
• If there is persistent or acute onset, refer the patient to a paediatric endocrinologist.
