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Examination of Inguinoscrotal and Scrotal Swelling
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a single testicular vein. On left side, it drains into left
renal vein; on the right side it drains into inferior vena
cava. Varicocele is common in tall, thin young men.
More common on the left side, but often can be bilateral.
Commonly it is idiopathic, may be due to absence
or incompetent valve at the junction of left testicular
vein and left renal vein causing inefficient drainage
of blood. Other reason is, due to perpendicular (right
angle) entry of the left testicular vein into the left renal
vein. In left sided renal cell carcinoma, tumour
proliferates into the left renal vein and blocks the entry
of left testicular vein causing varicocele on left side
which are irreducible. Varicocele causes increased
temperature in the scrotum which depresses the
spermatogenesis and so causes infertility ( correctable
infertility).
Types of varicocele: Primary/idiopathic– 95%: No
cause is found. There is incompetence of valves of
the testicular vein. It is common on left side as left
testicular vein joins left renal vein perpendicularly;
left side vein is longer and is liable to get compressed
by loaded sigmoid colon. Left renal vein is often
compressed between aorta and SMA. Secondary –
due to specific cause like left sided renal cell carcinoma
with a tumour thrombus in left renal vein causing
obstruction to venous flow of left testicular vein (Fig.
18.22).
441
A
Clinical features: Swelling in the root of the scrotum;
dragging pain in the groin and scrotum; ‘Bag of worms’
feeling; impulse on coughing (thrill feel); on lying
down it gets reduced slowly and spontaneously (except
in renal cell carcinoma). Bow sign: After holding the
varicocele between thumb and fingers, patient is asked
to bow. Varicocele gets reduced in size. Bowing reduces
the blood flow of testicular vein and pampiniform
plexus causing reduction in size.
Grading of varicocele: I–small; II–moderate; III–
large; IV - severely tortuous. Subfertility/infertility are
observed in even unilateral varicocele. It is a debate
whether it really causes subfertility. Possible causes
are – Altered heat exchange mechanism of the scrotum
due to varicocele → hyperthermia → inhibition of
spermatogenesis. Increased blood flow → increased
temperature in the testes → increases the metabolic
activity using glycogen storage → depletion of
glycogen → injury of parenchyma of testes →
B
Figs 18.22A and B: Left-sided varicocele
and also on table look.
oligospermia, hypoxia of testes. Same cause leads into
Leydig cell dysfunction; decreased testosterone levels.
Final effect is maturation arrest → poor spermatogenesis.
Investigations: Venous Doppler of the scrotum and
groin; US abdomen to look for kidney; Semen analysis.
Funiculitis
It is inflammation of the vas deferens. It is commonly
due to filariasis. It can be of gonococcal; tuberculous
aetiology. Filarial funiculitis presents as mild pain in
the inguinal canal and cord with fever; red, oedematous,
shiny skin. Often oedema is so severe that it should
be differentiated from strangulated inguinal hernia.
Palpation above the deep inguinal ring makes one to
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feel the hernial contents whereas in filariasis it is
normal. Tuberculous funiculitis is associated with
tuberculous epididymitis; having thickened, craggy,
beaded feel.
Filarial Epididymo-orchitis
Filarial inflammation begins in globus major making
it oedematous, firm, thickened and tender. Eventually
testis is involved and becomes tender. Secondary
hydrocele or chylocele develops.
Lymph Varix (Lymphangiectasis)
Here lymphatic vessels of the cord get dilated and
tortuous due to obstruction by filarial worm. Previous
periodic attacks of fever, pain, discomfort are obvious.
Presents as soft, cystic, boggy swelling in the inguinal/
inguinoscrotal region which has got thrill-like impulse
on coughing and gets reduced slowly and spontaneously on lying down. Groin lymph nodes may get
enlarged. Dancing filarial worm in US groin is
diagnostic. Lymph varix presenting as multiloculated
elongated cystic swelling in the cord is called as ‘diffuse
hydrocele of the cord’ .
Lymph Scrotum and Elephantiasis of Scrotum
It is dilatation and tortuosity of the cutaneous
lymphatics of the scrotum. Presents as excess rugosity;
vesicles in the scrotal skin which contains clear fluid;
often these vesicles may rupture causing lymphorrhagia. Secondary infection occurs; later slowly
fibrosis of skin takes place leading into elephantiasis
of the scrotum. Initial pitting oedema soon becomes
nonpitting, firm, thick skin progressing gradually
upwards. It contains lymph logged oedematous tissue
with hydrocele inside. Atrophy of testis due to lack
of nutrition is common (Fig. 18.23).
Orchitis
It is inflammation of the testis. It is commonly
associated with inflammation of the epididymis. Hence
it is called as epididymo-orchitis. Orchitis is due to
infection through blood, lymphatics or epididymis.
Causes: Viral infection—mumps; filarial disease;
leprosy; bacterial; brucellosis; infectious mononucleosis. It can be precipitated by retrograde spread due
Fig. 18.23: Scrotal elephantiasis—filarial cause.
to stricture urethra, after prostate or bladder surgery ,
after instrumentation. Syphilis involves testis—
causing formation of gummatous ulcer on the front
of the scrotum. Features: Pain in the testis often radiates
to groin due to associated funiculitis; Fever, tenderness
in the testis; Secondary hydrocele is common; Often
urinary infection is noticed.
Differential diagnosis: Torsion testis; Testicular
tumour. Syphilitic orchitis: Syphilis involves only
testis; never vas deferens. It can be—bilateral inter-
stitial orchitis seen in congenital syphilis (causing
pigeon-egg testes in infants; if infant becomes syphilitic
boy then he becomes lame (Clutton’s joints), deaf
(neurolabyrinthitis), blind (interstitial keratitis),
impotent (atrophy of testes); interstitial fibrosis is
bilateral causing gradual destruction of the seminiferous tubules with loss of testicular sensation without
any enlarged testis. T estis is dense, rounded hard and
mobile—‘billiard testis’; Gumma of testis is com-
monest type with unilateral painless slowly enlarged
hard testis with loss of testicular sensation. Testis is
adherent to anterior part of the scrotal skin leading
into softening and gummatous ulcer formation. Shotty
groin, epitrochlear and popliteal lymph nodes may
be palpable.
Examination of Inguinoscrotal and Scrotal Swelling
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Epididymitis
Inflammation of epididymis is commonly associated
with orchitis—epididymo-orchitis. Causes: Non-
specific, viral like mumps; bacterial; filarial; tuberculosis (It involves mainly epididymis not testis and so
ulcer/sinus occurs over the posterior aspect of the
scrotum not in front); gonococcal; schistosomiasis. It
can be acute or subacute or chronic. Acute when it
occurs from retrograde spread involves globus minor
first later entire epididymis and testis. Severe pain ,
oedema scrotum, thickened tender epididymis, secondary hydrocele are common (Fig. 18.24). There may
be associated prostatitis, urethritis, and cystitis also.
Blood born infection involves globus major first.
Retrograde spread can occur after prostatectomy,
catheterisation, and cystitis.
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firm nodular epididymis is common. Cold abscess,
sinus or undermined ulcer may be present on the
posterior aspect of the scrotum. Lesion will be on the
anterior aspect in anteverted testis. Scrotal skin looses
its normal rugosity with wasting of the tissue under
the skin. There is restricted mobility (upward and
downward) of testis. Thickened beaded vas (due to
tubercles) is typical. Secondary hydrocele develops
in 30% cases. 60% will be having renal tuberculosis.
Digital examination of rectum (P/R) shows tender
thickened palpable seminal vesicles and irregular
prostate. Pulmonary tuberculosis is evident in 50%
of cases.
Diffuse Lipoma of the Cord
It is a rare soft lobulated diffuse lipoma of the cord
involving inguinal portion. It does not show any
impulse on coughing.
Undescended Testis
It results from arrest of descent of the testis in some
parts of its path to the scrotum. Bilateral undescended
testis is called cryptorchidism (means hidden testis).
Anorchism: There is complete agenesis of testis. These
two can be differentiated by HCG test.
Fig. 18.24: Epididymo-orchitis with
hydrocele on table.
Tuberculous epididymitis: It is commonly due to
retrograde spread from tuberculous cystitis. It involves
globus minor (tail) first and later entire epididymis
and testis in very late cases. Blood spread from lungs
directly involves globus major first. Thickened, craggy ,
Embryology
Normally kidney ascends, testis descends during
development. Primitive testis develops from the genital
fold which is attached to the posterior abdominal wall
by mesorchium. It lies below the developing kidneys.
Wolffian duct develops into epididymis and vas
deferens. A fold of peritoneum develops at the junction
of vas deferens and epididymis which can be traced
down upto the developing phallus (scrotum) and is
called as gubernaculum. Along with some hormonal
factors, the muscular fibres in the gubernaculum assist
in the descent of testis. During 9th month of gestation
testis reaches deep inguinal ring. Later just before or
after delivery it descends into the scrotum.
Incidence
In premature infants - 30%. In full term infants - 4%.
In later childhood - 2%. Right testis is involved more
commonly in 50% cases, left alone in 30% cases,
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bilateral in 20% cases. It is due to gubernacular dysfunction, lack of HCG , Prune Belly syndrome, familial.
Pathology: Up to the age of six, microscopic changes
are uncommon. After that, testis gradually atrophies,
reduces its external as well as internal secretory activity.
Eventually grossly immature epithelial elements with
irreversible destructive changes of the germinal
epithelium occur.
Different location of testis: In the abdomen just above
the internal ring, extraperitoneally; in the inguinal
canal; in the superficial inguinal pouch. Bilateral
undescended testes which are clinically impalpable
is called as cryptorchidism. Scrotum is not fully
developed and testis cannot be brought down manually
to the bottom of the scrotum in undescended testis.
Retractile testis.
Complications of undescended testis: Sterility;
trauma and pain; an associated indirect inguinal hernia
(70%); torsion testis; epididymo-orchitis (as the pain
will be high up, it mimics acute appendicitis); testicular
atrophy; Malignant transformation in undescended
testis is 20 times more common than in normally
descended testis. It is higher in abdominal than in
inguinally located testis. Seminoma is the commonest
malignancy in undescended testis. The testis which
has normally descended on other side (in case of
unilateral undescended testis) is also more prone for
malignant transformation than normal individual.
US abdomen and groin; gonadal venogram and
laparoscopy are diagnostic methods available (Figs
18.25A to C).
A
B
Note: Undescended testis is a terminology which is
commonly used in general but by proper definition
correct terminology is different. But students should
use undescended testis as the required terminology.
Any problem in the mode of descent of testis is called
as imperfectly descended testis. Maldescended
testis is the testis that cannot be made to touch the
bottom of the scrotum. A true undescended testis is
the one which has not moved from its origin just below
the kidney and such situation is extremely rare.
Cryptorchidism in a male is a situation where both
C
Figs 18.25A to C: (A) Undescended testis—bilateral;
(B) Unilateral; (C) Laparoscopic view of undescended testis.
Examination of Inguinoscrotal and Scrotal Swelling
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testes are hidden and impalpable, probably above the
level of deep inguinal ring in the retroperitoneum.
Maldescended testis includes either undescended testis
or ectopic testis.
Ectopic Testis
Lockwood Theory
Eventhough there are multiple gubernaculum, scrotal
tail normally gets activated better and stronger and
so testis is brought down to the scrotum. In ectopic
testis scrotal tail weakens or ruptures and so one of
the other accessory tails will act stronger and pulls
the testis according to their site.
Different Sites
(1) Superficial inguinal pouch (commonest site); (2)
Perineum; (3) Root of the penis; (4) Femoral triangle
(Thigh). Here testis is functioning normally and of
normal size. It is more prone for trauma and can cause
psychological problem. Scrotum is not properly
developed.
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Fig. 18.26: Orr chair test.
Retractile Testis
It is due to the strong overaction of cremaster, as a
result testis is pulled up, to stay near the external ring
and often mistaken for undescended testis. Here testis
is normally developed, can be pulled down to the
bottom of the scrotum properly. Scrotum is also fully
developed. Child is made to sit on a chair with feet
kept on the chair; knees fully flexed and brought over
to chest wall; causing pressure on the inguinal canal
downwards pushing retractile testis down into the
scrotum – Orr chair test (Fig. 18.26).
Torsion of the Testis
It is an emergency condition of the testis, wherein
the testis twists (rotates) in its axis compromising its
blood supply. If not intervened and rectified within
12-24 hours, testis will become gangrenous. Right testis
rotates in clockwise direction whereas left rotates in
anticlockwise (Fig. 18.27).
Predisposing factors: (1) Inversion of the testis.
(2) High investment of the tunica vaginalis which acts
like a mesentery through which testis rotates. Here
testis hangs like a clapper in bell. (3) Presence of
Fig. 18.27: Right testis torsion occurs towards right
side (clockwise); left towards anticlockwise (left)
gap between the body of the testis and epididymis
as a result of which testis twists over epididymis.
(4) Heavy straining often precipitates torsion due to
vigorous contraction of the cremaster which is attached
spirally.
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Clinical features: It occurs in children and adolescents. It presents with sudden onset of pain in the
scrotum, groin and lower abdomen. Vomiting due to
pylorospasm is common. Tenderness, redness, and
oedema of the scrotal skin (Figs 18.28A to C). Torsion
occurring in an imperfectly descended testis is
impossible to differentiate it from strangulated hernia.
Absence of testis in the scrotum may give a clue.
Deming’s sign: Affected testis is positioned high
because of twisting of cord and spasm of cremaster
muscle.
Angell’ s sign: Opposite testis lies horizontally because
of the mesorchium between testis and epididymis and
is usually bilateral.
Differential diagnosis: (1) Acute epididymo-orchitiselevation of the scrotum relieves the pain of acute
epididymo-orchitis but aggravates in case of torsion
testis (Prehn’ s sign). (2) Strangulated inguinal hernia.
(3) Other structure in scrotum which can undergo
torsion is ‘Appendage of testis’. If the patient is able
to walk to clinician with feature of torsion then this
condition has to be thought of whereas in torsion testis
the pain is so severe that the clinician is summoned
to the patient’s bed. Secondary hydrocele of the torsion
testis is serosanguinous.
A
Testicular Tumours
It accounts for 1% of all malignant tumours; 99%
of testicular tumours are malignant.
Predisposing factors: Undescended testis, Klinefelter’s syndrome and testicular atrophy.
Classification: (1) Seminoma - 40%. (2) Teratoma32%. (3) Seminoma + teratoma - 14%. (4) Interstitial
tumours-1.5% (Leydig cell tumour (musculinises;
Sertoli cell tumour feminises). (5) Lymphomas - 7%.
(6) Others.
Histological classification: (1) Germ cell tumour –
Seminomatous: classic/spermatocytic/anaplastic.
Non-seminomatous: embryonal carcinoma/teratoma/
choriocarcinoma/yolk sac tumour. (2) Sex cord
tumours: Leydig cell tumour; Sertoli cell tumour.
(3) Combined germ cell and gonadal stromal tumour.
(4) Adnexal and paratesticular tumour. (5) Others –
Carcinoids, lymphomas, secondaries.
B
C
Figs 18.28A to C: Typical torsion testis which is
elevated with redness and adherent skin.
Examination of Inguinoscrotal and Scrotal Swelling
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Seminoma testis: It starts in the mediastinum of the
testis. Grossly it is lobulated, fleshy, homogenous,
creamy or pinkish in colour and it compresses adjacent
testicular tissues. Histologically, malignant cells
resemble spermatocytes which are clear cells, with
lymphocytic infiltration. It spreads through testicular
lymphatics into the para-aortic lymph nodes and then
to left supraclavicular lymph node. Through blood,
it spreads to lungs, bone, brain, liver. Seminoma is
further classified as typical (classic) which is
commonest; spermatocytic (in old age); anaplastic;
atypical.
Teratoma: It arises from totipotent cells, i.e. ecto,
meso, endoderms. Grossly tumour surface is irregular,
cut section shows solid and cystic spaces with areas
of haemorrhage. It often contains gelatinous fluid and
cartilaginous nodules (Fig. 18.29). Histologically there
are four types: (1) Teratoma differentiated – (1%);
(2) Teratoma intermediate - 30% common - Two sub-
types are A and B (more malignant); (3) Teratoma
anaplastic – 15% - secretes alpha feto protein (AFP);
(4) Teratoma tr ophoblastic - 1% - It shows high levels
of βHCG (normal level is 100 IU).
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Sertoli cell tumour (1%) feminises; Post-pubertal
tumour commonly arising from sertoli cells causes
feminising effect with gynaecomastia, loss of libido
and aspermia.
Clinical features: Enlargement of testis; fullness and
heaviness in the scrotum; pain in the testis (30%);
testis will be enlarged, firm, heavy, with loss of
testicular sensation; secondary hydrocele is common.
Cremaster is hypertrophied and thickened. Vas,
prostate and seminal vesicles are normal. It can spread
to cord tissues making it nodular and hard. Often in
epigastric region para-aortic lymph nodes may be
palpable as hard, nodular, nontender, nonmobile,
vertically placed, resonant mass (not moving with
respiration). There may be haemoptysis, altered
breath sounds and pleural effusion due to lung
secondaries; Bone pain and tenderness due to
secondaries in bone; Nodular secondaries in the liver.
Occasionally it may mimic acute epididymo-orchitis
or acute haematocele. Gynaecomastia may be present
in few teratomas.
Hurricane type is very aggressive, highly malignant
testicular tumour which is more often fatal in few
weeks. Rarely, if tumour comes out of the tunica
albuginea (tunica albuginea is resistant for malignant
cell infiltration), then scrotum gets infiltrated and
spread can occur to inguinal lymph nodes.
Fig. 18.29: Testicular teratoma fungating
through the skin.
Interstitial Cell Tumour
Leydig cell tumour (2%) musculinises; Prepubertal
tumour shows excessive output of androgens causing
sexual precocity , extreme muscular development and
may mimic infant hercules.
Differential diagnosis: Acute and chronic haematocele; acute epididymoorchitis; syphilitic orchitis; Lepra
orchitis.
Sign of vas: To differentiate tumour from infection
- in testicular tumours vas is normal, cord structures
may become bulky because of cremasteric hypertrophy
whereas in infection vas is thickened, beaded, and
tender.
Investigations: No FNAC; No scrotal approach; No
incision biopsy. Through inguinal approach, cord and
testis are exposed. A soft clamp is applied to the cord
at or above the level of the deep ring so has to prevent
dissemination through blood. Frozen section biopsy
is done from the suspected area. If tumour is positive
high orchidectomy is done (Chevassou manoeuvre).
Tumour markers βHCG , AFP are increased in teratoma;
Chest X-ray, CT chest; US abdomen; US scrotum to
see echogenicity of testis and tumour within.
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Staging of testicular tumours:
Lesion confined to testis
Nodes involved below the diaphragm
Nodes involved above the diaphragm
Distant (blood) spread
TNM staging
T
No evidence of tumour
0
Tis Carcinoma in situ
T
Tumour limited to testis and epididymis. Vascular/
1
lymphatic invasion not present. Tumour may invade
tunica albuginea but not tunica vaginalis
Tumour limited to testis and epididymis with
T
2
vascular/ lymphatic invasion. Or tumour extends
through the tunica albuginea with involvement of
tunica vaginalis
T
Tumour invades to spermatic cord with or without
3
vascular / lymphatic invasion
T
Tumour invades to scrotum with or without vascular/
4
lymphatic invasion
Regional nodes not involved
N
0
N
Single / multiple nodes – not more than 2 cm in
1
size
N
Regional nodes – between 2-5 cm
2
Regional nodes > 5 cm
N
3
SRB’s Clinical Surgery
Extravasation of the Urine
It may be superficial or deep.
Superficial
It is either due to bulbar urethral injury or due to bursting
of periurethral abscess after urethral stricture. Once
urine extravasates due to disruption of full thickness
of the urethra anteriorly, it collects in superficial
perineal space. This space is a closed cavity all around
except anteriorly where it communicates with scrotal
subcutaneous tissue deep to fascia Colles, penis
between superficial fascia and deeper Buck’s fascia,
in the anterior abdominal wall deep to Scarpa’a fascia.
It does not spread to thigh and ischiorectal space as
Fig. 18.30: Superficial extravasation of urine.
Scarpa’s fascia is attached firmly to fascia lata of thigh.
Superficial perineal space is closed above by inferior
fascia of perineal membrane; below by fascia of Colles;
laterally by ischiopubic rami. It is open and communicating only anteriorly . Entire scrotum, penis and often
lower abdominal wall are swollen containing urine.
It is painful; patient cannot pass urine through urethra;
Has severe pain and shock due to pelvic injury . Often
sepsis occurs and skin sloughs of leading into urinary
fistulas.
Deep
Urine spreads upwards into the extraperitoneal space
of the pelvis around the bladder and prostate into the
anterior abdominal wall causing deep extravasation
of the urine. Here rupture of urethra is at membranous
part of the urethra much more proximal than superficial
type (Fig. 18.30).
Examination of Male External Genitalia
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Examination of
Male External
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19
Genitalia
History
Phimosis, hypospadias are seen in infants and children.
Carcinoma of penis is seen in adult and old age.
Muslims and Jews undergo early circumcision and
so they are immune from developing carcinoma penis.
Inability to retract foreskin in a child as history
given by mother or ballooning of the prepuce during
urination or visible pinhole meatus are common.
Pinhole meatus may be congenital commonly or
acquired due to balanoposthitis or meatal ulcer.
History of paraphimosis – Inability to place back the
retracted prepuce. It may be precipitated in a patient
with mild phimosis by act of intercourse. Paraphimosis
may be painful.
History of ulcer in the penis should be asked in detail.
Its location, duration, progress, pain, discharge,
bleeding, urinary symptoms, change in the stream of
urine are important. Chancroid is due to Haemophillus
ducreyi (soft sore) develops in 4 days after exposure
as a painful, tender ulcer. Syphilitic Hunterian hard
chancre appears 4 weeks after exposure. Small painless
ulcer often disappears unnoticed in lymphogranuloma
venereum (LGV). Painless vesicle or papule later
forms a granulomatous ulcer in granuloma inguinale
(Donovan ulcer, lymph nodes are involved). Progressive painless ulcer may be carcinomatous ulcer.
History of discharge, its duration, site of discharge,
foul smelling or not should be asked.
History of sexual contacts is very important in all these
ulcers.
History of pain may be in the glans, in the ulcer, in
the urethra, during micturition (urethritis, stone,
prostatitis) or may be independent of act of micturition
(herpes, carcinoma, balanoposthitis, etc).
History of fever may be due to infection.
History of swelling in the groin should be noted.
Carcinoma of penis can spread into the inguinal lymph
nodes causing secondaries. Lymph nodes also can be
involved in syphilis, lymphogranuloma inguinale.
Often there will be pain, suppuration, ulceration or
fungation in the groin which should be asked in detail
in history.
General Examination
Anaemia, clubbing, jaundice, nutrition should be
assessed. Pulse, blood pressure should be recorded.
Local Examination
Inspection
Inspection of prepuce:
Phimosis, paraphimosis should be looked for by
holding the penis properly using a gloved hand.
Prepuceal swelling or oedema should be observed.
Pinhole meatus/ulcer over the prepuce should be
observed. If ulcer is present, its size, shape, edge, floor,
discharge, number should be noted. Raised everted
edge is a feature of carcinoma. Features of different
premalignant conditions like—leukoplakia, Paget’s
disease of glans/inside the prepuce, Erythroplasia of
Querat which is a red flat area in glans or inner aspect
of the prepuce should be looked for. Multiple warty
like projections may be condyloma acuminata.
V enereal warts are moist with foul smelling discharge.
Posthitis (inflammation of prepuce) or balanoposthitis
(inflammation of prepuce along with glans) with
discharge is obvious on inspection. Ballooning of
prepuce while micturition is obvious on inspection.
Altered urinary stream occurs in carcinoma penis which
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Fig. 19.1: Pinhole meatus causing phimosis. Ballooning
of prepuce is common.
Fig. 19.2: Paraphimosis after passing urinary catheter. After
passing urinary catheter, prepuce should be placed
backwards otherwise paraphimosis will develop.
is close to the meatus or rarely involving the urethra
(Figs 19.1 to 19.3).
Urethra should be examined for congenital
anomaly. If urethral meatus opens more proximally
along the ventral aspect, it is called as hypospadias.
If it opens proximally over the dorsal aspect it is called
as epispadias. Based on position it is categorised as
glandular (glans); coronal; penile; perineal with bifid
scrotum. Urethral meatus may not be visible in
carcinoma of the glans which is close to the meatus.
The body of penis is inspected for ulcer, swelling,
etc. Urethral papilloma from fossa navicularis may
protrude from external urethral meatus causing
Fig. 19.3: Erythroplasia of Querat. It is a premalignant
lesion.
Fig. 19.4: Hypospadias.
haematuria and pain. Often urethral stone exuding just
at the external meatus may be observed (Figs 19.4
and 19.5).
The groin is inspected for visible swelling as
enlarged lymph nodes (Fig. 19.6).
Palpation
Palpation should be done by wearing gloves.
One should look for tenderness, and warmness,
palpate the ulcer edge and base is palpated for
induration, extent of induration, whether bleeds on
touch. Prepuce may not be retracted back when there
is carcinoma under prepuce. Careful feeling of the
prepuce and glans together will appreciate the indurated swelling under the prepuce. Such patient might
require circumcision or dorsal slit to visualise the
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