Specifics of the Male Fertility Physical Exam
Some couples may prefer to leave the details of the exam to their health care provider. However, for those couples interested in a more in-depth discussion of the various aspects of the physical exam, this section can serve as a guide to what the doctor is looking for on the evaluation.
Two Testicles, One on Each Side
It is important to make sure that a testicle can be felt on each side. If a testicle is not palpable, then a reason for this should be found. Reasons may include a history of an undescended testicle that was not repaired, retractile testicles, neonatal testicular torsion, or surgical removal of a testicle.
Size and Consistency of the Testicle
Ninety-five percent of the volume of the testicles is made up by the cells that produce sperm. Therefore, a normal-size testicle is often a sign that sperm production is not severely impaired. (However, this is not always the case; see, for example, Maturation Arrest in the "Azoospermia" section of this website.
Small, firm testicles often indicate a problem with sperm production that occurred before the onset of puberty (such as Klinefelter’s disease). Small, soft testicles are typically more consistent with sperm production problems that developed after puberty.
Testicular volume can be measured in one of several ways. One is to measure the testicles’ dimensions—length, width, and height—and plug those into a formula:
Volume = 4/3π × (length/2) × (width/2) × (height/2)
Calipers can also be used to approximate the dimensions, although estimates can vary somewhat depending on how tightly the physician stretches the scrotal skin over the testicle as the measurements are taken.
Normal testicular dimensions are:
1) Length: 3–5 cm
2) Width: 2–4 cm
3) Height: 3 cm
Normal testicular volume is about 20 cm cubed, with a range of 15 to 25 cm cubed. (The units you see on a report may vary, but cubic centimeters, which are abbreviated as cm3 or cc, are the same as milliliters, which are abbreviated mL: 1 cm cubed = 1 cc = 1 mL.)
It is far easier to estimate the testicular volume using an orchidometer, which is a series of plastic beads of different sizes looped together on a string. Each bead is labeled with its volume in cubic centimeters or milliliters. The beads are held up alongside the scrotum during the physical exam to get an estimation of the testicular volume. As with the use of calipers, there is some subjectivity involved in measurement with an orchidometer, depending on how tightly the physician stretches the scrotal skin over the testicle while making the measurement. Normal testicular volumes generally range from 12 cc to 20 cc.
The most accurate way to measure testicular volume is with ultrasound. However, ultrasound testing can cost several hundred dollars, and most fertility patients do not need their testicular volume determined this accurately. In some circumstances, such as adolescents who have varicoceles, testicular volumes are followed over time to see if treatment is needed for the testicles to develop properly, and using ultrasound to track testicular volumes precisely over time makes sense with these patients. However, in the majority of adult male fertility patients, an approximate estimation of testicular volume is all that’s needed.
Testicular cancer occurs in higher rates in men with fertility problems. An abnormal testicular mass found on examination should be evaluated further with ultrasound.
Scrotal Skin Abnormalities
Genital warts (caused by the human papillomavirus, or HPV) are a fairly common form of sexually transmitted disease. Certain types of HPV have been associated with an increased risk of penile cancer in men and cervical cancer in women. If genital warts are found, they should be treated by ablative therapy (such as topical creams, laser ablation, etc.). These treatments do not permanently cure the man of HPV, but they can remove visible lesions and decrease (although not eliminate) the risk of spread to sexual partners. Female partners should have regular Pap smears with their gynecologist to look for abnormal cervical changes that might need further evaluation and treatment.
Present in Full on Both Sides
The epididymis, the structure on the side of the testicles in which the sperm mature, has three parts: the head, body, and tail. In congenital bilateral absence of the vas deferens, the body and tail of the epididymis can be missing, resulting in obstruction.
Cysts of the epididymis are quite common. In men of reproductive age, these cysts are usually relatively small and asymptomatic. On rare occasions, epididymal cysts can be associated with chronic discomfort in the scrotum. Occasionally they can also grow to be very large (grapefruit size or larger) and make sitting uncomfortable. By themselves, epididymal cysts generally do not cause fertility problems unless they are very large. However, surgical removal of these cysts can cause epididymal scarring, which can lead to obstruction problems.
Tumors of the epididymis are rare, and the majority that are found are benign, not cancerous. Therefore, when an asymptomatic mass that is clearly coming from the epididymis (not the testicle) is discovered, it is usually a cyst, and generally these do not need to be imaged by ultrasound. All men of reproductive age should do regular scrotal exams every few months in the shower. If any significant changes are noted with an epididymal mass over time, such as an increase in size, then ultrasound imaging is recommended. Also, if there is significant pain associated with an epididymal mass, then an ultrasound should also be performed.
Fullness or Congestion
A skilled health care professional should be able to determine if the epididymis feels swollen or congested. This can be consistent with a blockage of sperm transport, with sperm backing up into the epididymis and causing congestion. Congenital epididymal obstruction and previous vasectomy are two potential causes of this finding . Epididymal swelling can also be due to inflammation or infection within the epididymis.
The nerve supply for the testicle enters around the area of the head of the epididymis. Due to its rich nerve supply, the epididymis is often somewhat tender to the touch during a physical exam. However, extra tenderness can also be due to inflammation within the epididymis itself (epididymitis).
The spermatic cord contains the blood supply, nerves, and lymphatic drainage for the testicles. It also contains the vas deferens, which is a tube-like structure that carries the sperm to the ejaculatory ducts. In patients with congenital bilateral absence of the vas deferens (CBAVD), the vas deferens is typically missing on both sides. A vas deferens that is not palpable on only one side can either represent an atypical variant of CBAVD or be part of a mesonephric duct abnormality, affecting also the kidney and ureter on that side (see the "Genetics" section of this website for more information on CBAVD).
Dilated veins in the scrotum are called varicoceles; they are similar to varicose veins in the legs. Small varicoceles are not clinically significant, but larger varicoceles can have a negative impact on sperm production and quality. Most varicoceles can be diagnosed by examining the man while he is standing. When a man with a varicocele increases his intra-abdominal pressure (by performing what is called a Valsalva maneuver—it’s usually done by closing your mouth and pinching your nose shut, then trying to exhale), the doctor can usually feel what’s called an impulse within the dilated veins.
Varicoceles are classified on the following scale:
Subclinical: the varicocele can be seen on ultrasound but not felt on physical exam.
Grade 1: An impulse can be felt on Valsalva maneuver, but the veins do not feel dilated in size
Grade 2: Scrotal veins feel dilated on examination, and an impulse is felt on Valsalva maneuver.
Grade 3: Scrotal veins are enlarged to the point where they can be seen through the scrotal skin
with just a visual inspection. These dilated veins typically are described as feeling like a
“bag of worms” on physical examination.
Subclinical and Grade 1 varicoceles are typically not considered clinically significant, whereas Grades 2 and 3 varicoceles are potentially a cause of decreased semen parameters.
Sometimes a physical exam reveals a varicocele that is borderline in size. In other circumstances, a good evaluation of the veins cannot be obtained, either because of extreme obesity or because the patient experiences sensitivity or discomfort with deep palpation in the scrotal area. In these situations, a scrotal ultrasound can be performed, measuring the diameter of the largest scrotal veins while the man is in a standing position. Veins that are larger than 3.5 mm in size are considered potentially clinically significant. See the “Varicoceles” section this website for more information.
Normal Size and Location of Meatus
The meatus (opening) of the penis is typically located at the tip of the penile head. However, in men with hypospadias or epispadias, the location of the meatus can be elsewhere on the penis, or even in the perineal region (the area of skin between the penis and scrotum). If the meatus is located near the head of the penis, then there is unlikely to be any significant impact on fertility. However, if the meatus is not near the head of the penis, then during intercourse the sperm are likely not being deposited near the woman’s cervix, which can have a significant impact on the ability to establish a pregnancy naturally. This problem can often be overcome by collecting the sperm during ejaculation and using it in conjunction with intrauterine insemination (see "Female Fertility Treatments" section for more information on inseminations).
Presence or Absence of Discharge
A discharge of fluid from the opening of the penis can be a sign of infection within the urethra or genital duct system.
Presence or Absence of Skin Abnormalities
As with the scrotum, genital warts, caused by HPV, are relatively common. See the “Scrotal Skin Abnormalities” section above for more information on genital warts.