Overview

When taking a history regarding the genitourinary system, many personal and potentially awkward questions need to be asked including regarding sexual activity. Care should be taken to ensure the privacy and comfort of assessing patients.

A helpful way to alleviate the awkwardness and avoid the patient feeling like they have been singled out or judged is by normalising questions and prefacing them with something such as “This is something we ask all patients”. This allows for sensitive and non-judgmental discussion of these topics and is likely to help get better answers from the patient.

History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Scrotal/groin pain

  • Use SOCRATEs to assess pain:
    • Site:
      • Where is the pain?
      • Is it unilateral or bilateral?
    • Onset:
      • Did it come on suddenly?
      • What were they doing at the time it started?
        • Was there any trauma?
        • Were they playing sports or any other vigorous activity?
    • Character:
      • What is the pain like? (e.g. sharp, stabbing, dull, burning, stinging etc.)
    • Radiation:
      • Does the pain spread anywhere?
    • Associated symptoms:
      • See review of systems below
    • Timeline:
      • Is it continuous or intermittent?
      • Is it getting better, worse, or staying the same?
    • Exacerbating/relieving symptoms:
      • Does anything make the pain better or worse?
        • Such as using pain relief or changing position
    • Severity/scale:
      • On a scale of 0-10, where would they put the pain?
      • Has it stopped them from being able to carry out their usual activities?
  • Are there any associated swellings or masses?
  • If appropriate, take a sexual history

Scrotal/groin swellings or masses

  • Onset:
    • When did the mass first appear?
  • Timeline:
    • Has it changed in size over time?
  • Character:
    • Is it painful?
    • Is it red and/or warm?
  • Reducibility:
    • Does it reduce (disappear) with lying down or certain positions?
    • Does any activity make it more prominent? (e.g. sneezing/straining)
  • Are there any associated symptoms?
    • See review of systems below

Review of systems

  • Screen for genitourinary symptoms:
    • Dysuria, urinary frequency, haematuria, nocturia?
    • Urethral discharge?
    • Problems with the urinary stream?
    • Urinary incontinence?
    • Abdominal, pelvic, or groin pain or discomfort?
    • Abdominal, pelvic, or groin lumps?
  • Screen for general features:

Past Medical History

Questions include:

  • Do they have any other medical conditions?
    • New back pain in someone with a history of prostate cancer can suggest bone metastases
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Have they been exposed to any chemicals at work?
    • Exposure to aromatic amines such as dyes and rubber manufacturing materials can increase the risk of bladder cancer
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?
    • Travelling to an area endemic to schistosomiasis can increase the risk of bladder cancer

Physical Examinations

Overview

Examine the scrotum and inguinal region in the person both standing up and lying down:

  • Examine any lumps and assess for:
    • Size
    • Location:
      • Where is it in relation to the pubic tubercle?
      • Is it separate from the testis?
    • Tenderness:
    • Consistency:
      • Firm and solid masses are more suggestive of malignancy
      • Soft and fluctuant masses may suggest cysts or hernias
    • Reducibility:
      • Can the hernia be reduced?
    • Cough impulse:
      • Does coughing make the lump more pronounced?
    • The ability to ‘get above’ (feel the upper border of) the lump:
      • It is not possible to ‘get above’ a hernia
  • Examine the scrotum and testes and assess for:
    • Testicular lie – high-riding or transverse suggests a testicular torsion
    • Tenderness – suggests torsion or infection
    • Any lumps as above
    • The cremasteric reflex – absent in testicular torsion
    • Prehn’s sign – positive if elevation of the testis alleviates pain:
      • This is positive in epididymo-orchitis and negative in testicular torsion
    • Skin changes – ulcers, nodules, or plaques may suggest scrotal cancer (rare)
    • ‘Blue dot sign’ – ischaemic torted testicular appendage seen through the skin
    • A ‘bag of worms’ – suggests varicocele

Other features should be assessed such as:

Referral and Investigations

Referral

If testicular torsion or a strangulated hernia is suspected, arrange immediate hospital admission.

If testicular cancer is suspected, refer urgently to urology via a suspected cancer pathway (for an appointment within 2 weeks). Do not arrange an ultrasound scan or wait for investigations. 

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

  • Blood tests:
    • Testicular cancer tumour markers:
      • Refer if testicular cancer is suspected clinically and do not wait for tumour marker results. They still may be done while referring include alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and lactate dehydrogenase (LDH)
  • Orifice tests:
    • Urine dipsticks and urinalysis:
    • Urine microscopy, sensitivity, and culture:
      • For infection
    • Sexually transmitted infection tests:
      • Such as urinary nucleic acid amplification testing (NAAT)
  • Special tests:
    • Ultrasound scan:
      • Performed if scrotal swelling is not acute and if any of the following apply:
        • Diagnostic uncertainty
        • Hydrocele is seen in someone aged 18-40 years old (may be a sign of testicular cancer)
        • Persistent and unexplained testicular symptoms
        • Difficult to distinguish if the swelling is testicular or extra-testicular
        • History of trauma
        • Chronic haematocele

Differential Diagnoses

Testicular torsion

  • A history may reveal:
    • Acute, severe testicular pain – may radiate to groin or lower abdomen
    • Associated nausea and vomiting
    • There may be a history of intermittent self-limiting similar episodes
  • A physical examination may reveal:
    • Prehn’s sign is negative
    • Cremasteric reflex may be sent
  • Arrange immediate hospital admission if suspected, and keep a low threshold of suspicion

Epididymo-orchitis

  • A history may reveal:
    • May present similarly to testicular torsion
    • Acute scrotal pain and or swelling
    • Fever, dysuria, urethral discharge
    • Parotitis may be present if mumps orchitis is present
  • A physical examination may reveal:
    • Prehn’s sign is positive
    • Cremasteric reflex is present
    • Epididymis and/or testis are tender and swollen
    • Scrotal erythema may be seen
  • Investigations may reveal:
    • Younger people (<35 years old) and sexually active:
      • Assess for STI (e.g. nucleic acid amplification testing, NAAT)
    • >35 years old and low-risk sexual history:
      • Send a mid-stream urine sample for microscopy and culture

Epididymal cyst/spermatocele

  • A history may reveal:
    • Gradual onset and painless, soft lumps
  • A physical examination may reveal:
    • Painless, fluctuant lumps that lie above and behind the testis
    • It is possible to ‘get above the lump’ on examination
    • May transilluminate
  • Investigations may reveal:
    • Ultrasound may be considered if diagnosis is uncertain

Testicular cancer

  • A history may reveal:
    • Aged 20-40 years old with a painless testicular lump
      • Sometimes there may be some discomfort or a ‘dragging’, aching, or ‘heavy’ sensation in the scrotum
  • A physical examination may reveal:
    • A discrete, solid, firm mass on the testis
    • There may be an associated hydrocele
    • There may be supraclavicular lymphadenopathy or retroperitoneal lymphadenopathy (manifests as an abdominal mass with enlarged para-aortic lymph nodes)
    • Gynaecomastia may be present
  • Investigations may reveal:
    • Ultrasound:
      • Identifies suspicious mass
    • Tumour markers (AFP, beta-hCG, LDH):
      • May be elevated

Hydrocele

  • A history may reveal:
    • May be a sudden or gradual painless lump
  • A physical examination may reveal:
    • Painless, soft, fluctuant swelling
    • Usually able to ‘get above’ the swelling on examination
    • Transilluminates
    • May increase with activities that increase intra-abdominal pressure (e.g. coughing)
    • May be associated with testicular cancer
  • Investigations may reveal:
    • Ultrasound may be considered if:
      • There is any diagnostic doubt
      • There is suspicion of an underlying cause
      • The underlying testis cannot be palpated
      • There is tenderness on palpation
      • Transillumination shows internal shadows

Varicocele

  • A history may reveal:
    • Gradual onset of a usually painless lump, although it can cause dull, ‘dragging’ or ‘heavy’ scrotal discomfort, often when standing
    • There may be a history of subfertility
  • A physical examination may reveal:
    • Dilated tortuous veins and a ‘bag of worms’ consistency
    • Usually disappears when lying down and is worse when standing, straining, or with activity
    • If it does not disappear when lying down or there is an isolated right-sided varicocele, renal cell carcinoma or another mass 
  • Investigations may reveal:
    • An urgent referral to a urologist should be made if:
      • Varicocele appears suddenly and is painful
      • The varicocele does not drain when lying down
      • There is an isolated right-sided varicocele
    • Ultrasound scan with colour flow Doppler imaging

Haematocele

  • A history and physical examination may reveal:
    • May be sudden or gradual and follows trauma
    • May transilluminate
  • Investigations:
    • If after acute trauma – arrange hospital admission
    • If atraumatic/chronic – arrange ultrasound and refer to urology

Inguinal hernia

  • A history may reveal:
    • >90% of people affected are men
    • Sudden or gradual onset of a groin lump
    • May be painful if strangulated
  • A physical examination may reveal:
    • A lump above and medial to the pubic tubercle
    • It is not possible to ‘get above’ the lump
    • May enlarge with increased intra-abdominal pressure (e.g. cough impulse)
    • May be non-reducible if incarcerated
    • May be tender, erythematous, warm if strangulated with possible associated nausea, vomiting, fever
  • Next steps:
    • If no strangulation – refer routinely for surgery, even if asymptomatic
    • If strangulation is present – arrange immediate hospital admission

Femoral hernia

  • A history may reveal:
    • More common in women, especially if they have increased intra-abdominal pressure such as obesity or pregnancy
    • May be acute or gradual and often painful
  • A physical examination may reveal:
    • A lump below and lateral to the pubic tubercle
    • Commonly non-reducible and incarcerated
    • Cough impulse often absent due to how narrow the femoral ring is
    • May be tender, erythematous, warm if strangulated with possible associated nausea, vomiting, fever
  • Next steps:
    • If no strangulation – refer for surgery, even if asymptomatic due to high risk of strangulation
    • If strangulation is present – arrange immediate hospital admission

Squamous cell carcinoma of the scrotum

  • A history and physical examination may reveal:
    • Very rare
    • Gradual onset of a skin papule, plaque, ulcer, nodule, or non-healing skin lesion
    • May be painless and associated with inguinal lymphadenopathy
  • Next steps:
    • Urgently refer to secondary care via a suspected cancer pathway

Author

  • Ishraq Choudhury

    FY1 doctor working in North West England.

    MB ChB with Honours (2024, University of Manchester).
    MSc Clinical Immunology with Merit (2023, University of Manchester).<br Also an A-Level Biology, Chemistry, Physics, and Maths tutor.
    Interests in Medical Education, Neurology, and Rheumatology.
    Also a musician (Spotify artist page).
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