Physical examination

The scope of the examination depends on the man’s complaints. In most cases, the entire pelvic area is examined: penis, testicles, and prostate. If relevant complaints are present, the breast tissue is also inspected and palpated.

The examination effectively begins when the patient enters the office. Observations are made of movement, posture, body composition, skin condition, mood, and other general indicators.

Examination of the penis

• Observe the general development of the penis.
• Assess the mobility of the foreskin.
• Look for signs of inflammation on the glans, foreskin, and penile skin.
• Examine the location and characteristics of the urethral opening.
• Check for signs of urethral inflammation.
• If the patient reports pain or nodules within the penis, the internal penile structures should be palpated more thoroughly.

Scrotum and testicles examination

• Begin by assessing the external surface of the scrotum, then evaluate the position of the testicles within the scrotum.
• Inspect and palpate the testicles for size and asymmetry.
• At the same time, palpate the epididymis to assess its position, consistency, size, and any abnormalities.
• It is very important to evaluate the testicular consistency and check for hardening or nodules in the testicles or associated structures.
• Palpate over and behind the testicles to detect varicoceles.
• Examine the vas deferens for structural abnormalities.
• If there is suspicion, palpate the inguinal canal to check for enlarged lymph nodes or inguinal hernias.

The most important parameter is testicular volume. A normal testicular volume is considered to be 20 ml or more per testicle, giving a total volume of 40 ml or more for both testicles.

Borderline values, which may be associated with testicular diseases or fertility issues, are:

• Single testicle volume: 15–19 ml
• Total volume of both testicles: 30–39 ml

If the testicular volume is below 15 ml per testicle, and the total volume is below 30 ml, this usually indicates a significant health risk and is highly likely to be associated with reduced fertility.

Prostate examination

The prostate can be palpated either through the perineum (the area between the scrotum and the anus) or digitally via the rectum. The latter method is more accurate, as a larger portion of the prostate surface is accessible.

During the examination, the doctor inserts a finger into the patient’s rectum and palpates the posterior wall of the prostate to assess its size, shape, and consistency. The procedure usually lasts only a few seconds and is slightly uncomfortable. However, in cases of prostatitis, palpation of the prostate may be mildly painful.

Breast (mammary gland) examination

• Begin with visual inspection.
• Then palpate the breast tissue to check for the presence of glandular tissue and any other lumps.

Hairline changes

• In male-pattern baldness, the hairline recedes at the temples and hair thins at the crown of the scalp.
• These areas of the scalp are most affected by hormones.

Instrumental examinations

The choice of instrumental tests depends on the man’s complaints and the findings of initial examinations.

Body composition analysis

• The purpose of this test is to assess the man’s body composition and its relationship to potential complaints and internal bodily regulation, particularly hormone levels.
• To perform the test, the patient is asked to remove outer clothing, shoes, and socks.
• The examination is conducted using the impedance method and causes no discomfort

Testicular ultrasound

• The primary purpose of this examination is to clarify any abnormalities suspected during the physical examination.
• The ultrasound is performed on the surface of the scrotum and is not uncomfortable.

Transrectal ultrasound of the prostate and seminal vesicles

• This examination is performed when precise information about prostate size is needed for treatment planning or when a prostate tumor is suspected.
• It is also useful for diagnosing prostatitis, assessing the extent of prostate damage, and ruling out certain causes of male infertility.
• During the procedure, a plastic probe is inserted into the rectum, allowing a detailed view of the internal structures of the prostate and seminal vesicles.
• If a prostate tumor is suspected, this examination can be combined with small tissue biopsies from the prostate (see the next subsection).

Transrectal ultrasound with prostate biopsy

• This procedure is performed like a standard transrectal ultrasound, but during the examination, 10 to 12 (or sometimes more) small tissue samples are taken from the prostate using a thin needle through the rectal wall.
• Biopsy sampling may be slightly uncomfortable.
• Occasionally, it can cause minor rectal bleeding for a few days afterward.

Laboratory analyses

First-void urine

• The first-void urine must include the initial drops of urine.
• It is recommended to collect the sample in the morning from the first urine of the day.
• Alternatively, it can be collected later in the day, provided the patient has not urinated for at least 3–4 hours.
• This sample allows for assessment of urethral inflammation and evaluation of the risk of sexually transmitted infections.

Midstream urine

• Analysis of midstream urine allows indirect assessment of kidney function as well as the presence of inflammation and microorganisms in the bladder and kidneys.

Prostate secretion analysis

• The diagnosis of prostatitis relies solely on the analysis of material obtained from the prostate.
• Worldwide, the two- or three-glass test is most commonly used.
  • Two-glass test: The man first collects a small amount of midstream urine, after which part of the urine remains in the bladder. Then, prostate-specific material is collected by digital massage of the prostate, slightly more firm and prolonged than during a standard prostate exam, to express prostatic secretions into the urethra.
  • For analysis, both secretions exiting the urethra and first-void urine collected after prostate massage, or a mixture of both, can be used.
  • Three-glass test: In addition to the above, first-void morning urine is also analyzed.

Semen analysis

• Semen analysis is primarily used to assess male fertility, but it is also suitable for diagnosing genital tract infections and monitoring treatment effectiveness.
• It should be noted that semen analysis often underestimates both the presence and activity of prostatitis.
• Conversely, there are cases where patients have symptoms typical of prostatitis, but no inflammation is detected in the prostate, while inflammation is present in adjacent organs, such as the seminal vesicles.
• Inflammation of the seminal vesicles can be diagnosed only through semen analysis.

PSA test

• Prostate-specific antigen (PSA) is a substance produced exclusively by prostate tissue and plays an important role in creating a suitable environment for sperm in the seminal fluid.
• A portion of PSA enters the bloodstream, where it can be measured.
• In a healthy prostate, PSA levels in the blood are related to prostate size; as the prostate enlarges, PSA levels gradually increase.
• The PSA test is particularly valuable because prostate cancer cells release several times more PSA into the blood than normal prostate tissue.
• Certain types of prostatitis can also cause elevated PSA levels in the blood.
• Despite some criticism in recent years, the PSA test remains the best available tumor marker, used both for early detection of prostate cancer and for monitoring the course of prostate diseases after treatment.

In essence, PSA is still a test for prostate diseases.

• Any PSA value above the age-specific average is associated with a prostate condition, which may be:
  • Prostatitis (inflammation of the prostate),
  • Benign prostatic enlargement, or
  • Prostate cancer.

Hormone testing

Hormone tests are used to analyze the body’s internal regulation.

Male-specific hormone tests can be divided into two main groups:
First group includes FSH (follicle-stimulating hormone) and LH (luteinizing hormone), which reflect testicular function control and stimulation from the brain.

1. FSH stimulates Sertoli cells, which are responsible for sperm production.
2. LH stimulates Leydig cells, which produce male sex hormones.

Higher-than-normal levels of FSH or LH indicate damage to one or both of the primary testicular functions.

The second group of male hormone tests includes testosterone and SHBG (sex hormone–binding globulin) measurements, which together provide the level of free, bioavailable testosterone. Measuring total testosterone alone may not always give sufficient or accurate information.

• Additional tests may be ordered based on clinical indications:
  • Estradiol – important in evaluating breast changes.
  • DHEAS – part of the male-pattern baldness evaluation.
  • Prolactin – useful when investigating causes of low testosterone.
• In some cases, thyroid hormone tests may also be necessary.

Panel of biochemical analyses

• This panel is used to assess overall male health and associated risks.
• In addition to general health risks, tests reflecting liver function help evaluate the impact of alcohol consumption or overweight on a man’s health.

Sexually transmitted infection (STI) tests

• These tests are necessary to identify causes of urethritis and, occasionally, orchitis.
• STI testing is preferably performed on first-void urine (see above).
• In some cases, samples may also need to be taken from the rectum and/or oral mucosa.
• Blood tests are used to screen for sexually transmitted infections such as HIV, hepatitis, and syphilis.

Microbial cultures for detecting pathogenic microorganisms

Cultures are taken based on clinical need from the following sources:

• Under the foreskin

• First-void urine

• Semen

• Midstream urine

• Post–prostate massage urine