Overview

During adolescence, teenagers begin the process of developing a sexual self-concept, which involves the combination of physical sexual maturation, age-appropriate sexual behaviors, and formation of a positive sexual identity and sense of well-being. In early adolescence, boys might become preoccupied with body changes, become interested in sexual anatomy and sex, compare changes in their body with others, and explore touching and mutual masturbation. Along with the experience of spontaneous erections, ejaculation related to masturbation, and the onset of nocturnal ejaculatory events during sleep (ie, “wet dreams”), there are many reasons why preadolescent and older boys might have questions and anxieties about their emerging sexuality. Later, male adolescents begin to test their ability to attract others through dating and sexual behavior. It is not uncommon for a male to have anxieties and questions about genital size and function, especially when comparing himself to others and after initiating sexual behavior.^{1 (as cited in2)}

The male genital examination, including examination of the testicles (see below), represents an important part of a male adolescent’s complete physical examination during annual preventive health visits and, specifically, as part of a visit related to a genital complaint.³ The content of the pediatric/adolescent physical examination required to report preventive health care codes (CurrentProceduralTerminology [CPT] codes 99382–99384;  99392–99394) depends on  age and developmental level and would be expected to include a male genital examination. There are many reasons to perform a genital examination, including SMR for hair and genital progress in pubertal development; screening for visual signs of STIs such as herpes, warts, and asymptomatic urethral discharge; identification of signs for genetic diseases such as firm testes (Klinefelter syndrome) or ambiguous genitalia (congenital adrenal hyperplasia); evidence of structural anomalies including varicocele, which can affect fertility, or uncorrected hypospadias, which can result in significant embarrassment, problems with sexual function, and/or abnormal urine flow. Other issues might be related to an uncircumcised penis (eg, phimosis and hygiene); hair or skin findings for treatable conditions (eg, folliculitis and tinea cruris); previously unrecognized absent testes attributable to cryptorchidism; evidence of testicular atrophy secondary to central or exogenous causes (eg, steroids or marijuana use); and normal findings that might require reassurance (eg, pearly penile papules).^{4,5,6 (as cited in 7)}

Ultimately, one of the goals of the genital examination is to help the young man gain a better understanding of his own body and reproductive parts. For example, young men might not be aware of their genital anatomy, the importance of using genital protection as part of sports participation, or general issues related to their hygiene. Guidance can be given by briefly reviewing the main components of the physical examination and, as the examination progresses, by commenting on normal anatomy, what to expect next, and pertinent findings. Examination in gowns will help prevent missing important physical examination findings, such as gynecomastia or truncal acne. Avoiding lengthy discussions while the patient is undressed also allows for greater patient comfort.⁸

Genital development is a concern of many boys who may wonder about the size or shape of their penis, but they are unlikely to bring it up without some prompting by the care provider. Adolescents may have an unfounded perception of normal or desirable penis size, particularly if they have been exposed to pornography or have encountered commercial products reported to change the size of the penis. The physician should emphasize that young men come in all shapes and sizes, as do their penises, and should point out the relative unimportance of penis size for sexual function and satisfaction.⁹ If necessary, the physician should strongly caution against the use of any chemical or mechanical interventions claiming to change penis size. The mean penile flaccid length is 8.2 cm to 9.7 cm, with a range between 5.0 cm and 15.5 cm. The mean erect length is 15.1 cm, with a range between 11.4 cm and 19.0 cm. There is no predictable relationship between the size of the flaccid penis and erect length.¹⁰

Clinicians should have models, diagrams or other educational materials to demonstrate the differential diagnosis of scrotal masses and their significance. For example, while most young men are not concerned with fertility per se, patients with varicoceles should be alerted to their association with infertility in men.¹¹

Only 37% of males 15 to 44 years old had a testicular examination in the past year.^{12 (as cited in 13}) Testicular cancer is the leading cancer among males 18-25.¹⁴  Despite the lack of recommendations that support testicular cancer screening, the USPSTF has noted that “clinicians should be aware that patients who present with symptoms of testicular cancer are frequently diagnosed as having epididymitis, testicular trauma, hydrocele or other benign disorders.”^15,16 The American Cancer Society has stated that it “does not have a recommendation on regular testicular self-examinations for all men.”¹⁷ Risk factors for testicular cancer among men include being white; being between 13 and 39 years of age; having a history of cryptorchidism, testicular atrophy/dysgenesis, testicular trauma, HIV infection, and Klinefelter syndrome; or having a family history of testicular cancer.¹⁸

An external anal inspection, a digital rectal examination, and screening for hernia as part of the male adolescent physical examination should be performed on the basis of specific concerns or  complaints  such  as  a bulging mass or pain (hernia examination), hemorrhoid or rectal bleeding (digital rectal examination), or risk factors that would warrant an external anal inspection for HPV lesions in a young man who engages in receptive anal intercourse.¹⁹