Male Urogenital Physical Examination
A reconstructive examination documents the patient's current anatomy, tissue quality, symptoms and functional goals. Combine it with the history, prior operative records and appropriately selected investigations.[1]
Palpation and inspection give information that imaging does not: tissue quality, skin availability, tenderness, fibrosis texture and the extent of skin disease. Imaging and endoscopy give the map. It is done systematically, from glans to anus, at each visit.
For symptom instruments, diaries and the standing cough test, see Assessment Tools.
Preparation and Positioning
Explain the purpose and sequence, obtain consent, offer a chaperone and preserve privacy. Ask about pain, prior traumatic examinations, positioning limitations and any preference that would make the examination easier. Examine only what is indicated; record a declined or deferred component without assuming a normal result.
For transgender and gender-diverse patients, perform the genital examination in the position the patient prefers, and avoid having a trans woman or transfeminine patient stand for it. Ask permission before using anatomical terms for the patient's own body parts, and default to the terms the patient uses. Assume that a history of trauma, including a prior negative or discriminatory healthcare encounter, may be present in a TGD patient even when it is not volunteered.[16][17]
| Setting | Practical preparation |
|---|---|
| Routine genital examination | Good lighting, gloves, drape, lubricant and a ruler when measurements are relevant |
| Standing examination | Inspect the groin, assess a suspected hernia or varicocele, or perform a standardized stress test when indicated |
| Supine examination | Abdominal, penile and scrotal examination; adapt leg position for comfort |
| Rectal or detailed perineal examination | Use a tolerable position providing adequate exposure; assess hip mobility before planning operative lithotomy |
| Endoscopy, calibration or biopsy | A separately indicated procedure with suitable consent, equipment, infection precautions and analgesia |
Before reconstruction, document abdominal scars, stomas or suprapubic access, skin problems and positioning restrictions. If oral mucosal harvest is being considered, assess oral health, prior harvest scars and mouth opening.[1]
Equipment
| Item | Use |
|---|---|
| Headlamp or focused examination light | Meatal, foreskin and perineal inspection |
| Non-sterile gloves and water-based lubricant | Standard protection; rectal examination |
| Ruler or flexible tape | Stretched penile length, plaque dimensions |
| Anoscope | Rectal mucosa and suspected rectourethral fistula |
| Cotton-tipped applicator or wisp | Light-touch and perianal reflex testing |
| Tuning fork (128 Hz) | Vibration sense at the glans |
| Penlight or transillumination wand | Scrotal contents |
| Patient-supplied photograph of the erect penis | Curvature documentation in Peyronie's disease |
| Lubricant with lidocaine, calibrated instruments, small-caliber endoscope | Only when instrumentation is separately indicated |
Positioning
Supine is used for most of the examination: meatal and penile inspection, shaft palpation, Peyronie's assessment, scrotal examination, rectal examination and neurological testing. Standing is needed for varicocele grading with Valsalva and for inguinal hernia assessment, because a varicocele or hernia defect that is not palpable supine may become obvious upright. Lithotomy or a prone-jackknife position gives the best perineal exposure for bulbar palpation and rectourethral fistula assessment. The prone-jackknife position is used in the operating room. Dorsal lithotomy on an examination table gives comparable access in the clinic.
Penis — Meatal and Glans Inspection
Meatal Position and Appearance
Describe the meatus, glans, frenulum, foreskin and shaft skin. Record discharge, fissures, ulceration, induration, visible narrowing and scars. For hypospadias or epispadias, describe the actual anatomy, curvature, fistulae and prior repairs.
| Meatal position | Location | Reconstructive relevance |
|---|---|---|
| Orthotopic | Glans tip, ventral midline | Reference position |
| Epispadiac | Dorsal glans or shaft | Associated with the bladder exstrophy-epispadias complex; bladder neck and continence mechanism may be involved |
| Glanular or coronal hypospadias | Ventral glans or coronal sulcus | Often meatoplasty or a distal repair; chordee is variable |
| Penile hypospadias | Mid or proximal shaft | Ventral skin is deficient; staged repair is often used |
| Penoscrotal or perineal hypospadias | Penoscrotal junction or perineum | Bifid scrotum and significant chordee are common; evaluate for a difference of sex development when the anomaly is severe |
Failed hypospadias repair. In men with complications of earlier hypospadias surgery, the meatal position records the result of the most recent repair, not the original anatomy. Document the number of prior procedures, residual fistulae, skin quality and availability, residual chordee and the caliber of the neourethra. Obtain prior operative reports when possible. Each earlier operation reduces the remaining penile skin and subcutaneous vascularity, and previous flaps, grafts and incisions affect later options.
Meatal Caliber
Record visible narrowing and associated spraying, weak stream, dysuria or retention. If instrumentation is clinically needed, document the actual instrument, its caliber and whether it passed without force. Avoid converting an examination into unintended dilation.[1][2]
There is no universal French-size table that maps the appearance of a meatus to DVIU, urethroplasty or urgent meatotomy. The relevant questions are the patient's symptoms and emptying, the location and extent of disease, prior treatment and goals.
Lichen Sclerosus
LS is the skin finding that most changes reconstructive planning, because its extent determines graft choice and recurrence risk. Look for white atrophic or sclerotic plaques with a waxy or porcelain appearance, fissuring, adhesions, a scarred preputial ring and meatal involvement. In males, common sites are the glans, coronal sulcus, foreskin, meatus and perifrenular area; the vulval or perianal “figure-of-eight” pattern is not the usual male distribution.[3] A phimotic ring at the preputial orifice is often the earliest sign. Advanced disease obliterates the coronal sulcus, atrophies the glans and closes the meatus.
Typical LS can be diagnosed clinically. Biopsy is indicated when the diagnosis is uncertain, treatment fails, or neoplasia is suspected.[19][3][24] A new persistent ulcer, hyperkeratotic focus or indurated lesion warrants prompt assessment and biopsy when neoplasia is suspected.[19]
Topical corticosteroids are central to genital LS treatment. Persistent LS-related phimosis may require circumcision, and the removed foreskin should undergo histology. LS can extend into the urethra, so map the disease along the glans, meatus and shaft, and assess meatal and urethral obstruction separately with RUG or endoscopy. Avoid genital skin grafts or flaps for LS-related urethral reconstruction, because microscopic LS may be present in skin that looks normal and the reconstruction remains prone to recurrent disease. Oral mucosa and perineal urethrostomy are among the options, selected according to disease extent and patient priorities. Neither a small meatus nor any visible LS automatically mandates complete urethral excision.[3][4][15] Patients with persistent LS need long-term surveillance because of the risk of penile squamous cell carcinoma.[15]
See Lichen Sclerosus for treatment and surveillance.
Foreskin and Penile Skin
Retract the foreskin gently only as tolerated, inspect the concealed glans and return the foreskin to its normal position afterwards. Document whether exposure is limited by phimosis, buried penis, pain or adhesions. A trapped retracted foreskin with swelling requires prompt assessment and treatment.
The foreskin examination distinguishes several findings.
| Finding | Description | Action |
|---|---|---|
| Fully retractable | Foreskin retracts beyond the coronal sulcus | Inspect the inner surface |
| Phimosis | Foreskin cannot be retracted; may be physiological in a child or pathological (LS, recurrent balanitis) | Distinguish the cause; circumcision may be needed before urethroplasty |
| Paraphimosis | Retracted foreskin is trapped behind the corona with venous congestion | Urological emergency: manual reduction, dorsal slit or circumcision |
| LS phimotic ring | White, indurated ring at the preputial orifice | Do not force retraction; plan circumcision at or before urethroplasty |
| Preputial LS without meatal involvement | Inner and outer preputial disease | Map the extent; circumcision removes the most commonly affected tissue; reinspect the meatus afterwards |
For reconstruction, describe skin availability, mobility, scarring, hair distribution and prior incisions. Healthy penile skin is soft, mobile and pliable without thickening or tethering. Skin is unsuitable for a flap in documented LS, in heavily scarred or previously grafted skin and after earlier penile-flap urethroplasty. Tunica vaginalis is a separate tissue flap, not a type of scrotal skin graft.
Glans Inspection
Inspect the whole glans, corona and coronal sulcus.
- Condylomata acuminata are soft, verrucous, papillary growths. Biopsy atypical lesions and map the extent, because the distal urethra may be involved.
- Penile intraepithelial neoplasia (erythroplasia of Queyrat) presents as red, velvety, sharply demarcated plaques. Biopsy is required to establish the diagnosis of a suspicious penile lesion .[19]
- Squamous cell carcinoma presents as an ulcerated, raised, irregular, indurated lesion that may bleed. Biopsy is required to establish the diagnosis of a suspicious penile lesion .[19]
- Balanitis presents with erythema, edema and exudate. Candidal balanitis (satellite lesions), circinate balanitis and plasma cell (Zoon) balanitis (orange-red glistening patch) are distinguished from LS.
- Scars from earlier surgery include circumcision scars (skin redundancy or deficiency) and meatoplasty changes.
Urethral Calibration and Instrumentation
Routine blind passage of curved sounds or Hegar dilators is not a screening examination. Calibration can itself dilate a narrowing and change subsequent assessment. If it is needed to answer a specific distal-caliber question, use lubricant with topical lidocaine, advance by gentle guidance and stop at the first resistance. A larger instrument is not forced through to establish a “normal” caliber. EAU advises that calibration be used with caution after urethroplasty for the same reason.[2]
False Passage
A false passage forms when an instrument or catheter advanced against resistance leaves the lumen and tracks through the urethral wall. It makes later reconstruction harder. Signs include sudden loss of resistance after a period of firmness, meatal bleeding out of proportion to the instrument, sharp pain with advancement and an instrument that cannot be withdrawn smoothly. The rule is to never advance against resistance. If an instrument does not pass with gentle pressure, withdraw it, image the urethra and choose the next step from the images.
For suspected stricture, combine symptoms and examination with uroflowmetry, residual urine and anatomic testing as indicated. RUG maps strictures before reconstruction; add VCUG when the proximal extent is poorly shown, including near-obliterative disease. Small-caliber endoscopy can answer selected questions without deliberately dilating the narrowing.[1]
In acute pelvic or perineal trauma, blood at the meatus, inability to void and swelling raise concern for urethral injury. Absent meatal blood does not exclude injury. Follow the trauma pathway, including RUG when indicated after stabilization; repeated blind instrumentation can worsen an injury.[5]
Penile Shaft, Urethra and Perineum
Inspect before palpating. Hold the penis gently and palpate the ventral surface from the penoscrotal junction to the meatus with the pads of two fingers, then the accessible perineum. Normal corpus spongiosum is soft, compressible and uniform. Assess focal tenderness, induration, scars, fluctuance, skin fixation and palpable abnormalities. Document location and whether pressure reproduces the patient's symptoms. Palpable spongiofibrosis loosely tracks the length of the diseased segment.
| Finding | Interpretation and next step |
|---|---|
| Focal firmness or induration | Spongiofibrosis around a stricture; soft tissue beyond it is the tissue available for anastomosis |
| Diffuse firmness along the shaft | Extensive stricture disease or pan-urethral LS; may prompt consideration of graft or staged reconstruction |
| Firm tissue after urethral surgery | May represent postoperative fibrosis; establish recurrent narrowing with symptoms, flow and anatomic testing when indicated |
| Gritty or crepitant texture | Calcification within spongiofibrosis; wider excision may be needed at surgery |
| Draining opening or urine-like discharge | Describe its position, surrounding skin and relation to voiding; determine the tract with directed evaluation |
| Tender swelling, erythema or fluctuance | Assess infection and possible abscess, urinary obstruction and systemic illness; arrange imaging or drainage according to the clinical situation |
| Perineal bruising after trauma | Supports concern for injury |
| Prior fistula repair, radiation or extensive scars | Anticipate altered tissue quality and operative planes |
Avoid routine blind probing of fistulae or forceful occluded-urethral dye injection. Further evaluation may involve urethrography, endoscopy, imaging or examination under anesthesia, depending on the suspected communication.[1][6]
Urethrocutaneous Fistula and Periurethral Abscess
Inspect the ventral shaft and penoscrotal junction for small fistulous openings. They are often subtle: a dimple or pit, sometimes with surrounding erythema or skin retraction. Patients frequently miss them, especially at the penoscrotal junction. Document the number of openings, their distance from the meatus and any drainage, and ask about double-stream voiding and wetness between voids. Gentle instillation of dilute dye through the meatus can confirm a urethral communication when the diagnosis is uncertain.
Untreated or inadequately drained periurethral abscess produces fluctuant warmth along the ventral shaft with a boggy or cystic consistency. Long-standing obstruction with recurrent periurethral infection can leave multiple openings across the scrotum and perineum (“watering-can perineum”), induration and skin bridges between prior openings. Abscess needs drainage and treatment of infection before reconstruction.
Chordee
Chordee is curvature at erection. It is congenital (hypospadias-associated) or acquired (post-inflammatory, post-traumatic, Peyronie's disease). Ask about the direction of curvature during erection. Ventral curvature is typical of hypospadias and reflects fibrous chordee tissue or ventral skin shortage. Dorsal or lateral curvature suggests Peyronie's disease. Ask the patient for a photograph of the erect penis, taken with consent and against a neutral background, and record the angle with a protractor or goniometer application.
Perineum
Examine the perineum in lithotomy or prone-jackknife position with good light. Record the condition of the perineal skin and relevant scars.
Scars. A midline or inverted-Y scar between the posterior scrotum and anus indicates prior perineal urethroplasty. Assess width and pliability. Fistula-repair scars are smaller and often eccentric and may be keloid. Irregular non-surgical scars suggest prior trauma.
Acute injury. Butterfly-pattern perineal ecchymosis is a recognized sign of urethral injury after straddle or pelvic trauma. Edema, erythema and skin necrosis suggest urine extravasation with infection or necrotizing infection.
Bulbar urethra. With one hand on the penile urethra, press upward in the midperineum with the fingertips of the other. Normal bulbar urethra is soft and compressible and indistinct from the surrounding corpus spongiosum. Cord-like firmness suggests spongiofibrosis, fluctuance suggests periurethral abscess, and a tender point suggests active disease near the stricture.
Perianal skin. Inspect the anal verge in all four quadrants. Fistula-in-ano openings and perianal condylomata are relevant to fistula assessment and to any planned transperineal or transanal approach. Telangiectasia, atrophy or fibrosis of perianal skin suggests prior irradiation, which reduces tissue quality and healing and raises the question of interposition tissue in fistula repair.
Acute urinary retention, systemic illness with genital or perineal infection, rapidly progressive swelling or crepitus, sudden severe scrotal pain, or new saddle sensory loss with bladder or bowel or limb symptoms require urgent assessment. Complete an emergency evaluation rather than delaying care for the remainder of an elective examination.
Peyronie's Disease Examination
Record onset, recent change, pain, erectile function, intercourse difficulty and distress. With the penis gently stretched, describe plaque location and palpable extent, deformity and baseline length using a reproducible method.[7]
Palpate the tunica albuginea systematically with the penis on gentle stretch. The dorsal surface is the most common plaque site. Roll the shaft to examine both lateral surfaces. A ventral plaque is uncommon, and spongiofibrosis from a urethral stricture can mimic it. A plaque is a discrete, firm or hard area in an otherwise smooth tunica.
| Parameter | Record |
|---|---|
| Location | Dorsal, lateral or ventral; proximal, mid or distal shaft |
| Size | Length and width in cm |
| Consistency | Soft, firm, hard or calcified |
| Tenderness | Record tenderness; pain with erection or recent curvature change suggests active disease. Assess pain resolution and unchanged curvature for at least three months.[7] |
| Margins | Well defined or indistinct |
A circumferential or near-circumferential plaque produces a palpable waist. In hourglass or hinge deformity the corpora buckle at the narrowing during erection and the patient describes a hinge rather than a curve. EAU describes extratunical grafting as able to correct indentation in hourglass or hinge deformity, and these deformities weigh against simple plication.[7] Calcified plaques are bony hard. Calcification is compatible with stable disease. Calcified tunica does not hold sutures.
Objective erection assessment may use suitable home photographs, vacuum-assisted erection or an in-office pharmacologically induced erection. Document curvature direction and angle, indentation or hourglass deformity, hinge instability and erection quality. Use ultrasound selectively to assess calcification or vascular function.[7]
Stability depends on the clinical course, including no recent change in deformity for at least three months. Treatment selection considers intercourse function, erectile response to treatment, penile length, complexity and patient preference.[7]
Measure stretched length consistently and record the method, for example: patient supine, ruler pressed against the pubic symphysis at the dorsal base, gentle traction on the glans, measurement to the tip of the glans, repeated twice. EAU recommends measuring stretched or erect length because it influences treatment decisions.[7] Preoperative length is the baseline for postoperative comparison. A single value below 10 cm does not diagnose acquired shortening. Assess erectile function formally, for example with the IIEF-5, before any Peyronie's surgery. Grafting can worsen erections, and comorbid erectile dysfunction bears on the choice between grafting and a prosthesis. See Peyronie's Disease for management.
Scrotum and Contents
Examine in a warm room so that the cremaster is relaxed. Inspect the skin and palpate each testis, epididymis and spermatic cord separately. Record side, tenderness, consistency, asymmetry, focal masses, scars, swelling and any difficulty distinguishing structures. If estimating testicular volume, identify the method; an orchidometer estimate is not interchangeable with ultrasound volume. EAU uses Lambert's formula (length × width × height × 0.71) for ultrasound volume.[9] EAU reports a Prader orchidometer mean of 20.0 ± 5.0 mL in a European general population and cautions that reference values vary by population.[9] Unilateral atrophy suggests prior torsion, mumps orchitis, varicocele or inguinal surgery. Bilateral atrophy suggests exogenous androgen use, hypogonadism or prior chemotherapy or radiation. Increased firmness raises concern for tumor or orchitis. Separate the testis from the epididymis to avoid confusing them.
The epididymis is normally soft and non-tender. Fullness or induration follows vasectomy or prior epididymitis. A firm, tender nodule at the vas-epididymal junction is a sperm granuloma.
Inspect the scrotal wall for fistulous openings after abscess or Fournier gangrene, and for scarring, graft contraction and loss of rugation after Fournier gangrene. These findings bear on the tissue available for scrotal flap reconstruction. Avoid irradiated or previously necrotic skin. Sebaceous cysts and lipomas are distinguished from epididymal structures.
Transillumination is an adjunct. A fluid-filled structure such as a hydrocele or spermatocele glows when a light is placed against the dependent scrotal wall in a darkened room. A suspected intratesticular mass requires ultrasound and the appropriate oncologic assessment. Do not aspirate it.[8]
Varicocele is present in almost 15% of the general male population and in 35% to 40% of men presenting with infertility.[9] For suspected varicocele, examine standing in a warm room at rest and with Valsalva, then assess decompression supine. Grade I is palpable only with Valsalva, grade II palpable at rest, and grade III visible; use Doppler when examination is inconclusive.[9] Most clinical varicoceles are left-sided or bilateral. EAU advises further examination for abdominal, retroperitoneal and congenital pathology when a clinical right varicocele is isolated.[9] AUA/ASRM advises against routine abdominal imaging for the sole indication of an isolated small or moderate right varicocele , and its text says imaging should be considered for a new-onset or non-reducible varicocele, especially if large.[10]
Sudden severe scrotal pain requires urgent torsion assessment. An intact cremasteric reflex, relief with elevation, or preserved Doppler arterial flow cannot safely exclude torsion when the presentation remains concerning; imaging must not create an inappropriate delay to exploration.[11][12]
Digital Rectal Examination
In men with chronic pelvic pain, palpate pelvic-floor muscles transrectally for tenderness suggesting myalgia .[18]
Perform DRE when it addresses the presentation, after consent and with appropriate positioning (left lateral or dorsal lithotomy). In the reconstructive setting it is done last, after the external and perineal examination. Inspect the perianal region first, warn the patient, and insert a lubricated finger slowly along the rectal curve. Gently assess tenderness, a mass, prostate findings when relevant, resting anal tone and voluntary squeeze.
| Prostate finding | Interpretation | Reconstructive relevance |
|---|---|---|
| Firm-elastic, smooth, bilobed | Consistent with a benign gland | Baseline |
| Enlarged, smooth | Benign enlargement is likely | Bulk can complicate retrograde identification of the posterior urethra; DRE size is only a rough estimate |
| Hard, irregular nodule | Carcinoma or post-biopsy fibrosis | PSA and urologic evaluation before reconstruction |
| Woody, fixed induration | Radiation fibrosis with rectoprostatic adhesions | Anticipate obliterated planes and complex fistula repair |
| Boggy, tender | Possible prostatitis | Assess for infection before instrumentation[18] |
| Prostate absent after radical prostatectomy | Expected postoperative finding | If obstructive symptoms or retention raise concern for vesicourethral anastomotic stenosis, assess flow and PVR and use cystoscopy when indicated.[1][20] |
Resting anal tone reflects the internal sphincter. The voluntary squeeze reflects the external sphincter and pudendal (S2 to S4) function; grade it 0 to 5 as any motor examination, and note whether pain or misunderstanding limited it.
DRE gives only a rough estimate of prostate size and may underestimate enlargement.[13] After pelvic trauma, a “high-riding prostate” is unreliable; concern for associated rectal injury (up to 5% of PFUI) is a separate reason to examine.[5]
Suspected Rectourethral Fistula
Ask about pneumaturia, fecaluria and urine per rectum, previous prostate treatment, radiation, infection and baseline continence. A reachable rectal opening is typically on the anterior rectal wall.[6]
Anoscopy can show a small fistulous mucosal defect on the anterior rectal wall at the level of the prostate, and dilute methylene blue instilled through a urethral catheter with the balloon inflated in the bladder can stain the rectal opening. Cystoscopy and rectal endoscopy, RUG and VCUG and selected cross-sectional imaging define the communication, outlet and tissue condition; biopsy is considered when malignancy is suspected. Do not routinely pass a finger or sound through a tract. Assess mobility of the rectal wall over the prostate. A fixed, adherent plane suggests radiation fibrosis or prior pelvic sepsis and bears on the route of repair and the need for interposition tissue. Radiation, stricture and tissue damage influence multidisciplinary repair planning. Transperineal repair with vascularized tissue interposition is an option for complex cases.[6]
Focused Neurological Examination
Use a targeted examination when neurological disease, pelvic trauma, altered sensation or sphincter dysfunction is relevant. Record bilateral findings and compare them with the history and prior neurological baseline.[14]
| Component | Documentation |
|---|---|
| Sensation | Perineal, perianal and genital sensation; distribution and symmetry of reduction, plus relevant limb findings |
| Anal function | Resting tone and voluntary contraction, including whether the maneuver was understood and limited by pain |
| Sacral reflexes | Anal reflex and bulbocavernosus reflex when indicated; method, presence and symmetry |
| Broader neurological findings | Limb power/reflexes, gait or other findings relevant to the suspected lesion |
The bulbocavernosus reflex is a sacral reflex. The afferent limb is the dorsal nerve of the penis, the reflex arc passes through the S2 to S4 cord, and the efferent limb runs in the pudendal nerve to the bulbocavernosus and external anal sphincter. With a finger at the anal verge, squeeze the glans and feel for sphincter contraction. Repeat two or three times, since asymmetric responses are meaningful. Do not pull firmly on an inflated catheter balloon to elicit it. An absent reflex fits a lower motor neuron lesion (pudendal nerve, cauda equina or sacral cord), and a brisk reflex fits a suprasacral lesion. In acute spinal shock all reflexes may be absent regardless of the level of injury, so an absent reflex in the acute period does not localize the lesion and should be re-examined later. Combine findings with specialist neurological assessment and urodynamics when indicated.[14]
The anal (anocutaneous) reflex is tested by stroking the perianal skin in four quadrants with a wisp or blunt pin. Contraction of the external sphincter indicates an intact S2 to S4 sacral reflex arc.[21] The cremasteric reflex (afferent and efferent limbs L1 to L2) is tested by stroking the inner thigh; the ipsilateral testis rises. It can be lost after inguinal surgery that injures the genitofemoral nerve.
Test sensation bilaterally with a wisp and then a blunt pin in the relevant territories.
| Territory | Level | Test location |
|---|---|---|
| Medial proximal thigh | L1 to L2 | Ilioinguinal and genitofemoral distribution |
| Posterior scrotum and base of penis | S2 | Posterior scrotal skin |
| Perineum | S3 | Between scrotum and anus |
| Perianal skin | S4 | About 1 cm from the anal verge |
Unilateral loss suggests unilateral pudendal injury, for example after pelvic fracture or hernia repair. Bilateral saddle loss needs urgent evaluation for cauda equina syndrome.
The dorsal nerve of the penis carries sensation from the glans and shaft. Perineal nerve branches can be injured during bulbar dissection and contribute to genital sensory changes.[22] Test light touch along the dorsal shaft and vibration at the glans with a 128 Hz tuning fork, compare sides and record the result as a baseline for postoperative comparison.
New saddle sensory loss with urinary retention, bowel dysfunction or progressive limb symptoms warrants urgent evaluation for spinal compression. In a patient susceptible to autonomic dysreflexia, genital, bladder and bowel procedures may provoke an episode; plan monitoring and prompt management.[14]
Post-Urethroplasty Assessment
Follow-up assesses symptoms and bother, flow, emptying, complications, sexual function and urethral patency. Scheduled dilation from 16 to 22 Fr is not a surveillance test. If calibration is used for a particular question, it should not become unplanned treatment.[2]
EAU strongly recommends at least one year of follow-up and weakly recommends a risk-adjusted protocol and flexible cystoscopy three months after urethroplasty. Subsequent cystoscopy or urethrography depends on recurrence risk, baseline findings and deterioration in symptoms or flow. Penile, graft or flap, LS, radiation and complex repairs may need longer surveillance. Explain how to seek reassessment for late recurrence.[2]
At each visit, palpate the repair site. Mild firmness at the repair line is the expected scar. New or progressive firmness beyond it, or new nodularity, with obstructive symptoms raises concern for recurrence. Inspect the ventral shaft and perineum for new fistulous openings and ask about double-stream voiding, wetness without clear voiding and skin eruptions. Confirm a suspected fistula with urethrography.
EAU recommends validated questionnaires to assess sexual function after urethral stricture surgery, and identifies sexual dysfunction as an independent predictor of patient dissatisfaction.[2] Compare postoperative erectile and ejaculatory symptoms with their preoperative baseline, including the effects of the original injury and other comorbidities. Erectile dysfunction that appears after a previously normal recovery from urethroplasty is assessed against preoperative and earlier postoperative function, including vascular, neurologic, hormonal, medication and psychosocial contributors; a PDE5 inhibitor is a treatment option when appropriate.[23]
Examination by Presentation
| Presentation | Main elements | Specific focus |
|---|---|---|
| Anterior urethral stricture | Meatus; ventral shaft and perineal palpation; skin quality | Spongiofibrosis; LS mapping; skin available for flap |
| Posterior or membranous stenosis | DRE (prostate position and mobility); sacral reflexes; perineal scars | Sphincter function; prostate displacement after pelvic fracture |
| Failed hypospadias repair | Meatal position and caliber; skin quality; chordee; residual fistulae | Number of prior repairs; donor sites; vascularity of residual skin |
| Pelvic fracture urethral injury | Perineal ecchymosis and meatal blood (acute); sacral reflexes; DRE; perineal scars | Neurological status at presentation and follow-up; prostate position |
| Rectourethral fistula | DRE; anoscopy; perianal skin; rectoprostatic plane | Fistula location and size; rectal mucosa; radiation history; prior repairs |
| Peyronie's disease | Plaque palpation; hourglass or hinge deformity; stretched length; erect photograph; erectile function | Stable or active phase; curvature direction and angle; baseline erections |
| Lichen sclerosus | Meatus and glans; foreskin; extent along the shaft; biopsy if atypical | Proximal extent; eligibility of donor skin |
| Post-urethroplasty surveillance | Symptoms and flow; repair-site palpation; fistula check; sexual function; dorsal penile sensation | Recurrence; functional change; long-term LS surveillance |
| Scrotal pathology | Transillumination; testicular size and consistency; epididymis; varicocele standing with Valsalva | Exclude malignancy; assess Fournier sequelae when fistula is present |
Concise Documentation Checklist
Record findings actually assessed, with any limitations:
- Reason for examination, consent, chaperone and positioning limitations.
- Meatus, glans, foreskin, penile skin and prior repair anatomy; lesions needing investigation.
- Relevant plaque and deformity findings, erection-assessment method and length-measurement method.
- Testes, epididymides, cords, scrotal skin and any groin findings.
- Perineal scars, tenderness, drainage and suspected fistula location.
- DRE and focused neurological findings when indicated; distinguish untested from normal.
- Relationship to symptoms, objective tests and baseline function; required next investigation or urgent action.
References
1. European Association of Urology. Urethral Strictures: Diagnostic Evaluation. 2026. Guideline chapter.
2. European Association of Urology. Urethral Strictures: Follow-up. 2026. Guideline chapter.
3. Kirtschig G, Woelber L, Günthert A, et al. Evidence- and consensus-based guideline on lichen sclerosus. J Dtsch Dermatol Ges. 2026;24:566–584. doi:10.1111/ddg.70000. Full text.
4. European Association of Urology. Urethral Strictures: Disease Management in Males. 2026. Section 6.3.1.e, LS-related penile urethral strictures. Guideline chapter.
5. European Association of Urology. EAU Guidelines on Urological Trauma, section 4.4 (urethral trauma evaluation; limited update March 2026). Guideline chapter.
6. Chen S, Gao R, Li H, Wang K. Management of acquired rectourethral fistulas in adults. Asian J Urol. 2018;5:149–154. doi:10.1016/j.ajur.2018.01.003. Full text.
7. European Association of Urology. Guidelines on Sexual and Reproductive Health, Limited Update March 2026, sections 8.1 and 8.2 (penile curvature and Peyronie's disease). Guideline chapter.
8. European Association of Urology. Testicular Cancer: Diagnostic Evaluation. 2026. Sections 5.1–5.2.1. Guideline chapter.
9. European Association of Urology. Guidelines on Sexual and Reproductive Health, Limited Update March 2026, section 11.4.3 (varicocele: classification, diagnosis, prevalence, Lambert formula). Guideline chapter.
10. American Urological Association / American Society for Reproductive Medicine. Diagnosis and Treatment of Infertility in Men. Amended 2024. Statement 24 and discussion. Guideline.
11. European Association of Urology. Paediatric Urology: Acute Scrotum. 2026. Guideline chapter.
12. Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg. 2003;38:1248–1249. doi:10.1016/S0022-3468(03)00280-X. PubMed.
13. European Association of Urology. Management of Non-neurogenic Male LUTS: Diagnostic Evaluation. 2026. Sections 4.1–4.6. Guideline chapter.
14. European Association of Urology. Neuro-urology: The Guideline. 2026. Section 3.3.6 and autonomic dysreflexia assessment. Guideline chapter.
15. Stewart L, McCammon K, Metro M, Virasoro R. SIU/ICUD Consultation on Urethral Strictures: Anterior urethra-lichen sclerosus. Urology. 2014;83(3 Suppl):S27–S30. doi:10.1016/j.urology.2013.09.013. PubMed.
16. Chung PH, Spigner S, Swaminathan V, Teplitsky S, Frasso R. Perspectives and experiences of transgender and non-binary individuals on seeking urological care. Urology. 2021;148:47–52. doi:10.1016/j.urology.2020.10.026.
17. Substance Abuse and Mental Health Services Administration. SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. 2014. SAMHSA Library.
18. Lai HH, Pontari MA, Argoff CE, et al. Male Chronic Pelvic Pain: AUA Guideline: Part I Evaluation and Management Approach. J Urol. 2025;214(2):116-126. doi:10.1097/JU.0000000000004564 Full 2025 guideline
19. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Penile Cancer. Version 2.2026. June 5, 2026.
20. Fauconnier S, Waterloos M, Verla W. "Post-prostate-treatment stenosis and bladder neck contracture: reconstructive options and continence trade-offs." Curr Opin Urol. 2026;36(4):349–353. doi:10.1097/MOU.0000000000001402
21. Previnaire JG, Alexander M. "The sacral exam—what is needed to best care for our patients?" Spinal Cord Ser Cases. 2020;6:3. doi:10.1038/s41394-019-0252-2
22. Calleja Hermosa P, Campos-Juanatey F, Varea Malo R, Correas Gómez MÁ, Gutiérrez Baños JL. "Sexual function after anterior urethroplasty: a systematic review." Transl Androl Urol. 2021;10(6):2554–2573. doi:10.21037/tau-20-1307
23. European Association of Urology. "Guidelines on Sexual and Reproductive Health: Management of Erectile Dysfunction." 2026. Guideline chapter.
24. EuroGuiDerm. Guideline on Lichen Sclerosus. 2023 full guideline; journal publications 2024. Full guideline.