Male Urogenital Physical Examination

The male urogenital physical examination is the indispensable starting point of every reconstructive urology consultation. It defines the anatomy the surgeon will operate on, reveals findings that no imaging modality can replicate — the texture of periurethral fibrosis, the feel of a fluctuant abscess, the resistance of a tight meatus, the extent of lichen sclerosus — and fundamentally shapes the operative plan. Imaging (retrograde urethrogram, MRI, ultrasound) provides roadmaps; the physical examination answers questions that images cannot: Is this skin useable as a flap or graft? Is the stricture truly obliterative or merely tight? Is there active lichen sclerosus beyond what the eye can see? Does the perineal body allow a satisfactory posterior approach? Is the sacral reflex arc intact? A systematic, anatomically ordered examination performed at every visit — not delegated to junior members of the team — is a defining characteristic of expert reconstructive urology practice.

---

Equipment

Item	Purpose
Adequate examination lighting (headlamp preferred)	Meatal, foreskin, and perineal inspection
Non-sterile gloves, water-based lubricant	Standard protection; instrument passage
Bougie-à-boule set (8–30 Fr, graduated 2 Fr steps)	Urethral calibration — preferred method
Van Buren urethral sounds (curved) or Hegar dilators	Office calibration, especially proximal urethra
Centimetre ruler or flexible tape measure	Stretched penile length, plaque dimensions, perineal body measurement
Anoscope (medium)	Rectourethral fistula inspection; rectal mucosal assessment
Cotton-tipped applicator	Fistula probing; adjunct to urethral inspection
2% lidocaine gel (10 mL syringe with urethral adaptor)	Topical anaesthesia for calibration
4×4 gauze, small drape	Basic field preparation
Camera or smartphone (patient-provided photograph of erect penis)	Curvature quantification in Peyronie's disease

---

Positioning

Supine (standard): Used for the majority of the examination — meatal and penile inspection, urethral calibration, shaft palpation, Peyronie's assessment, scrotal examination, DRE, neurological testing. The supine position allows systematic access from the glans to the anus in a single repositioning sequence.

Standing: Essential for varicocele grading (Valsalva-enhanced) and inguinal hernia assessment. A varicocele that is not palpable supine may become a prominent "bag of worms" with the patient standing and performing Valsalva. Hernia defects may only be felt with the patient upright and coughing.

Lithotomy or prone-jackknife: Required for detailed perineal assessment, perineal body measurement, bulbar urethral palpation, and rectourethral fistula examination. The prone-jackknife position (buttocks elevated, thighs slightly spread) is used in theatre and provides the best perineal exposure; in the clinic, dorsal lithotomy on a standard table achieves equivalent access.

---

Penis — Meatal and Glans Inspection

Meatal Position

Identify the location of the urethral meatus precisely. Normal (orthotopic) position is at the tip of the glans on the ventral midline.

Classification	Location	Reconstructive Relevance
Orthotopic	Glans tip, ventral midline	Normal reference
Epispadiac	Dorsal surface of glans or shaft	Associated with bladder exstrophy; bladder neck and continence mechanism involved
Glanular hypospadias	Ventral glans, proximal to tip	Mild; often only meatoplasty required
Coronal hypospadias	Coronal sulcus	Variable chordee; may need staged repair
Penile hypospadias	Mid or proximal shaft	Ventral skin deficient; two-stage repair commonly required
Penoscrotal hypospadias	Junction of penis and scrotum	Severe; bifid scrotum, significant chordee
Perineal hypospadias	Perineum	Most severe; may have DSD; perineal urethroplasty required

:::info Failed Hypospadias Repair (Hypospadias Cripple) In men presenting with complications of prior hypospadias surgery, the meatal position records the outcome of the most recent repair, not the original anatomy. Document the number of prior procedures, location of residual fistulae, skin quality and availability, presence of residual chordee, and caliber of the neourethra. Each prior surgery diminishes remaining penile skin and subcutaneous vascularity, incrementally limiting options for subsequent reconstruction. :::

Meatal Caliber

Visual inspection alone is inadequate for caliber assessment. The meatus should admit an instrument of known size.

Technique:

1. Apply a small amount of lubricant to the meatus.
2. Gently insert a bougie-à-boule of the expected size (18 Fr for a normal adult male meatus) — the bulbous tip palpates through the meatus without force.
3. Progress upward in 2 Fr increments until resistance is met; the largest size passing freely = the caliber.
4. Alternatively, advance a calibration sound; a 16/18 Fr sound passing without resistance excludes significant meatal stenosis.

Clinical interpretation:

Caliber	Interpretation
≥18 Fr	Adequate for normal voiding; meatal stenosis excluded
14–18 Fr	Borderline; correlate with flow rate and post-void residual
<14 Fr	Meatal stenosis; meatoplasty or meatotomy likely required
<10 Fr	Severe stenosis; high likelihood of proximal extension
Pin-point / obliterated	Complete meatal obstruction; urgent meatotomy or dilation needed

:::warning Lichen Sclerosus — Do Not Dilate Blindly In the presence of visible lichen sclerosus (white plaque at meatus), do not perform forceful dilation. The friable scarred tissue will split, bleed, and promote further scarring. Calibration should be gentle and diagnostic, not therapeutic. Definitive management requires excision of diseased tissue and graft reconstruction (buccal mucosal graft). :::

Lichen Sclerosus (Balanitis Xerotica Obliterans, BXO)

Lichen sclerosus (LS) of the male genitalia is the single most important skin finding the reconstructive urologist must recognise. Its extent directly determines the reconstructive approach, graft material selection, and long-term recurrence risk.

Classic appearance:

• White, atrophic, sclerotic plaques affecting the glans, meatus, and prepuce
• Figure-of-eight distribution: the meatus and glans are obliterated by confluent white scarring extending around the coronal sulcus
• Waxy or porcelain-white colour; skin loses normal architecture
• Prepuce: non-retractable (phimosis), inner preputial skin shows white plaque; phimotic ring at the preputial orifice is often the earliest sign
• Advanced disease: obliteration of the coronal sulcus, atrophy of the glans, complete meatal stenosis

Proximal extension: LS extends into the urethra in 20–40% of cases. Extension beyond the navicular fossa into the penile urethra requires formal urethroplasty with buccal mucosal graft (BMG). Extension to the bulbar urethra occurs in severe cases. Retrograde urethrogram and, where available, direct visual internal urethrotomy with biopsy, maps proximal extent.

Reconstructive implications:

• Do not use penile skin as graft or flap material in any patient with documented LS — microscopic LS may be present in visually normal-appearing penile skin and will cause the graft to fail with progressive scarring.
• After urethroplasty, LS will recur at the anastomosis if residual diseased tissue is not completely excised; long-term urethrographic and clinical surveillance is mandatory.
• All excised tissue should be sent for histopathology to confirm LS and exclude squamous cell carcinoma (LS carries a 4–8% lifetime risk of penile SCC at the site of disease).

Indications for biopsy: Any suspicious lesion, atypical pigmentation, raised or ulcerated area, or failure to respond to ultra-potent topical corticosteroid treatment should be biopsied (2–4 mm punch biopsy from the lesion margin) to exclude dysplasia or carcinoma.

Foreskin Assessment

In uncircumcised patients:

Finding	Description	Action
Fully retractable	Foreskin withdraws completely beyond the coronal sulcus	Normal; inspect inner surface
Phimosis	Foreskin cannot be retracted; may be physiological (child) or pathological (LS, recurrent balanitis)	Distinguish physiological vs. LS; circumcision may be required before urethroplasty
Paraphimosis	Retracted foreskin becomes entrapped behind corona; venous congestion	Urological emergency; manual reduction, dorsal slit, or circumcision
LS phimotic ring	White indurated ring at preputial orifice	LS confirmed; do not attempt forceful retraction; plan circumcision at or before urethroplasty
Preputial LS	Inner and outer preputial LS without meatal involvement	Map extent; circumcision removes the most commonly affected tissue; inspect meatus post-circumcision

Glans Inspection

Inspect the entire glans surface, corona, and coronal sulcus:

• Condylomata acuminata: Soft verrucous papillary growths; confirm clinical diagnosis; biopsy atypical lesions; map extent (may involve distal urethra)
• Penile intraepithelial neoplasia (PeIN) / Erythroplasia of Queyrat: Red, velvety, sharply demarcated plaques on the glans; pre-malignant; biopsy mandatory
• Squamous cell carcinoma: Ulcerated, raised, irregular, indurated lesion; may bleed; biopsy required; different reconstructive pathway (oncological partial penectomy)
• Balanitis: Erythema, oedema, exudate; distinguish LS from candidal balanitis (satellite lesions), circinate balanitis (Reiter's syndrome), plasma cell balanitis (Zoon's balanitis — orange-red glistening patch)
• Erosions or scarring from prior surgery: Previous circumcision scar (location, skin redundancy or deficiency); prior meatoplasty changes

---

Urethral Calibration

Urethral calibration is a quantitative physical examination skill that requires practice but provides information unavailable from imaging alone. Retrograde urethrogram identifies stricture location and approximate length; calibration tells you the functional diameter at the meatus and confirms patency at that point.

Bougie-à-Boule Technique (Preferred)

The bougie-à-boule is a graduated set of spherical-tipped metal bougies (typically 8–30 Fr in 2 Fr steps). The spherical tip palpates through narrowings more sensitively than a cylindrical sound and causes less mucosal trauma.

Technique:

1. Patient supine; penis held vertically (12 o'clock position).
2. Instill 5–10 mL of 2% lidocaine gel through a urethral adaptor; allow 3–5 minutes for anaesthesia.
3. Begin with an 18 Fr bougie (expected normal caliber). If expected stenosis, begin at 10–12 Fr.
4. Lubricate the bougie; gently advance the bulbous tip through the meatus.
5. Allow the bougie to advance by gravity and gentle guidance — do not force.
6. Note the first point of resistance: this is the narrowest point (usually at the meatus or navicular fossa in LS, or at the stricture in bulbar disease).
7. Record the largest bougie that passes without resistance as the caliber.
8. Progress upward in 2 Fr increments to confirm.

Urethral Sounds (Hegar / Van Buren)

Van Buren sounds are curved metal instruments designed for the male urethra. They are used in the office when calibration of the prostatic urethra is needed (e.g., post-TURP stenosis) or when the stricture appears more proximal than the bougie can reliably reach.

Van Buren technique:

1. Instill lidocaine gel and wait.
2. Hold the penis perpendicular to the body (straight up).
3. Insert the curved sound tip-first with the curve directed upward (12 o'clock).
4. When the tip has passed the membranous urethra, depress the handle toward the abdomen while advancing — the sound follows the curve of the urethra into the bladder.
5. Gentle rotation confirms free passage. Resistance = stricture; do not force.

Clinical Caliber Interpretation

Caliber	Interpretation	Clinical Action
≥24 Fr	Normal adult male urethra	Stricture excluded at this level
20–24 Fr	Borderline / narrow normal	Correlate with flow rate; monitor
18–20 Fr	Mild narrowing	Consider DVIU if symptomatic; urethroplasty if recurrent
<18 Fr	Urethral stricture confirmed	Urethroplasty planning; RUG/MCU
<14 Fr	Significant stricture	Likely obliterative component; RUG mandatory
<10 Fr	Severe stricture / near-obliterative	RUG + antegrade (SPT-based) study; excision and primary anastomosis vs. graft
Hairline / obliterated	Complete obstruction	Suprapubic catheter; combined antegrade-retrograde planning

False Passages

A false passage is created when a sound or catheter is advanced against resistance and penetrates the urethral wall rather than traversing the lumen. This is a serious complication that increases surgical difficulty.

Signs of a false passage:

• Sudden loss of resistance after a period of firmness (the instrument has exited the lumen)
• Bleeding from the meatus disproportionate to the instrument size
• Patient reports sharp pain with advancement (distinct from dull pressure of normal advancement)
• Inability to withdraw the instrument smoothly

:::warning Stop at Resistance The cardinal rule of urethral instrumentation: never advance against resistance. If the instrument does not pass with gentle, controlled pressure, withdraw and reassess. Obtain imaging before attempting further instrumentation. Forcing instruments through obstructed urethrae creates false passages, splits the urethra, and makes subsequent reconstruction significantly more difficult. :::

---

Penile Shaft and Urethral Palpation

Palpation of the ventral penile shaft is the physical examination correlate of the retrograde urethrogram: it localises and characterises the stricture disease.

Technique

With the patient supine, hold the penis gently in one hand and palpate the ventral surface systematically from the penoscrotal junction proximally to the meatus distally, using the pads of the index and middle fingers of the other hand.

Apply gentle, firm pressure against the corpus spongiosum. Normal corpus spongiosum has a soft, compressible, uniform consistency — slightly firmer than surrounding subcutaneous tissue.

Findings and Interpretation

Palpation Finding	Interpretation	Reconstructive Significance
Focal firmness / induration	Spongiofibrosis — submucosal fibrosis surrounding the stricture	Extent of palpable firmness correlates with stricture length; soft tissue beyond = healthy for anastomosis
Diffuse firmness	Pan-urethral LS, extensive stricture disease	May require staged graft urethroplasty
Fluctuant tender mass	Periurethral abscess	Urgent drainage required; likely periurethral fistula formation
Tender point	Active infection / early abscess at stricture site	Correlates with stricture location; tenderness will resolve after appropriate treatment
Palpable cord-like mass	Dense spongiofibrosis at stricture	Guides incision length at urethroplasty
Crepitus / granular texture	Calcification within spongiofibrosis	May require wider excision; calcified tissue will not support anastomosis

Urethrocutaneous Fistulae

Inspect the ventral penile shaft meticulously for small fistulous openings. They are often subtle — a small dimple or pit, sometimes with surrounding erythema or skin retraction.

Examination technique:

• If a fistula is suspected, fill the urethra with dilute methylene blue (via urethral syringe) with the meatus occluded; blue staining at a skin opening confirms fistula
• Probe small openings gently with a fine lacrimal probe or small cotton-tipped applicator to confirm fistulous tract and assess depth

Key point: Patients frequently miss ventral shaft fistulae themselves, particularly if small or located at the penoscrotal junction where visibility is limited. Document number, location (distance from meatus), and estimated depth.

Periurethral Abscess and Fistula

In the context of untreated or inadequately drained periurethral abscess, examine for:

• Fluctuant warmth along the ventral shaft — "boggy" or cystic consistency
• Multiple fistulous openings ("watering-can perineum" in severe cases)
• Skin induration, scarring, and skin bridges between prior fistula openings

:::tip Skin Quality Assessment for Flap Planning While palpating the penile shaft, assess the quality of the penile skin for potential use as a flap (e.g., penile fasciocutaneous flap, Orandi flap). Avoid penile skin in: documented LS, circumcision scar (reduced vascularity), prior urethroplasty using penile flaps, and heavily scarred or grafted skin. Healthy penile skin is soft, mobile, and pliable without thickening or tethering. :::

Chordee Assessment

Chordee (penile curvature at erection) may be congenital (hypospadias-associated) or acquired (post-inflammatory, post-traumatic, Peyronie's disease). It cannot be assessed on flaccid examination.

Office approach:

• Ask the patient directly about erection-time curvature and the direction (ventral is most common with hypospadias; dorsal or lateral with Peyronie's)
• Ask the patient to provide a photograph of the erect penis (photograph consent discussed with the patient; many urology-specific apps or patient-supplied smartphone photographs are acceptable)
• Ventral chordee in hypospadias: caused by fibrous chordee tissue and/or skin shortage on the ventral shaft; must be fully released at the time of urethroplasty before a neourethra is constructed
• Degree of curvature estimated from photograph using protractor or digital goniometer app

---

Peyronie's Disease Examination

Peyronie's disease is characterised by abnormal fibrous plaque formation within the tunica albuginea, causing penile curvature, deformity, and loss of length during erection. The physical examination provides information essential for surgical planning, including plaque location, calcification status, hourglass deformity, stretched penile length, and erectile function baseline.

Erect Photograph

A patient-provided photograph of the erect penis taken against a neutral background is mandatory for curvature quantification. Goniometric measurement of the curvature on the photograph (angle between the shaft proximal to the plaque and the distal penile axis) provides the surgical target for correction. Typical thresholds:

• <30° curvature: conservative management (penile traction, pharmacotherapy) reasonable
• 30–60° curvature without significant shortening: plication (Nesbit/Lemberger or tunical plication) appropriate
• >60° or significant shortening/indentation: incision/excision and grafting; consider inflatable penile prosthesis if comorbid erectile dysfunction

Plaque Palpation

Palpate the entire tunica albuginea systematically with the penis on gentle stretch:

Dorsal surface (most common location — 70%): Place both thumbs on the dorsal shaft and apply controlled pressure while moving proximal to distal. Normal tunica albuginea is smooth and uniform. A Peyronie's plaque is a discrete, well-demarcated, firm or hard area.

Lateral surfaces: Rotate the penis to expose right and left lateral aspects; palpate with index and middle fingers.

Ventral (rare, <5%): Palpate along the corpus spongiosum, noting that spongiofibrosis from a urethral stricture can mimic a ventral plaque.

Document for each plaque:

Parameter	Assessment
Location	Dorsal / right lateral / left lateral / ventral; proximal / mid / distal third of shaft
Size	Length × width in cm
Consistency	Soft / firm / hard / calcified (bony-hard)
Tenderness	Present = active inflammatory phase; absent = stable / chronic phase
Margins	Well-defined or indistinct

Calcification

Calcified plaques are bony-hard to palpation and may be visible on plain X-ray (pelvic plain film or dedicated penile X-ray if clinical uncertainty). Calcified plaques are always in the stable (quiescent) phase. Calcification:

• Confirms stable disease (surgery may proceed if curvature is functionally disabling)
• Requires larger excision margins at grafting (calcified tissue cannot be sutured)
• Affects graft sizing: the area of excised calcification must be measured precisely intra-operatively

Hourglass Deformity / Hinge Effect

A circumferential or near-circumferential plaque produces a visible and palpable waist (narrowing) on the penile shaft:

• Palpation: A discrete indentation felt circumferentially at the plaque site; the shaft on either side of the indentation feels normal
• Hinge effect: The corpora buckle at the narrowing during erection rather than deviating; the patient describes a "hinge" rather than a curve
• Significance: Plication procedures are contraindicated if hourglass deformity or hinge effect is present; incision and grafting (or penile prosthesis) required

Stretched Penile Length (SPL)

Penile length measurement is mandatory pre-operatively in Peyronie's disease patients as a baseline comparison for post-operative length assessment. Loss of penile length is a recognised complication of Peyronie's itself (progressive shortening in the active phase) and of surgical correction.

Technique:

1. Patient supine.
2. Using one hand, place the ruler flush against the pubic symphysis on the dorsal base of the penis.
3. With the other hand, apply gentle but firm traction on the glans to stretch the flaccid penis to its maximum length.
4. Measure from the pubic symphysis to the tip of the glans (not the meatus).
5. Document in cm. Repeat twice; average.

Reference range: Normal adult SPL 12–16 cm (mean approximately 13.5 cm). Values <10 cm in the context of Peyronie's indicate significant disease-related shortening.

:::info Erectile Function Before Reconstruction Assess erectile function formally (IIEF-5 score, or focused history: presence of spontaneous/morning erections, hardness sufficient for penetration, use of PDE5 inhibitors) before any Peyronie's surgery. Men with moderate-to-severe erectile dysfunction (IIEF-5 <17) should be counselled that incision-and-grafting procedures may worsen erectile function, and inflatable penile prosthesis implantation (with or without manual modelling) is the preferred approach when comorbid ED is present. :::

---

Scrotum and Contents

Systematic Scrotal Examination

Perform in a warm room (room-temperature scrotum allows the cremasteric reflex to relax). Position: supine for initial palpation, then standing for varicocele assessment.

Transillumination

Position a bright light source (penlight or transillumination wand) against the dependent scrotal wall in a darkened room:

• Transillumination (glowing pink-red): Fluid-filled structure — hydrocele, spermatocele, epididymal cyst
• No transillumination (dark/opaque): Solid or complex structure — testicular tumour, haematocele, orchitis, non-cystic spermatocele

:::warning Solid Scrotal Mass Any non-transilluminating scrotal mass associated with the testis is a malignant germ cell tumour until proven otherwise. Do not aspirate. Request urgent scrotal ultrasound. Serum tumour markers (AFP, β-HCG, LDH) and urological oncology referral take priority over any reconstructive procedure. :::

Testicular Assessment

Size: Estimate volume using a Prader orchidometer (bead comparison) or note dimensions (length × width × height); Tanner stage in adolescents. Normal adult testicular volume 15–25 mL.

Finding	Interpretation
Symmetric normal volume (15–25 mL)	Normal
Unilateral atrophy <10 mL	Prior torsion, mumps orchitis, varicocele effect, post-operative (after inguinal surgery)
Bilateral atrophy	Exogenous androgen use, hypogonadism, prior chemotherapy/radiation
Increased firmness	Tumour, orchitis
Soft / doughy texture	Atrophy; reduced spermatogenesis; relevant if fertility is a concern

Palpation technique:

• Grasp testis between thumb, index, and middle finger of each hand in turn
• Palpate the anterior, posterior, and inferior surfaces systematically
• Normal: firm-rubbery, uniform, non-tender
• Separate the testis from the epididymis to avoid confusion

Epididymis

Palpate the epididymis along the posterior-superior testicular surface from the head (superior pole) through the body to the tail (inferior pole):

• Normal: Soft, non-tender, approximately 7–8 mm wide
• Fullness / induration: Epididymal obstruction (post-vasectomy, prior epididymitis), sperm granuloma
• Tenderness: Acute or chronic epididymitis; important to distinguish from testicular torsion (entire testis tender, elevated, horizontal lie)
• Sperm granuloma: Firm, tender nodule at the vas deferens–epididymal junction; common post-vasectomy

Varicocele

Varicoceles are dilated, tortuous veins of the pampiniform plexus, present in approximately 15% of the general male population and in 35–40% of men presenting with infertility.

Classification (WHO/Dubin-Amelar):

Grade	Clinical Finding
Grade I	Not visible or palpable at rest; palpable only during Valsalva manoeuvre
Grade II	Palpable at rest without Valsalva; not visible through scrotal skin
Grade III	Visible through scrotal skin as dilated tortuous veins; "bag of worms" appearance

Examination technique:

1. Patient standing in a warm room (essential for cremasteric relaxation).
2. Inspect the lateral scrotal skin for visible venous engorgement (Grade III).
3. Palpate the spermatic cord above the testis with the patient breathing normally.
4. Ask the patient to perform Valsalva (sustained deep breath and straining): Grade I varicoceles fill and become palpable; Grade II-III remain palpable and may enlarge further.
5. Note laterality: 90% of clinical varicoceles are left-sided or bilateral. An isolated right-sided varicocele should prompt evaluation for right-sided retroperitoneal pathology (caval or renal vein compression by mass).

Scrotal Wall Assessment

Inspect the entire scrotal skin for:

• Fistulous openings: Post-Fournier gangrene, post-abscess, urethrocutaneous fistula extending to the scrotum; probe with lacrimal probe and inject dilute methylene blue to confirm connection to urethra
• Fournier's gangrene sequelae: Areas of scarring, skin graft contraction, loss of normal scrotal rugation; assess tissue availability if scrotal flap reconstruction is being considered
• Skin quality: Thin, mobile, well-vascularised scrotal skin can be used for scrotal flap urethroplasty (e.g., tunica vaginalis flap, scrotal skin flap in two-stage repairs); avoid in areas of prior Fournier's or radiation damage
• Sebaceous cysts / lipomas: Distinguish from epididymal structures

---

Perineal Examination

The perineum is examined with the patient in dorsal lithotomy with thighs flexed and abducted (clinic examination) or in the prone-jackknife position (theatre). Adequate lighting is essential; a headlamp provides the most consistent illumination.

Inspection

Prior surgical scars:

• Perineal urethroplasty (bulbar or posterior): midline or inverted-Y scar between posterior scrotum and anus; assess scar quality, width, and pliability — a well-healed scar does not preclude repeat surgery
• Fistula repair scars: smaller, often eccentric; may have keloid formation
• Perineal trauma: assess for irregular, non-surgical scarring

Acute injury findings:

• Butterfly (straddle) ecchymosis: Semicircular hematoma overlying the perineum, extending around the perineal body but not crossing the midline posteriorly; in the context of trauma, this is pathognomonic for bulbar urethral disruption until proven otherwise — retrograde urethrogram is mandatory before any urethral instrumentation
• Oedema, erythema, skin necrosis: signs of extravasation of infected urine or Fournier's gangrene

Perineal Body Integrity

Measure the perineal body: the distance from the posterior scrotal raphe to the anterior anal verge.

• Normal: 3–4 cm
• Shortened (<2 cm): Prior perineal surgery, fistula repair, Fournier's gangrene, congenital short perineum — limits the posterior perineal operative approach and the ability to mobilise the bulbar urethra
• Palpate the perineal body: a firm, fibrous, well-defined structure normally; soft and poorly defined if inadequate

Bulbar Urethral Palpation

Through the perineum, the bulbar urethra can be palpated as a midline structure beneath the perineal skin and subcutaneous fat:

1. With the patient in lithotomy, place one hand on the penile urethra from above.
2. Press upward firmly in the midperineum with the other hand's fingertips.
3. Normal bulbar urethra: soft, compressible, indistinct from surrounding corpus spongiosum.
4. Palpable cord-like firmness: Spongiofibrosis at a bulbar stricture — identifies the location and provides tactile guidance to the surgeon.
5. Fluctuance: Periurethral abscess or abscess communicating from the urethra.
6. Tender point: Active stricture disease; correlates with the location seen on retrograde urethrogram.

Perianal Inspection

Inspect the anal verge in all four quadrants:

• Fistula-in-ano openings: External openings (typically within 3 cm of anal verge); relevant when assessing for rectourethral fistula — a high anal fistula posterior to the urethra may track to the urethra
• Condylomata: Perianal warts may coexist with intraurethral lesions; map extent
• Prolapsed haemorrhoids / rectal prolapse: Relevant if transperineal or transanal approach to rectourethral fistula is planned
• Prior irradiation changes: Perianal skin telangiectasia, skin atrophy, fibrosis — suggests post-radiation rectourethral fistula; tissue quality is reduced and healing is impaired; Martius flap or omental interposition should be planned

Scrotal-Perineal-Urethral Fistulae

When fistulae are present, the perineum must be examined systematically. Multiple openings communicating between the scrotum, perineum, and urethra ("watering-can perineum") represent the result of long-standing urethral obstruction with recurrent periurethral infection. Probe each opening gently with a lacrimal probe; inject methylene blue into the urethra (via catheter with meatus occluded) to confirm urethrocutaneous communication.

---

Digital Rectal Examination (DRE)

DRE is performed last in the examination sequence, after the external and perineal examination is complete. In the reconstructive context, DRE serves different purposes from its oncological role: it characterises the prostate in relation to the urethra and rectum, assesses the integrity of the anorectal canal, and in selected cases allows combined digital-instrumental fistula assessment.

Technique

Patient in left lateral decubitus (sims) or dorsal lithotomy. Lubricate the gloved index finger with water-based gel. Warn the patient before insertion. Insert the finger slowly, directing posteriorly to follow the rectal curve.

Prostate Assessment

Finding	Interpretation	Reconstructive Relevance
Normal (firm-elastic, bilobed, smooth)	Benign prostate	Baseline
Enlarged, smooth, firm-elastic	Benign prostatic hyperplasia	Prostatic bulk may prevent retrograde identification of the posterior urethra after PFUI
Indurated / hard / irregular nodule	Prostate carcinoma or post-biopsy fibrosis	Biopsy / PSA before urethroplasty if suspicious
Post-radiation induration (woody-hard, fixed)	Radiation fibrosis; rectoprostatic adhesions	Predicts high fistula repair complexity; tissue planes obliterated; omental flap indicated
Boggy / fluctuant / tender	Acute or chronic prostatitis	Treat infection before instrumentation
Absent posterior wall definition	Prior radical prostatectomy, anastomotic scarring	Bladder neck contracture; assess vesicourethral anastomosis by combined cystoscopy + DRE

Size estimation: Normal prostate 20–30 g (walnut-sized). 30–50 g = mildly enlarged; >50 g = significant BPH. Estimate by the examiner's perception of the prostate width and length against expected normal.

Prostatic Floor and Rectourethral Fistula Assessment

The rectourethral fistula (RUF) examination requires a combined technique:

Finger-and-sound technique:

1. Pass a well-lubricated metal sound (16 Fr Van Buren) into the urethra under sedation or local anaesthesia.
2. Simultaneously perform DRE with the other hand.
3. The examining finger in the rectum can palpate the sound through the prostatic floor.
4. Normal: A firm transrectal impression of the sound is felt, but the rectal mucosa is intact and smooth — there is no defect.
5. Fistula present: The examining finger feels a dimple, track, or communicating opening at the prostatic floor; the sound may be palpable at very close range or visible in the anoscope.

Anoscopy for RUF:

• Insert an anoscope with the patient in lithotomy to inspect the posterior rectal wall at the level of the prostate
• A fistula opening appears as a small defect in the rectal mucosa, often on the posterior rectal wall at the 6 o'clock position when the prostate lies anteriorly
• Methylene blue injected via a urethral catheter (with balloon inflated to maintain bladder seal) will stain the rectal fistula opening blue

Rectoprostatic Plane Assessment

Assess the mobility of the prostate relative to the anterior rectal wall:

• Mobile (normal plane): Prostate "slips" slightly relative to the rectal wall; a definable tissue plane is sensed
• Fixed / adherent: Prostate and rectum feel fused; no plane of movement; typical of post-radiation fibrosis or prior pelvic sepsis

:::warning Fixed Rectoprostatic Plane A fixed rectoprostatic plane indicates that standard transperineal posterior dissection for rectourethral fistula repair will be extremely hazardous. Rectal injury risk is high. Plan for: (a) transanorectal (York-Mason) approach, (b) posterior sagittal transrectal (TEMS-assisted) approach, or (c) abdominal route with omental flap. Ensure a bowel preparation and diverting colostomy is in place before repair. :::

Anal Sphincter Tone

Resting tone (internal anal sphincter — autonomic/sympathetic): On finger insertion, the initial squeeze felt is resting anal tone. Reduced resting tone indicates internal anal sphincter dysfunction (neuropathic, post-radiation, post-operative injury).

Voluntary squeeze (external anal sphincter — somatic, pudendal nerve S2–S4): Ask the patient to "squeeze tightly around my finger." Assess strength 0–5 as for any motor assessment. Reduced squeeze indicates pudendal neuropathy or EAS injury — relevant when assessing continence prognosis after posterior urethral reconstruction.

---

Neurological Examination

Neurological assessment of the perineum and lower urinary tract is particularly important in two clinical contexts: (1) posterior urethral injury (pelvic fracture urethral injury, PFUI) where injury to the pudendal nerve and pelvic plexus affects both continence and erectile function; (2) post-urethroplasty surveillance where dorsal nerve of penis function may have been affected by bulbar dissection.

Bulbocavernosus Reflex (BCR)

The bulbocavernosus reflex is the most clinically useful neurological test in reconstructive urology.

Reflex arc: Dorsal nerve of penis (afferent) → pudendal nerve → S2–S4 sacral cord → pudendal nerve efferent → bulbocavernosus and external anal sphincter.

Technique:

1. Patient supine with hips slightly flexed.
2. Place one or two fingers at the anal verge (or perform DRE with one finger in the rectum) to detect contraction of the external anal sphincter.
3. Stimulus: Squeeze the glans penis briskly (or tug a urethral catheter balloon firmly and quickly — the "tug test").
4. Positive response: Immediate, involuntary, visible and/or palpable contraction of the bulbocavernosus muscle and external anal sphincter.
5. Repeat 2–3 times; asymmetric responses are meaningful.

Interpretation:

BCR Finding	Interpretation	Clinical Implication
Present	Intact S2–S4 reflex arc	Normal somatic pudendal innervation
Absent	Lower motor neuron lesion (pudendal nerve injury, cauda equina, sacral cord injury) OR acute spinal shock (cannot distinguish in acute phase)	Predicts erectile dysfunction; predicts poor post-PFUI continence; if absent in acute trauma, re-test at 3 months post-injury
Hyperreflexic (exaggerated)	Upper motor neuron lesion (suprasacral)	Detrusor overactivity expected; assess post-injury spasticity

:::info BCR in Acute Spinal Cord Injury In the acute phase of complete spinal cord injury (spinal shock), all reflexes including the BCR may be absent regardless of the level of injury. A BCR absent at 6 hours post-injury may return at 2 weeks. Do not conclude peripheral pudendal nerve injury based solely on absent BCR in the acute period. Re-examine at 3 and 6 months before attributing absent BCR to pudendal neuropathy from PFUI. :::

Anal Wink (Anocutaneous Reflex)

Gently stroke the perianal skin in four quadrants (12, 3, 6, 9 o'clock positions) with a cotton wisp or blunt pin:

• Present wink: Involuntary external anal sphincter contraction = intact S4 reflex arc
• Absent in one or two quadrants: Possible unilateral S4 or inferior haemorrhoidal nerve injury
• Absent in all quadrants: Significant sacral neuropathy; associated with fecal incontinence risk

Cremasteric Reflex

Stroke the inner thigh skin upward with a blunt instrument → normal response is ipsilateral cremasteric muscle contraction, pulling the testis upward:

• Reflex arc: Femoral branch of genitofemoral nerve (afferent L1–L2) → cremaster (efferent L1–L2)
• Clinical relevance: Absent post-inguinal hernia repair = genitofemoral nerve injury; absent unilaterally in testicular torsion (loss of cremasteric reflex is a reliable early sign); reduced in lower lumbar disc lesions

Perineal Sensation

Using a cotton wisp (light touch) and then a blunt pin (sharp touch), test bilaterally in each dermatomal territory:

Dermatomal Territory	Level	Nerve	Test Location
Inner proximal thigh	L1–L2	Ilioinguinal / genitofemoral	Medial upper thigh
Posterior scrotum / base of penis	S2	Posterior scrotal branch of pudendal	Posterior scrotal skin
Perineum and midscrotum	S3	Perineal branch of pudendal	Between scrotum and anus
Perianal skin	S4	Inferior rectal branch of pudendal	Perianal 1 cm from verge

Unilateral loss: Unilateral pudendal nerve injury; consider PFUI with unilateral nerve traction, prior hernia repair, or pelvic fracture Bilateral saddle anesthesia (S2–S4): Cauda equina syndrome until proven otherwise — urgent MRI lumbosacral spine required

Dorsal Penile Sensation

The dorsal nerve of the penis is the sensory branch of the pudendal nerve (S2–S4) and is the primary sensory pathway from the glans and penile shaft. It is at risk during bulbar urethroplasty (mobilisation of the proximal corpus spongiosum and dissection around the bulbar vessels).

Test:

1. Light touch along the dorsal penile shaft from base to glans.
2. Vibration sense using a 128 Hz tuning fork applied to the glans.
3. Compare symmetry left and right dorsal surface.

Document: Normal / reduced (unilateral or bilateral) / absent. This forms the baseline for comparison in post-urethroplasty follow-up.

---

Post-Urethroplasty and Post-Procedural Assessment

The follow-up examination after urethroplasty is a structured, protocol-driven assessment that mirrors the pre-operative examination and provides objective evidence of success or failure.

Calibration at Follow-Up

Calibration is the most direct test of urethroplasty patency. Perform at 3, 6, and 12 months post-operatively, then annually:

• Pass a 16 Fr bougie or sound as a screening calibration: passes freely = ≥16 Fr
• If 16 Fr passes, proceed to 18, 20, 22 Fr — document the largest size passing without resistance
• Success: Restoration of caliber to ≥18–20 Fr
• Failure (recurrence): Caliber <16 Fr associated with symptoms; confirm with RUG before intervention

Anastomotic Site Palpation

At each follow-up, palpate the site of the urethroplasty:

• Expected finding: Mild firmness at the anastomotic line — this is normal post-operative palpable scar and does not indicate recurrence
• Concerning finding: Progressive or new firmness beyond the original anastomotic site, especially with new obstructive symptoms
• Recurrent nodularity: Dense new spongiofibrosis developing at the repair; indicates recurrence even before caliber loss is measurable

Fistula Check

Inspect the ventral penile shaft and perineum for new fistulous openings at every follow-up visit. Early post-operative fistulae (within 3 months) may be occult — ask specifically about double-stream voiding, wetness without clear voiding, or skin eruptions on the ventral shaft. Confirm with retrograde urethrogram if fistula is suspected.

Erectile Function Post-Urethroplasty

Erectile dysfunction after urethroplasty occurs in approximately 1–5% after bulbar repairs and in up to 30–50% after posterior urethral reconstruction (PFUI repair), depending on the degree of pre-existing nerve injury. Assess formally using the IIEF-5 score at each visit and compare to pre-operative baseline. Erectile dysfunction presenting after a previously successful erection implies nerve traction injury at the level of the repair and should prompt:

• PDE5 inhibitor trial (first-line)
• Penile rehabilitation (daily PDE5 inhibitor)
• Referral for penile prosthesis if refractory

---

Integrated Examination Approach by Presentation

Clinical Presentation	Key Examination Elements	Specific Focus
Urethral stricture (anterior)	Meatal inspection and calibration; ventral shaft palpation; perineal palpation; DRE (assess prostate contribution)	Extent of spongiofibrosis; LS assessment; skin quality for flap
Urethral stricture (posterior / membranous)	DRE (prostate position and mobility); BCR; perineal body assessment; calibration (if catheter-free)	Bladder neck competence history; prostate displacement post-PFUI
Failed hypospadias repair	Meatal position and caliber; skin quality (LS? prior flap sites?); chordee (patient photograph); residual fistulae; calibration	Number of prior repairs; available donor sites; residual skin vascularity
Pelvic fracture urethral injury (PFUI)	Butterfly perineal ecchymosis (acute); blood at meatus (acute); BCR; DRE for prostate position / floating; perineal inspection for scar	Neurological status at presentation and follow-up; perineal body length; prostate gap assessment
Rectourethral fistula	DRE (finger-and-sound technique); anoscopy; perineal inspection; anorectal mucosal assessment; rectoprostatic plane mobility	Fistula location and size; rectal mucosal health; radiation history; prior repairs
Peyronie's disease	Plaque palpation (location, size, consistency, calcification); hourglass/hinge assessment; SPL; erect photograph; IIEF-5	Stable vs. active phase; curvature degree and direction; erectile function baseline
BXO / Lichen sclerosus	Meatal inspection; meatal caliber; foreskin assessment; extent mapping along shaft and glans; biopsy if atypical	Proximal extent (navicular? penile? bulbar?); skin donor site eligibility
Post-urethroplasty surveillance	Calibration (18–22 Fr); anastomotic site palpation; fistula check (ventral shaft and perineum); IIEF-5; dorsal penile sensation	Recurrence detection; erectile function change; long-term LS surveillance
Scrotal / testicular pathology	Transillumination; testicular size and consistency; epididymis; varicocele (standing + Valsalva); scrotal skin	Exclude malignancy; assess for relevant Fournier's sequelae if fistula present

---

Documentation Template

MALE UROGENITAL EXAMINATION

PENIS:
Meatus: □ Orthotopic  □ Hypospadiac → location: _________________
         □ Epispadiac
Meatal caliber: _______ Fr  (method: □ bougie-à-boule  □ sound)
Foreskin: □ Circumcised  □ Retractable  □ Phimosis  □ LS phimotic ring
Glans / meatal skin: □ Normal  □ LS (extent: ___________________)
                     □ Condyloma  □ Lesion / mass (describe): _____
Urethral calibration (largest sound passed freely): _______ Fr
Ventral shaft palpation: □ Normal  □ Firmness at: _______________
                          □ Fluctuance  □ Fistula at: _____________
Chordee: □ None  □ Present (direction: _____  degree by photograph: _____°)

PEYRONIE'S:
Plaque: □ None  □ Present → location: _______  size: ______ × ______ cm
         consistency: □ Soft  □ Firm  □ Hard/calcified
Hourglass / hinge effect: □ No  □ Yes
Stretched penile length: _______ cm
Erectile function: IIEF-5: _______  □ Normal  □ Mildly reduced  □ Severe ED
PDE5 inhibitor use: □ No  □ Yes (agent and dose: _______________)

SCROTUM:
Testes: R _______ mL  □ Normal  □ Atrophy  □ Mass
        L _______ mL  □ Normal  □ Atrophy  □ Mass
Epididymis: □ Normal  □ Fullness  □ Tender  □ Sperm granuloma
Varicocele: □ None  □ Right  □ Left  □ Bilateral → Grade: _______
Scrotal skin: □ Normal  □ Fistula at: _________  □ Post-Fournier scarring
Transillumination: □ Not performed  □ Normal  □ Non-transilluminating mass

PERINEUM:
Scars: □ None  □ Prior urethroplasty  □ Fistula repair  □ Trauma  □ Other: ____
Butterfly ecchymosis: □ No  □ Yes
Perineal body length: _______ cm  □ Normal (≥3 cm)  □ Short (<3 cm)
Bulbar palpation: □ Normal  □ Firmness at _______  □ Fluctuance
Perineal fistulae: □ None  □ Present at: _____  methylene blue: □ + (urethral)  □ −
Perianal inspection: □ Normal  □ Fistula-in-ano  □ Condyloma  □ Other: _____

DRE:
Sphincter tone: □ Normal  □ Reduced  □ Hypertonic
Voluntary squeeze: _______/5
Prostate: size _______ g  consistency: □ Normal  □ BPH  □ Indurated  □ Tender
Rectoprostatic plane: □ Mobile  □ Fixed / adherent
Fistula orifice on rectal mucosa: □ None  □ Present (location: _____________)

NEUROLOGICAL:
BCR: □ Present  □ Absent  □ Not tested
Anal wink: □ Present all quadrants  □ Absent: _______
Cremasteric reflex: R □ Present  □ Absent  L □ Present  □ Absent
Perineal sensation:
  Posterior scrotum (S2): R □ Intact  □ Reduced  L □ Intact  □ Reduced
  Perineum (S3):          R □ Intact  □ Reduced  L □ Intact  □ Reduced
  Perianal (S4):          R □ Intact  □ Reduced  L □ Intact  □ Reduced
  Bilateral saddle anesthesia: □ No  □ Yes (→ urgent MRI spine)
Dorsal penile sensation: □ Intact  □ Reduced  □ Absent

---

References

1. Wessells H, Angermeier KW, Elliott S, et al. Male Urethral Stricture: American Urological Association Guideline. J Urol. 2017;197(1):182–190. PMID: 27650552

2. Lumen N, Campos-Juanatey F, Greenwell T, et al. European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease. Eur Urol. 2021;80(2):190–200. PMID: 34020797

3. Barbagli G, Mirri F, Gallucci M, et al. Histological evidence of lichen sclerosus in consecutive series of 104 patients with penile carcinoma. Int J Urol. 2017;24(11):814–817. PMID: 28884799

4. Barbagli G, Sansalone S, Djordjevic M, et al. Lichen sclerosus: an update for urologists. Eur Urol Suppl. 2019;18(1):64–69. PMID: 30930613

5. Mulhall JP, Stahl PJ, Stember DS, et al. Clinical outcomes analysis: timing of penile prosthesis implantation after radical prostatectomy impacts sexual outcomes. J Sex Med. 2013;10(9):2362–2368. PMID: 23859441

6. Bella AJ, Perelman MA, Brant WO, et al. Peyronie's Disease (CME). J Sex Med. 2007;4(6):1527–1538. PMID: 17725816

7. Mulhall JP, Schiff J, Guhring P. An analysis of the natural history of Peyronie's disease. J Urol. 2006;175(6):2115–2118. PMID: 16697816

8. Mundy AR, Andrich DE. Pelvic fracture-related injuries of the bladder neck and prostate: their nature, cause and management. BJU Int. 2010;105(9):1302–1308. PMID: 19874300

9. Chapple CR, Png D. Contemporary management of urethral trauma and the post-traumatic stricture. Curr Opin Urol. 1999;9(3):253–260. PMID: 10422002

10. Jordan GH, Schlossberg SM. Surgery of the penis and urethra. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds). Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016. pp. 900–948.

11. Voelzke BB, Breyer BN. Measurement of patientreported urethral stricture symptom severity: psychometric evaluation of the Urethral Stricture Score (USS). J Urol. 2014;191(1):215–219. PMID: 23850542

12. Kulkarni SB, Barbagli G, Kirpekar D, et al. Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol. 2009;55(4):945–956. PMID: 18599191