A complete examination of the infertile male is important to identify general health issues associated with infertility. For example, the patient should be adequately virilized; signs of decreased body hair or gynecomastia may suggest androgen deficiency.

The scrotal contents should be carefully palpated with the patient standing. As it is often psychologically uncomfortable for young men to be examined, one helpful hint is to make the examination as efficient and as matter of fact as possible. Two features should be noted about the testis: size and consistency. Size is assessed by measuring the long axis and width; as an alternative, an orchidometer can be placed next to the testis for volume determination (

Figure 42-5). Standard values of testis size have been reported for normal men and include a mean testis length of 4.6 cm (range 3.6-5.5 cm), a mean width of 2.6 cm (range 2.1-3.2 cm), and a mean volume of 18.6 mL (± 4.6 mL) (

Figure 42-6). Consistency is more difficult to assess but can be described as firm (normal) or soft (abnormal). A smaller or softer than normal testis usually indicates impaired spermatogenesis.

The peritesticular area should also be examined. Irregularities of the epididymis, located posterior-lateral to the testis, include induration, tenderness, or cysts. The presence or absence of the scrotal vas deferens is critical to observe, as 2% of infertile men may present with CAVD. Engorgement of the pampiniform plexus of veins in the scrotum is indicative of a varicocele. Asymmetry of the spermatic cords is the usual initial observation, followed by the feeling of an “impulse” with increased intra-abdominal pressure associated with a Valsalva maneuver. Varicoceles are usually found on the left side (90%) and are commonly associated with atrophy of the left testis. A discrepancy in testis size between the right and left sides should alert the clinician to the possibility of varicocele.

Prostate or penile abnormalities should also be noted. Penile abnormalities such as hypospadias, abnormal curvature, or phimosis could result in inadequate delivery of semen to the upper vaginal vault during intercourse. Prostatic infection may be detected by the finding of a boggy, tender prostate on rectal examination. Prostate cancer, often suspected with unusual firmness or a nodule within the prostate, can occasionally be diagnosed in infertile men. Enlarged seminal vesicles, indicative of ejaculatory duct obstruction, may also be palpable on rectal examination.