Male Reproductive Anatomy: Self-Exam, Infertility, Vasectomy, and Circumcision

Introduction

The male reproductive system consists of external and internal organs responsible for hormone production, spermatogenesis, and delivery of sperm. Understanding normal anatomy, performing regular self-examination, and recognizing abnormalities are essential for early detection of conditions including testicular cancer, infertility, and sexual dysfunction.

Anatomy Overview

Organ	Function	Clinical Significance
Testes	Sperm production (spermatogenesis) and testosterone production	Site of testicular cancer; torsion; varicocele
Epididymis	Storage and maturation of sperm	Epididymitis (infection/inflammation)
Vas deferens	Transport of sperm from epididymis to ejaculatory duct	Vasectomy (cut/occluded here)
Seminal vesicles	Produce 60-70% of seminal fluid (fructose, prostaglandins)	Causes of low semen volume
Prostate gland	Produces 20-30% of seminal fluid (PSA, acid phosphatase, zinc)	BPH, prostatitis, prostate cancer
Bulbourethral glands (Cowper)	Pre-ejaculate fluid (lubrication, neutralizes urethral acidity)	Usually asymptomatic
Penis	Organ for urine elimination and sperm delivery	Peyronie disease, erectile dysfunction, urethral stricture
Scrotum	Holds testes, regulates temperature (contraction/relaxation)	Scrotal masses, infections

Testicular Self-Examination (TSE)

Technique

Step	Instruction
1	Perform monthly, ideally after warm bath or shower (scrotal skin relaxed)
2	Stand in front of mirror; examine scrotum for swelling, asymmetry
3	Support scrotum in palm of hand
4	Roll each testicle gently between thumb and fingers
5	Feel for the epididymis (soft, cord-like structure on top and behind each testicle)
6	Palpate the spermatic cord (vas deferens) above testicle
7	Note normal size, shape, consistency (firm but not hard; smooth, oval)
8	Report any changes to healthcare provider

What to Look For

Finding	Significance
Painless lump or enlargement	Possible testicular cancer (most common sign)
Dull ache or heavy sensation	Possible testicular cancer
Sharp pain	Possible torsion, trauma, infection
Scrotal swelling	Possible hydrocele, varicocele, hernia
Tenderness in epididymis	Epididymitis
“Bag of worms” sensation above testicle	Varicocele
Absent testicle	Cryptorchidism (undescended); prior orchiectomy

Male Infertility

Incidence and Causes

Category	Percentage
Male factor only	20-30%
Male and female combined	20-30%
Female factor only	30-40%
Unexplained	10-20%

Causes of Male Infertility

Category	Conditions	Percentage of Male Infertility
Idiopathic	No identifiable cause despite complete evaluation	30-40%
Varicocele	Dilated scrotal veins causing increased testicular temperature and oxidative stress	35-40%
Hormonal (hypogonadotropic hypogonadism)	Kallmann syndrome, pituitary tumor, anabolic steroid use	2-5%
Post-testicular obstruction	Congenital absence of vas deferens (CF mutation), vasectomy, infection	10-20%
Testicular failure	Klinefelter (XXY), cryptorchidism, orchitis (mumps), chemotherapy, radiation	10-15%
Genetic	Klinefelter, Y-microdeletion, CF (CFTR mutation), chromosomal translocations	5-10%
Ejaculatory dysfunction	Retrograde ejaculation (surgery, diabetes, spinal cord injury), anejaculation	2-5%
Autoimmune	Anti-sperm antibodies	5-10%
Infection	Prior epididymitis, orchitis, prostatitis, STIs	5-10%
Lifestyle	Smoking, alcohol, obesity, heat exposure, stress, medications	Variable

Semen Analysis (WHO 5th Edition, 2010)

Parameter	Lower Reference Limit
Semen volume	1.5 mL
pH	7.2-8.0
Sperm concentration	15 million/mL
Total sperm count	39 million per ejaculate
Total motility (PR + NP)	40%
Progressive motility (PR)	32%
Normal morphology (strict Kruger)	4%
Vitality (live sperm)	58%
Leukocytes	<1.0 million/mL
Immunobead test (anti-sperm antibodies)	<50% coated
Semen fructose	Present (normal seminal vesicle function)

Infertility Evaluation (Male)

Test	When Indicated	Clinical Utility
History and physical	All	Sexual history, prior fertility, medical/surgical history, lifestyle, varicocele, testicular atrophy, secondary sexual characteristics
Semen analysis (x2)	All (first-line)	Confirms abnormality; 2-3 samples over weeks
Hormonal evaluation	Abnormal semen analysis	FSH, LH, total/free testosterone, prolactin, estradiol
Post-ejaculate urinalysis	Low volume or suspected retrograde ejaculation	Detects sperm in urine
Scrotal ultrasound	Abnormal physical exam	Confirm varicocele, hydrocele, evaluate for testicular mass
Transrectal ultrasound	Suspected obstruction (low volume, normal size, no CF)	Evaluate ejaculatory ducts, seminal vesicles
Genetic testing	Azoospermia, severe oligospermia, CF suspicion	Karyotype, Y-microdeletion, CFTR mutation
Testicular biopsy	Azoospermia with normal FSH and testicular size	Distinguish obstruction from spermatogenic failure
Anti-sperm antibody testing	Abnormal sperm motility or agglutination	Immunobead or MAR test

Treatment

Cause	Treatment
Varicocele	Varicocelectomy (microsurgical) improves semen parameters in 60-80%; natural conception rates improved
Hypogonadotropic hypogonadism	hCG + FSH (gonadotropin therapy); sperm production in 6-18 months
Obstruction	Vasovasostomy (post-vasectomy); transurethral resection of ejaculatory ducts
Idiopathic (no cause found)	Lifestyle modification, antioxidants (vitamin C, E, CoQ10, zinc, selenium) limited evidence; IUI or IVF/ICSI
Severe male factor (low count/motility)	ICSI-IVF (intracytoplasmic sperm injection)
Azoospermia (no sperm in ejaculate)	TESE (testicular sperm extraction) + ICSI; micro-TESE best success
Retrograde ejaculation	Alpha-adrenergic agonists (pseudoephedrine, imipramine); sperm retrieval from urine
Genetic causes	ICSI + consider PGT for genetic testing of embryos
Immunologic	IUI (sperm washed to remove antibodies)

Vasectomy

Procedure Details

Aspect	Description
Anesthesia	Local (lidocaine, no sedation typically)
Incision	Small scrotal incision(s) or no-scalpel technique
Procedure	Vas deferens isolated, divided, and occluded (ligation, cautery, fascial interposition, or clips)
Duration	15-30 minutes
Recovery	1-2 days; scrotal support, ice, limited activity for 48 hours
Time to azoospermia	3 months or 20 ejaculations
Confirmation	Semen analysis showing no sperm (one or two negative samples)
Efficacy	>99.9%
Failure rate	1 in 2,000-4,000 (recanalization most common cause)

No-Scalpel Vasectomy

Feature	Traditional	No-Scalpel
Instrument	Scalpel incision	Ringed clamp + puncture
Incision size	1-2 cm (may need suture)	2-4 mm (usually no suture)
Bleeding	More	Minimal
Hematoma risk	2-5%	<1%
Infection risk	Slightly higher	Lower
Recovery	Similar	Similar
Efficacy	Equal	Equal

Side Effects and Complications

Complication	Frequency	Management
Hematoma	1-5%	Scrotal support, ice, NSAIDs; surgical evacuation if large
Infection	1-3%	Oral antibiotics
Granuloma (sperm leak)	10-30% (often asymptomatic)	NSAIDs; may resolve spontaneously; excision rarely needed
Chronic testicular pain (congestive epididymitis)	1-2% (significant)	NSAIDs, scrotal support; vasovasostomy if severe
Failure	1 in 2,000-4,000	Repeat vasectomy or other contraception
Regret	2-6%	Vasectomy reversal or sperm retrieval
Cancer/autoimmune	No increased risk	Reassurance

Vasectomy Reversal (Vasovasostomy)

Aspect	Details
Indications	Desire for biological children after vasectomy
Procedure	Microsurgical reconnection of vas deferens under general or regional anesthesia
Duration	2-5 hours
Tuition	30-90% patency (sperm); 30-80% pregnancy
Time since vasectomy	<3 years: 90% patency, 60-80% pregnancy; >15 years: 30-50% patency
Factors	Length of vas resected, presence of sperm granuloma, surgical technique
Alternatives	Sperm retrieval + ICSI-IVF (typically less successful per cycle but avoids surgery)

Circumcision

Aspect	Details
Definition	Surgical removal of the foreskin (prepuce) covering the glans penis
Prevalence	60-65% of male newborns in US; varies globally (higher in US, Middle East; lower in Europe, Asia)
Timing	Newborn (most common), childhood, or adulthood
Procedure for newborn	Dorsal penile block or ring block (local anesthesia); Gomco clamp, Plastibell, or Mogen clamp
Healing	5-10 days; petroleum jelly for first few days; normal bathing allowed

Medical Benefits vs Risks

Aspect	Benefit	Risk
UTI reduction	10x reduction in uncircumcised infants (1% vs 0.1%)	Bleeding (0.1-1%)
Penile cancer	Virtually eliminated in circumcised men (0.1% vs 0.5-1% lifetime)	Infection (0.1-0.5%)
HIV transmission (heterosexual)	50-60% reduction (African RCTs)	Removal of healthy tissue
STI transmission (HPV, HSV)	30-50% reduction in HPV, HSV-2	Anesthetic complications (rare)
Phimosis/paraphimosis	Eliminates these conditions	Meatal stenosis (5-10% of circumcised males - most common late complication)
Balanitis (foreskin infection)	Reduced	Poor cosmetic outcome (variation)
Cervical cancer risk in female partners	Reduced (HPV-related)	Personal preference/religious concerns

American Academy of Pediatrics (2012) Position

Statement	Detail
Health benefits	Benefits of newborn circumcision outweigh risks
Benefits include	Reduced UTI (10x), reduced penile cancer (lifetime), reduced HIV (60% in African trials), reduced HPV/HSV
Recommendation	Not universal; parents should make informed decision based on medical benefits, risks, and cultural/religious/personal preferences
Insurance coverage	Varies by state; Medicaid coverage varies
Pain management	Local anesthesia is safe and effective; should always be used

Phimosis and Paraphimosis

Condition	Phimosis	Paraphimosis
Definition	Inability to retract foreskin over glans	Retracted foreskin cannot be returned to normal position
Age	Normal in children (physiologic); resolves by age 3-5 in 90%	Any age
Cause	Physiologic adhesion, scarring (balanitis xerotica obliterans, lichen sclerosus)	Retracted foreskin left in place (sexual activity, catheter placement)
Symptoms	Difficulty with hygiene, ballooning during urination, pain with erection	Painful, swollen glans, can progress to ischemia
Treatment (physiologic)	Reassurance (up to age 3-5); gentle retraction with bathing	Manual reduction (compress glans, push proximally)
Treatment (pathologic)	Topical steroid (betamethasone 0.05%) 2x daily x4-8 weeks (70-80% success); circumcision if fails	Ice/cold compress; osmotic reduction (sugar, wrapped); dorsal slit if reduction fails
Emergency	N/A	Yes (if cannot reduce, may need dorsal slit or emergent circumcision)

Penile Anatomy Conditions

Condition	Description	Treatment
Peyronie disease	Fibrous plaque in tunica albuginea causing penile curvature with erection	Observation (may resolve in 1 year for mild); collagenase (Xiaflex) injection for curvature >30-90 degrees; surgical plication or grafting
Penile fracture	Rupture of tunica albuginea during erection (trauma, “cracking” sound, sudden detumescence, swelling)	Surgical emergency: immediate repair
Urethral stricture	Narrowing of urethra from scar tissue (infection, trauma, instrumentation)	Urethral dilation, internal urethrotomy, urethroplasty
Hypospadias	Urethral opening on ventral surface of penis	Surgical repair (optimal timing 6-18 months)
Epispadias	Urethral opening on dorsal surface	Surgical repair
Buried penis	Penis hidden by suprapubic fat pad	Weight loss; surgical correction if symptomatic
Testicular torsion	Spermatic cord twists, causing testicular ischemia	Surgical emergency: detorsion + orchiopexy within 4-6 hours