Chapter 20: Male Genitalia

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Welcome back to The Deep Dive.

Today we are shifting gears and moving into a topic that is absolutely fundamental to clinical practice.

Yet, let's be honest, it is often a source of significant anxiety for students and, you know, for patients too.

Oh, absolutely.

For everyone in the room.

So we are doing a dedicated deep dive into clinical skills and physical diagnosis.

Specifically, we are tackling chapter 20 of Bates' Guide to Physical Examination and History -Taking, the 13th edition.

That's right.

And the focus of chapter 20 is the male genitalia.

Exactly.

And before anyone sort of clicks away thinking this is just going to be dry anatomy, let me tell you the mission here is pretty crucial.

It really is.

We are looking to demystify a physical examination area that is often glossed over or, you know, rushed because of that awkwardness factor.

Yeah.

Our goal for this session is to provide a comprehensive step -by -step audio walkthrough of the text.

We're talking anatomy, the nuances of history taking, the actual examination techniques, which are very specific, and of course, health promotion.

It's all about building a mental map.

That's what it comes down to.

If you can visualize the anatomy and understand the logic behind the techniques that Bates describes,

a lot of that anxiety just dissipates.

Right.

You move from being unsure to being a competent clinician.

Yeah.

So we're going to strictly follow the chapter's structure.

We want you to be able to visualize the diagrams, the tables, and the actual movements as we talk.

Okay.

So let's unpack this starting right at the foundation.

Anatomy and Physiology.

The text opens with a review and it references figure 20 -1 right away.

It starts with a shaft of the penis.

Now visually, we tend to think of it as like one single unit, but Bates breaks it down into three specific columns of vascular erectile tissue.

Right.

And that's so important for understanding how it all works.

Yeah.

It's really an engineering marvel.

You have the corpus spongiosum, which is the column that actually contains the urethra, and then flanking it, you have the two corpora cavernosa.

Let's visualize these columns for a second because figure 20 -1 in lays them out really clearly.

When you say the corpus spongiosum contains the urethra, that means it's running along the underside of the penis, right?

The ventral side.

Correct.

If the penis is flaccid, the corpus spongiosum is ventral.

It actually forms the bulb of the penis way at the root, deep in the perineum, and then it extends all the way out to form the glands.

So when you look at the head of the penis, the glands, you're essentially looking at the expanded end of the corpus spongiosum.

You've got it.

That's the perfect way to picture it.

And the glands itself is described as this cone -shaped tip with an expanded base called the corona.

Exactly.

The corona is that ridge that sort of lip at the base of the glands.

And structurally, this is where we have to differentiate between circumcised and uncircumcised anatomy.

Right.

In an uncircumcised individual, you have the prepuce, which is just another name for the foreskin.

It's this loose, hood -like fold of skin that covers the glands.

And the text makes a specific point to mention

Yeah, smigma.

It's the secretion from the glands that can collect under that foreskin.

It's described as a cheesy whitish material, which sounds a little alarming, but it's a normal finding.

It's a normal finding, but it's clinically relevant for hygiene and especially for inspection.

It's not necessarily a pathology, but it's something you need to be able to identify so you don't mistake it for, say, a yeast infection or something else.

And you have to retract the foreskin to see it, which we'll get to in the exam part.

Absolutely.

So running through all of this architecture is the urethra.

Like we said, it runs ventrally along the underside and it opens into the metis.

And Bates describes the urethral metis as a vertical slit -like opening located somewhat ventrally at the very tip of the glands.

Right.

And knowing exactly where that opening should be is so key, isn't it?

Because if it's displaced, if it's not right at the tip, that's a congenital anomaly we need to spot.

For sure.

We'll talk about hypospadias later, but the normal anatomy you're looking for is a vertical slit right at the tip.

Okay.

So moving down from the shaft, we get to the scrotum and the testes.

Bates defines the testes as paired ovoid glands.

And I love that they give us specific dimensions here because normal can feel so subjective until you have the numbers.

It really can.

You need a baseline to compare against as the physical diagnosis is all about precision.

So what are we looking for?

For prepubertal boys, the testes are normally about 1 .5 to 2 centimeters in length.

But post puberty, we're looking for something more in the range of 4 to 5 centimeters.

And what are they made of?

They consist primarily of seminiferous tubules and interstitial tissue.

And they're covered by this fibrous outer coating called the tunica albuginia.

And these glands are housed in the scrotum, which the text describes as a loose wrinkled pouch divided into two compartments.

But here is where it gets really interesting for me, the layers inside.

We need to talk about the tunica vaginalis.

This feels like the most critical anatomical concept for understanding pathology in this region.

It absolutely is.

You cannot understand scrotal swelling without understanding this structure.

The tunica vaginalis is a serious membrane.

And the wild thing is it's actually derived from the peritonium of the abdomen.

So wait, let's pause there.

It's derived from the abdomen.

How does that happen?

You have to think about the embryology.

When the testes descend during fetal development, they start way up in the abdomen near the kidneys, and they have to drop down through the inguinal canal into the scrotum.

As they descend, they basically drag this little layer of peritonium down with them.

So it's like a little piece of the abdomen residing in the scrotum.

Exactly.

It's a remnant of that journey.

And because it's a serious membrane, just like the peritonium or the pleura, it has two layers.

There's a parietal layer that cloaks the anterior two -thirds of the testes and a visceral layer that lines the adjacent scrotum.

Why does this matter?

Because between those two layers is a potential space.

A potential space meaning usually there's nothing there, but there could be.

You got it.

Usually the layers just slide against each other with a tiny bit of lubricating fluid.

But if fluid accumulates there abnormally from inflammation or a blockage or something else, that is what we call a hydrosul.

Ah, so a hydrosul isn't inside the testicle itself.

Nope.

It's fluid trapped in this little peritoneal pocket surrounding the testicle.

That makes total sense.

So if you don't understand the layers, you won't understand where that fluid is sitting.

Okay.

Now what's sitting on the postrilateral surface of the testes, the epididymis?

The epididymis.

Visually, think of it as comma -shaped.

Texture -wise, the text describes it as softer than the testes.

Its whole job is storage, maturation, and transport of sperm.

So it's like a sperm nursery and boot camp all in one.

That's a great way to put it.

It consists of these tightly coiled tubules.

And importantly, for the exam, you should be able to feel a sulcus or a little groove that separates the epididymis from the testes.

Okay.

So we have the factory, the testes, and the storage unit, the epididymis.

Now we need the transport system.

This is the vas deferens.

And Bates traces this journey explicitly, and it is quite a trek.

It is.

It's a long road.

It starts at the tail of the epididymis.

The vas deferens is a firm muscular cord.

It travels up out of the squirtle sac, go through the inguinal canal, and enters the pelvic cavity.

And this is where my mental map usually gets a little fuzzy, but the text is very clear.

It loops anteriorly over the ureter.

Right, which is an important surgical landmark.

It goes behind the bladder and then merges with the seminal vesicle.

Exactly.

And once it merges with the seminal vesicle, it's not called the vas deferens anymore.

It becomes the ejaculatory duct.

Okay.

And that duct then traverses the prostate gland and finally empties into the urethra.

So during ejaculation, secretions from the vas, the seminal vesicles, and the prostate all mix together to form the seminal fluid.

And when we talk about the spermatic cord, which we're going to palpate in the exam, we aren't just talking about the vas deferens, are we?

No, it's a bundle.

The spermatic cord consists of the vas deferens, but also all the blood vessels, the nerves, and muscle fibers, specifically the cremaster muscle.

So you feel all of that together as one cord -like structure.

That's right.

Okay, let's move to the landscape of the exam itself, the groin.

Figure 22 in the text is the guide here.

It talks about the junctional area between the abdomen and the thigh.

Yes.

And we have this triangle of landmarks we absolutely need to know.

You cannot do a proper hernia exam without these three points.

You have the anterior superior iliac spine, the aces, that bony point on your hip.

Right.

You have the pubic tubercle on the pubic bone.

And running between them is the inguinal ligament.

You can almost feel it on yourself if you press deep enough.

You can.

Yeah.

And the inguinal canal lies just medial and parallel to that ligament.

It's like a tunnel, really.

It's exactly a tunnel.

And tunnels have openings.

You have the internal ring, which is the internal opening.

The text notes this is about one centimeter above the midpoint of the inguinal ligament.

But, and this is super important, neither the internal ring nor the canal itself is palpable through the abdominal wall.

You can't the internal ring directly from the outside.

But you can feel the external ring.

Yes.

The external ring is described as a triangular slit -like structure.

And it's located just above and lateral to the pubic tubercle.

That is the exit door of the tunnel.

And that is a palpable landmark.

That's our target.

That's where we're going to be directing our attention and our finger during the hernia exam.

Now, that's the inguinal canal.

But there is another canal nearby that causes a femoral canal.

How do we locate that one?

Bates gives us a very specific and honestly, very useful finger method for this.

It's all happening below the inguinal ligament.

You place your right index finger on the patient's right femoral artery.

You find the pulse.

Okay.

Your middle finger will then naturally overlie the femoral vein.

And your ring finger that sits right on the femoral canal, navel, from lateral to medial, nerve, artery, vein, empty space, lymphatics.

That E is the femoral canal.

Index on artery, middle on vein, ring on canal.

Why does that specific location matter so much?

Why do we care about that canal?

Because femoral hernias protrude right there.

And the text warns us.

Femoral hernias are distinct from inguinal hernias.

They are much more likely to present as emergencies with bowel incarceration or strangulation.

Oh, wow.

So knowing exactly where to put that ring finger is a safety issue.

If you feel a mass there, your level of concern should immediately go up.

Okay.

Speaking of safety and connecting the dots, we need to talk about the lymphatic drainage.

This is one of those rules that if you don't know it, you will absolutely miss a diagnosis.

You will because the drainage pathways are not all the same.

They're not intuitive.

So where does everything drain?

It's strictly divided based on embryology.

Lymph from the skin of the penis and the scrotum drains to the inguinal nodes, the ones you can feel in the groin.

Okay.

So a skin infection on the penis would cause a swollen groin node.

Exactly.

The deep and external inguinal nodes specifically.

But what about the tests themselves?

That's the million dollar question, isn't it?

It is.

And this is the crucial clinical note.

The testes develop intra -abdominally, remember, near the kidneys.

So their lymph drainage follows their blood supply all the way back up into the abdomen.

They don't drain to the groin.

They do not.

They drain into the lumbar and pre -aortic nodes deep inside the abdomen.

So practically speaking, if a man has testicular cancer, you will not feel it in the inguinal nodes.

If you feel an enlarged inguinal node, it's probably an issue with the penis or the scrotum infection, the skin lesion, but a testicular mass itself drains deep or you can't palpate the nodes at all.

That is a massive, massive distinction.

Wow.

Okay.

Before we get to the interview, the text touches briefly on sexual development and function.

It mentions the hormonal cascade.

Right.

The hypothalamic pituitary gonadal axis.

Hypothalamus releases GRH.

That tells the pituitary to release LH and FSH.

And what do LH and FSH do?

To oversimplify it, but keep it clinically relevant, LH stimulates testosterone production in the lady cells of the testes.

FSH regulates sperm production in the seminiferous tubules.

But the text highlights another hormone, 5 -alpha -dihydrocastosterone or 5 -alpha -DHT.

What makes that one so special?

Well, testosterone is converted to 5 -alpha -DHT in the tissues and 5 -alpha -DHT is like the super testosterone.

This is the specific trigger for most of the pubertal growth, the body hair, the voice change, the genital growth.

Got it.

And regarding the physiology of an erection, it describes an interplay of neural signals.

Yes.

It's not just one pathway.

It distinguishes between visual or auditory stimuli, you know, psychogenic erection versus tactile stimuli, which is a reflex erection.

Visual and auditory cues trigger sympathetic outflow from the T11 to L2 spinal levels.

And tactile.

Tactile stimulation, actually touching, triggers parasympathetic pathways from S2 to S4.

Both pathways ultimately increase nitric oxide and cyclic GMP, which leads to local vasodilation and the erection itself.

It's a complex neural handshake.

Okay, let's pivot.

We have the anatomy down.

We have the map.

Now we have a patient in the room.

We are moving into the health history,

the interview.

And Bates addresses the elephant in the room immediately.

This is awkward.

The text acknowledges that our training in sexual health is often limited, but the clinician's demeanor is everything.

You have to be respectful, direct, and non -judgmental.

The goal is simply to make the patient comfortable enough to be honest.

Exactly.

If they are comfortable, you don't get the history, and you miss the diagnosis.

End of story.

So what are the common or concerning symptoms we are hunting for?

Discharge is a big one.

And we need to differentiate by its appearance.

If a patient reports discharge, your first question should be, what does it look like?

And what are the classic descriptions?

Yellow discharge strongly points toward gonorrhea.

White or scanty, clearish discharge points toward non -gonococcal urethritis, which is usually chlamydia.

Okay.

Then there are lesions.

Right.

And again, use your eyes and your history.

Are they painful?

Are they ulcers?

Are they warts?

Ulcers usually suggest either syphilis, which is classically painless, or herpes, which is classically painful.

And warts?

Warts are almost always HPV.

What about itching?

Cruritus.

If the chief complaint is intense itching, look very closely at the skin for excoriations.

Those are scratch marks.

You should immediately suspect lice, which the text calls

pediculosis, pubis, or scabies.

And then there's pain and swelling in the scrotum.

We have to distinguish between painless and painful.

Right.

This is a critical differential.

You have to sort this out.

Painless swelling could be something benign like a hydrosil, or it could be something like cancer.

And painful swelling.

Painful swelling is an emergency until proven otherwise.

You're thinking about infection like epididymitis or orchitis, or the true surgical emergency testicular torsion.

The text also gives us a script for addressing STIs.

It suggests a very specific way to phrase the question about sexual practices because, as it says, STIs can happen anywhere.

I love this quote from the book.

It's so practical.

It says, tell the patient,

sexually transmitted infections can involve anybody opening where you have sex.

That's a great line.

It is because it immediately justifies why you're asking about oral and anal sex.

It's not about being nosy.

It's about biology and risk.

And it also mentions universal HIV testing.

Yes.

Ask every patient, do you have any concerns about HIV infection?

It should just be part of the routine screening conversation.

And finally, under history, it mentions systemic connections.

You aren't just looking at the groin in isolation.

Never.

You have to think about the whole body.

If a patient comes in with a genital lesion, but also has a rash on their hands and feet, plus joint pain and a fever, you have to think bigger.

You have to think about disseminated gonococcal infection or secondary syphilis.

The genital exam is part of the whole body assessment.

All right, let's get into the action.

The physical examination, step -by -step techniques.

First off, getting started.

Anxiety management starts before you even touch the patient.

Explain every single step before you do it.

Tell them what you're going to do and why.

Positioning.

The patient can be standing or sitting.

Standing is often better for the hernia exam.

Yeah.

And you must wear gloves.

No exceptions.

And draping.

Draping is key.

It's about dignity.

You want to expose the groin, but keep the chest, abdomen and thighs covered with a sheet.

Okay, we are inspecting the penis.

What are we looking for?

Start with the skin.

Look to those excoriations we mentioned for lice.

Then the prepuce.

If they're uncircumcised, you must retract the foreskin.

This is non -negotiable.

You have to do it to detect chancres or carcinomas that might be hiding underneath.

And the text defines two terms here that are really important.

Fomosis and parafomosis.

Right.

Fomosis is when the foreskin is too tight and it cannot be retracted at all.

You just can't pull it back.

And parafomosis.

Parafomosis is the opposite.

It's when the foreskin is retracted, but it's so tight it can't be returned to its original position, it gets stuck.

And that's a problem.

That's a medical issue because it can act like a tourniquet and cause swelling and edema of the glands.

So we check the glands for inflammation, which is called ballonitis, and we check the metis position if the hole is on the bottom.

It's hypospadias.

And if it's on the top.

That's hypospadias.

Much rarer, but you have to look.

Correct.

Now, for discharge, figure 20 to 3 in the book shows the technique.

Yes.

You just gently compress the glands between your index finger and thumb.

If the patient tells you they've had discharge but you don't see any, you can ask them to milk the shaft, to strip the shaft from the base of the glands to try and expel any fluid.

Then we palpate the shaft.

That's right.

You're feeling for any induration, any hardness.

The text specifically mentions Peyronie disease here, which presents as palpable hard plaques under the skin that cause a painful curvature during erection.

And this is a huge safety tip.

Yeah.

What do you have to do before moving on?

If you retracted the foreskin for the exam, you absolutely must replace it before moving on.

Why is that so important?

Because if you leave it retracted, you can cause a paraphormosis.

You could be the one causing the medical emergency.

Always replace the foreskin.

Good catch.

Okay.

Now we move to the scrotum and its contents.

Inspection first.

Lift the scrotum up so you can see the backside.

You might see epidermoid cysts.

Figure 20 -4 shows these pretty well.

What do they look like?

They're benign, dome -shaped, and usually yellow or white nodules.

They're basically just occluded follicles.

Nothing to worry about, but you should be able to identify them so you can reassure the patient.

And we also check the contour for asymmetry.

Right.

Is one side of the scrotum noticeably smaller or emptier?

That could suggest cryptorchidism, which is an undescended testicle.

Now, palpation technique.

One hand or two?

Either works.

Whatever you're comfortable with.

Figure 20 -5 shows the technique.

You want to cradle the testes.

You gently slide the contents, the testes and epididymis, between your thumb and first two fingers.

And what are the normal findings you're looking for?

You're looking for something that is firm, descended, symmetric with the other side and non -tender to gentle pressure.

An abnormal.

What's the biggest red flag?

A painless nodule.

Any hard, fixed painless lump on the testicle itself is cancer until proven otherwise.

We also have to feel the epididymis and the spermatic cord.

The epididymis is on the posterior surface.

It should feel nodular and cord -like.

It's really important not to confuse it with an abnormal mass.

And the spermatic cord.

You palpate it from the epididymis all the way up to the external inguinal ring.

The vas deferens within it should feel slightly stiff and tubular.

And if it feels like a bag of worms.

That is the classic textbook description of a varico -U.

Those are dilated varicose veins in the spermatic cord.

You can't miss it once you've felt it.

Okay, now we get to the section that I think requires the most technical skill, special techniques, specifically for hernias and masses.

This is where that anatomy we learned really meets the mechanics of the exam.

We know that 96 % of growing hernias are inguinal, but we have to evaluate them properly.

Walk us through the palpation technique in figure 20 to 7.

Let's do this step by step.

Okay, so you're going to ask the patient to stand.

You place your finger at the anterior inferior margin of the scrotum.

You're actually going to push upward, invaginating or sort of folding the loose scrotal skin into the inguinal canal.

So your finger is kind of pushing the skin ahead of it into the tunnel.

Exactly.

You're following the spermatic cord up towards the inguinal ligament.

Okay.

You find the external inguinal ring, that slit -like opening we talked about.

Your finger should slip right into it.

You can gently palpate the ring in its floor.

Then with your finger in that spot, you ask the patient to turn his head and cough.

And you are feeling for a bulge, a distinctive impulse.

A very distinctive impulse.

And the text gives us a guide to interpreting that cough impulse, although it does note that clinical differentiation is difficult.

The sensitivity is only about 74%.

But what's the general rule?

Generally, if the bulge touches the very tip of your finger, it suggests an indirect hernia.

That's a hernia coming down the canal from the internal ring.

And if it pushes against the side of your finger?

That suggests a direct hernia, which is coming from a weakness in the floor of the canal near the external ring.

It's bulging straight out.

And the text reminds us to check for femoral hernias too.

Absolutely.

You have to palpate the anterior thigh, just medial to that femoral canal location we found earlier.

Feel for any bulges there when they cough.

And we also have to check for reducibility.

Yes.

Can the mass be pushed back in?

If it's tender or if the patient feels nauseous when you try, you stop immediately.

You have to suspect incarceration or strangulation.

Which is a surgical emergency.

A surgical emergency.

A blood supply to the bowel could be cut off.

Okay.

What if there is a mass in the scrotum and we aren't sure if it's a hernia that's gone all the way down or if it's something else like a hydrocell?

The text suggests the Get Above It test.

This is a fantastic bedside trick.

It's so simple and so effective.

You try to get your fingers above the mass within the scrotum.

What does that tell you?

If you can place your fingers above the mass, it means the mass is contained within the scrotum.

It's probably a hydroseal or a testicular mass.

And if you can't?

If you cannot get above it, if the mass feels like it continues up into the inguinal canal, it's almost certainly an inguinal hernia that has descended down from the abdomen.

That's a great clinical pearl.

What about transillumination?

Another classic old school tool.

You darken the room,

you take a strong light source like a pen light or an otoscope head, and you shine it through the scrotum from behind the mass.

And what are you looking for?

If it glows red, it means the light is passing through fluid.

It's cystic.

That's a positive transillumination and it strongly suggests a hydroseal.

And if it doesn't glow?

If it blocks the light completely, it means the mass is solid.

It's made of tissue or blood.

That could be a hernia, a tumor, or just the normal testis itself.

Okay, let's talk about testicular self -examination or TSE.

The book mentions there's a bit of a debate here.

There is.

The U .S.

Preventive Services Task Force, the USPSTF, actually says not to screen asymptomatic men.

They give it a D recommendation.

But the American Cancer Society says something different.

Right.

The ACS says men should be aware of what's normal for them and report changes.

So Bates provides the instructions in box 20 to 1.

And what are those instructions?

The best time is after a warm bath or shower when the scrotal skin is relaxed.

You want to teach the patient to gently roll the testicle between their thumb and fingers.

And what's the crucial thing to teach them?

To identify the epididymis on the back of the testicle.

It's a normal cord -like structure.

So many men freak out thinking that's a lump.

You have to teach them what's normal so they can recognize what's abnormal.

And what should they report?

Any heart lumps?

Any painless enlargement?

Or any new pain?

We are coming down the homestretch now.

Documentation and clinical reasoning.

How do we write this down in the chart?

Bates contrasts normal and abnormal, which is really helpful.

A good, crisp, normal note might read,

testes descended bilaterally, smooth without masses,

epididymis nontender.

Clear and concise.

Exactly.

But an abnormal note needs more detail.

Give me an example.

Something like, one by one centimeter firm nodule on the left lateral testicle.

It is fixed and nontender.

That description immediately triggers a suspicion of carcinoma in anyone who reads the note.

The details matter.

The text also provides these incredibly useful tables, 20 to 1 through 20 to 4, breaking down specific abnormalities.

Let's hit the highlights.

STIs from table 211.

Okay.

Primary syphilis presents as a painless erosion, a chonker with a clean base.

The incubation period is long, 9 to 90 days.

Contrast that with genital herpes.

Genital herpes presents as grouped vesicles on an erythematous base, and they are typically very painful.

The incubation is much shorter, 2 to 7 days.

And chancroid.

Chancroid is a painful, deep ulcer with ragged necrotic margins.

Very different look.

And HPV.

HPV presents as condylamata acuminata, which are these cauliflower -like warts.

Now let's jump to the scrotal abnormalities in tables 23 and 20 to 4.

We've mentioned torsion a few times.

Testicular torsion is an acute event.

It is acutely painful, and the scrotum is swollen.

A key physical finding is that the affected organ is often retracted upward in the scrotum.

It's sitting higher than the other one.

And the key sign.

The chromastorheic reflex is absent.

If you stroke the inner thigh, the testicle does not rise.

This is a surgical emergency.

Time is tissue.

What about acute epididymitis?

How is that different?

That's inflammation of the epididymis.

It's also painful and swollen, and often it's so inflamed that it's hard to distinguish from the testes itself.

And the cause.

It's usually bacterial.

In younger sexually active men, you think chlamydia or gonorrhea.

In older men, you think E.

coli from a urinary source.

And crimtorchidism.

That's the undescended testes.

The scrotal sac is empty or atrophied on one side.

This is a huge deal because it's the major risk factor for developing testicular cancer later in life.

One more from the tables.

Spermatotulli.

Spermatotulli is a painless cystic mass that's found just above the testes.

It feels separate from the testes itself, and it will transaluminate because it's filled with fluid containing sperm.

Okay.

Last section.

Health promotion.

The bigger picture.

Let's talk about testicular cancer.

It's the most common solid cancer in men ages 20 to 34.

The statistics are important to know.

And the risk factors.

We mentioned the big one.

Pryptorchidism is number one.

An undescended testicle increases the risk somewhere between three and 17 times.

Other risks are family history, Klinefelter syndrome, and HIV infection.

What's the prognosis?

The good news is the prognosis is excellent if it's caught early.

It is highly curable.

The text says about 70 % of cases are localized at the time of diagnosis.

And of course the text closes with STI prevention referencing the need for screening based on risk behaviors.

Right.

Screening for gonorrhea, chlamydia, syphilis, and HIV.

It all ties back to taking that good non -judgmental history.

This has been a massive amount of information.

From the three columns of the penile shaft all the way to the get -above -it test for hernias.

It is a lot, but it's so logical.

If you understand the anatomy, the why, then the exam steps, the how, just make sense.

And it lets you recognize the true emergencies.

Exactly.

You can differentiate torsion and strangulated hernias from the more chronic issues, and that's what saves lives.

And I think it's worth reflecting on the text's introduction again.

It mentioned the closet in medical education when it comes to sexual health training.

I remember that line.

By mastering Chapter 20, by getting comfortable with these words and these movements, we are in a way stepping out of that closet.

We're providing better, more complete, and more inclusive patient care.

Absolutely.

Competence cures awkwardness.

Yeah.

Every time.

Well said.

That brings us to the end of this deep dive into Bates's Chapter 20, male genitalia.

Thank you for listening, for visualizing, and for learning with us.

Keep practicing those landmarks and those techniques.

Signing off from the Last Minute Lecture Team.

We'll see you on the next deep dive.