Note that in about 80% of men, pubic hair spreads farther up the abdomen in a triangular pattern pointing toward the umbilicus. Because this kind of spread, known as stage 6, is not completed until the mid-20s or later, it is not considered a pubertal change.
Testosterone levels decline with aging and may affect both libido and sexual function. Erection becomes more dependent on tactile stimulation and less responsive to erotic cues. Pubic hair may decrease and become gray. The penis decreases in size and the testicles drop lower in the scrotum. Although the testes often decrease in size with protracted illnesses, they do not necessarily change size with aging per se.
■ Sexual function, sexual preference
■ Penile discharge or lesions
■ Scrotal pain, swelling, or lesions
For men, questions about the genital system follow naturally after those dealing with the urinary system. You will need to review sexual function and screen for symptoms of infection. Begin with general questions such as "How is sexual function for you?" "Are you satisfied with your sexual life?" "What about your ability to perform sexually?" If the patient reports a sexual problem, ask him to tell you about it. Ask if there has been any change in desire or level of sexual activity in recent years. What does he think has caused it, what has he tried to do about it, and what are his hopes? Identify the patient's sexual preference as to partners (male, female, or both). Find out if the patient's partner has any concerns.
Direct questions help you to assess each phase of the sexual response. To assess libido, or desire, ask "Have you maintained an interest in sex?" For the arousal phase, ask "Are you able to achieve and maintain an erection?" Explore the timing, severity, setting, and any other factors that may be contributing. Have any changes in the relationship with his partner or in his life circumstances coincided with onset of the problem? Are there circumstances when erection is normal? On awakening in the early morning or during the night? With other partners? With masturbation?
Lack of libido may arise from psychogenic causes such as depression, endocrine dysfunction, or side effects of medications.
Erectile dysfunction from psychogenic causes, especially if early morning erection preserved; also from decreased testosterone, decreased blood flow in hypo-gastric arterial system, impaired neural innervation
Other questions relate to the phase of orgasm and ejaculation of semen. If ejaculation is premature, or early and out of control, ask "About how long does intercourse last?" "Do you climax too soon?" "Do you feel like you have any control over climaxing?" "Do you think your partner would like intercourse to last longer?" For reduced or absent ejaculation, "Do you find that you cannot have orgasm even though you can have an erection?" Try to determine if the problem involves the pleasurable sensation of orgasm, the ejaculation of seminal fluid, or both. Review the frequency and setting of the problem, medications, surgery, and neurologic symptoms.
To assess the possibility of genital infection from sexually transmitted diseases (STDs), ask about any discharge from the penis, dripping, or staining of underwear. If penile discharge is present, assess the amount, its color and consistency, and any fever, chills, rash, or associated symptoms.
Premature ejaculation is common, especially in young men. Less common is reduced or absent ejaculation affecting middle-aged or older men. Possible causes are medications, surgery, neurologic deficits, or lack of androgen. Lack of orgasm with ejaculation is usually psychogenic.
Penile discharge in gonococcal (usually yellow) and nongonococcal urethritis (may be clear or white)
Inquire about sores or growths on the penis, and any pain or swelling in the scrotum. Ask about previous genital symptoms or a past history of diseases such as herpes, gonorrhea, or syphilis. A patient who has multiple partners, is homosexual, uses illicit drugs, or has a prior history of STDs is at increased risk for STDs.
Because STDs may involve other parts of the body, additional questions are often indicated. An introductory explanation may be useful. "Sexually transmitted diseases can involve any body opening where you have sex. It's important for you to tell me which openings you use." And further, as needed, "Do you have oral sex? Anal sex?" If the patient's answers are affirmative, ask about symptoms such as sore throat, diarrhea, rectal bleeding, and anal itching or pain.
For the many patients without symptoms or known risk factors, it is wise to ask, "Do you have any concerns about HIV infection?" and to continue with the more general questions suggested on pp. 45-46.
Important Topics for Health Promotion and Counseling
■ Prevention of STDs and HIV
■ Testicular self-examination
See Table 10-1, Abnormalities of the Penis (p. 378) and Table 10-2, Abnormalities of the Male Genitalia (pp. 379-380). In addition to STDs, many skin conditions affect the genitalia; likewise some STDs have minimal symptoms or signs.
Infections from oral-penile transmission include gonorrhea, Chlamydia, syphilis, and herpes. Symptomatic or asymptomatic proctitis may follow anal intercourse.
Health promotion and counseling should address patient education about STDs and HIV, early detection of infection during history taking and physical examination, and identification and treatment of infected partners. Discussion of risk factors for STDs and HIV is especially important for adolescents and younger patients, the age groups that are most adversely affected. Clinicians must be comfortable with eliciting the sexual history and with asking frank but tactful questions about sexual practices. A minimal history includes identifying the patient's sexual orientation, the number of sexual partners in the past month, and any history of STDs (see Chap. 2, p. 45). Questions should be clear and nonjudgmental. You should also identify use of alcohol and drugs, particularly injection drugs. Counsel patients at risk about limiting the number of partners, using condoms, and establishing regular medical care for treatment of STDs and HIV. It is important for men to seek prompt attention for any genital lesions or penile discharge.
The U.S. Preventive Services Task Force recommends counseling and testing for HIV infection in the following groups: all persons at increased risk for infection with HIV, STDs, or both; men with male partners; past or present injection drug users; any past or present partners of individuals with HIV infection, bisexual practices, or injection drug use; and patients with a history of transfusion between 1978 and 1985.
In addition, encourage men, especially those between the ages of 15 and 35, to perform monthly testicular self-examinations and to seek physician evaluation for the following findings: any painless lump, swelling, or enlargement in either testicle; pain or discomfort in a testicle or the scrotum; a feeling of heaviness or a sudden fluid collection in the scrotum; or a dull ache in the lower abdomen or the groin. (See p. 377 for instructions to patients.)
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