5/14 Scrotum, Penis, Testis Flashcards
∆ = difference
What two tools can almost always help you diagnose scrotal masses??
ULTRASOUND *know this* Transilluminatio n(helps to see cystic structures)
What is acute scrotum?
acute painful swelling of the scrotum; various etiologies (infectious, inflammatory, neoplastic, trauma, vascular problems etc etc - we’ll go through 1-2 examples of each)
∆ btwn Epididymitis and Epididymo-orchitis?
Epididymitis - Infection of epididymis
Epididymo-orchitis - Infection of epididymis that extends to the testes
both are infectious causes of acute scrotum
What are the common causes of Epididymitis and Epididymo-orchitis?
know this
Children – congenital GU abnormalities; E. coli or GNR
Young men – Chlamydia and gonorrhea (usually sudden onset of pain in the testicles (indicative of infection), burning with voiding)
Older men – associated with LUTS, E. Coli or Pseudomonas
How can you tell if someone has chlamydia vs BPH as the cause of their Epididymitis and Epididymo-orchitis?
chlamydia - usually sudden onset of pain in the testicles (indicative of infection), burning with voiding
BPH - lower urinary tract symptoms (urgency/frequency)
How would gonorrhea cause Epididymitis or Epididymo-orchitis?
urethra –> prostate –> seminal vesicles –> epididymis
inflammation may lead to abscess and destruction!
How do you know if mumps is causing the orchitis?
acute orchitis occurs ~1 wk after the onset of swelling in the parotid glands
How do you know if TB is causing the orchitis?
orchitis usually occurs after subsequent infection in upper GU tract (prostate, seminal vesicles, kidney)
How do you know if syphillis (3˚) is causing the orchitis?
testes –> epididymis
presence of inflammation and endarteritis or gumma
What is the gross hx of Epididymitis or Epididymo-orchitis?
suppurative inflammation and abscesses (may lead to chronic inflammation and scarring)
What is the hx findings of Epididymitis or Epididymo-orchitis?
how do these things form?
sperm granulomas
integrity of BM of seminiferous tubules disrupted after inflammation/orchitis –> spillage of spermatozoa into the interstitium
Body mounts a strong immune response against acid-fast component in the lipid in spermatozoa –> formation of granuloma (contains histiocytes)
US finding of Epididymitis or Epididymo-orchitis?
increased or “reactive” flow secondary to inflammation
review: what causes fournier’s gangrene?
clinical presentation?
treatment?
polymicrobial (aerobic + anaerobic) infection
Necrotizing cellulitis and fasciitis, crepitus (air in skin)
emergency surgical debridement otherwise it can spread rapidly
What type of reaction does Henoch-Scholein Purpura cause in acute scrotum?
inflammatory cause of acute scrotum
review: what causes Henoch-Scholein Purpura?
When does it usually occur?
trmt?
Systemic vasculitis due to IgA immune complex deposition in post-capillary venules
often follows an acute respiratory illness (peak incidence is during the winter)
trmt: self-limiting
review: what is the typical presentation of Henoch-Scholein Purpura? (obv related it to acute scrotum..)
Tetrad of sx usually affects gravity dependent areas: palpable purpura joint pain abdominal pain glomerulonephritis
orchitis can result (pain/swelling of the testicles)
how can tumors cause acute scrotum?
Tumor that causes the tunica albuginea surrounding the testicle to tear
how can trauma to the testes cause acute scrotum?
Testicular rupture due to trauma, causes tears in the tunica albuginea surrounding the testicle, resulting in damage to the testicle. blood in the scrotum
What is a hematocele and how does it cause an acute scrotum?
hematocele - occur when blood collects under the tunica albuginea
usually occurs due to trauma to the testes…ouch.
How does testicular torsion cause an acute scrotum? What are the presenting sx?
Torsion (twisting of the spermatic cord and blood supply to the testicle), resulting in intense engorgement and hemorrhagic infarction if it is not rapidly corrected
Symptoms:
- sudden onset in testicular pain
- absent cremasteric reflet
What are the 2 types of testicular torsion? Who does it usually affect?/
Intravaginal torsion - adults
Extravaginal torsion - neonates
know this
What is intravaginal torsion of the testicles and how does it cause an acute scrotum?
who is most at risk?
testicle torsion occurs within the tunica vaginalis, usually bilateral
high risk with “bell clapper deformity”, where the tunica vaginalis testis completely encircles the testis, epididymis, and distal spermatic cord, thus predisposing the testes to torsion at a high point of attachment
What does intravaginal torsion occur?
increased weight of the testicle after puberty + sudden contraction of the cremaster muscle (which inserts in a spiral fashion into the spermatic cord) causes torsion
What is extravaginal torsion of the testicles and how does it cause an acute scrotum?
who is most at risk?
testicle torsion occurs outside of the tunica vaginalis, where the testes and gubernaculum are not fixed and can freely rotate.
The spermatic cord undergo torsion as a unit, twisting on its blood supply and causing infarction
NOTE that this is NOT associated with bell clapper deformity
US findings testicular torsion?
absence of flow in testes (can be unilateral or bilateral)
∆ in etiology btwn incarcerated hernia and strangulated hernia?
Incarcerated: bowel, omental, or abdominal content herniates but can be returned to its original compartment with manual manipulation
strangulated: blood supply to the herniated tissue is compromised (herniated contents pass through a restrictive opening that reduces venous return -> swelling that compromises circulation to affected area)
∆ in sx btwn incarcerated hernia and strangulated hernia?
incarcerated: severe pain + pulling in groin, nausea + vomiting
strangulated: severe pain + tenderness
Which one is a surgical emergency: incarcerated hernia and strangulated hernia
surgical emergency due to tissue necrosis risk
Path of indirect hernia?
enters internal (deep) inguinal ring (lateral to inferior epigastric artery)
exits the external (superficial) ring, and into the scrotum; usually follows the path of the descent of the testes.
covered by all 3 layers of the spermatic fascia
Why does indirect hernia occur? Who does it usually occur in?
testicles arises in the posterior abdominal wall and descends during gestation and exits the anterior abdominal wall into the testes and takes some of the peritoneum with it into the scrotum = tunica vaginalis is actually a piece of the peritoneum
usually the extended piece fibroses off but if it doesn’t then it is a potential space for hernia.
children/infants are almost always indirect hernias bc the tunica vaginalis hasn’t properly obliterated
path of direct hernia?
who does it usually occur in?
protrudes through the inguinal triangle (medial to the inferior epigastric artery) - directly through abdominal wall - and out external (superficial) inguinal ring
covered by external spermatic fascia; usually older men
What is a spermatocele? Does it cause acute scrotum?
it is an epididymal cyst that is slowly enlarging and occurs OUTSIDE of the tunica vaginalis
No it does not cause acute scrotum - this is actually painless cause it’s slow growing
If you were to aspirate a spermatocele, what would you find?
watery fluid that contains spermatozoa
How would you diagnose spermatocele?
US - fluid filled cyst
Transillumination (+)
How does a spermatocele compare to a hydrocele?
spermatocele = fluid OUTSIDE of the tunica vaginalis; + for spermatozoa
Hydrocele = fluid within the tunica vaginalis, - for spermatozoa (it’s a cystic dilation of an extra-testicular structure; lined by tunica vaginalis)
∆ btwn spermatocele hydrocele chylocele hematocele
spermatocele = fluid OUTSIDE of the tunica vaginalis
Hydrocele = fluid WITHIN the tunica vaginalis
Chylocele - chyle or fatty lymph WITHIN the tunica vaginalis; due to lymphatic obstruction or lymphatic rupture
Hematocele – blood WITHIN the tunical vaginalis
risk factors for testes cancer?
Cryptorchidism (undescended testicle)
Family hx/prior hx of testis cancer - greatest
Infertility – reflection of problems in the testicle
Iso-Chromosome 12p (+ in 70% of patients)
clinical presentation of testes cancer?
Males age 15-35
Painless solid mass of body of the testis
May have history of minor trauma
U/S: hypoechoic solid mass = cancer until proven otherwise
how does testicular cancer present on an US?
hypoechoic solid mass = cancer until proven otherwise
tumor markers of testicular cancer? bonus points if you can say where they are produced from.
AFP – yolk sac elements; t1/2 = 5d
ßhCG – produced by syncytiotrophoblasts; t1/2 = 24h
LDH – measure of cellular turnover or tumor burden
general treatment of testicular cancer? Why is it done this way?
inguinal orchiectomy - incision is in the abdomen prevents contamination of the scrotal lymphatics, which drain to the inguinal LN
How is testicular cancer graded?
TNMS: Tumor Nodes Metastases Serum Markers
How is testicular cancer staged?
Stage 1 – limited to testicle (T1-T4)
Stage 2 – primary + nodal tumor, but no evidence of metz
Stage 3 – evidence of metz
Two types of germ cell tumors?
Seminomatous GCT
Non-Seminomatous GCT
Types of Seminomatous GCT?
Seminoma
Spermatoctic seminoma
seminoma
when does it usually occur? is it malignant? prognosis? clinical presentation? tumor markers?
peak incidence: 30s
MALIGNANT - usually late metastasis, but excellent prognosis b/c it extremely sensitive to chemotherapy and radiation
painless, homogenous testicular enlargement
markers: isochromosome 12p, placental ALP
seminoma
gross hx:
micro hx:
Gross: firm, tan, solid, bulging, bulky, no necrosis or hemorrhage
microHx: sheets of lymphocytes + large polyhedral cells with “fried egg appearance”; divided by fibrous septa, may be associated w/ granulomatous reaction
Spermatoctic seminoma
when does it usually occur?
is it malignant?
prognosis?
tumor markers?
peak incidence: mid 60s
not malignant - does not metz outside of the testes; excellent prognosis b/c it extremely sensitive to chemotherapy and radiation
tumor markers: NONE
Spermatoctic seminoma
gross hx:
micro hx:
gross; mucoid, solid gray
micro: 3 cell types (small medium large, with medium being the most common) in edematous stroma, ø lymphocytes, ø granulomas (unlike the classic seminoma)
if the pathology shows a pure seminoma but there is an elevated AFP, what does this mean?
means that there is an undetected additional component of NSGCT and should be treated as a NSGCT
(Non-Seminomatous GCT)
Where does Non-Seminomatous GCT usually arise from?
What are the different types of Non-Seminomatous GCT?
Arise from germinal (seminiferous) epithelium
Tends to recapitulate normal embryogenesis - their pattern is usually differentiated toward >1 components of the embryo:
- Embryonal carcinoma
- Yolk sac tumor
- Choriocarcinoma
- Teratoma
Embryonal carcinoma is also known as:
is it malignant?
presentation?
tumor markers?
“angry tumor”
MALIGNANT
PAINFUL (worse prognosis than seminoma)
markers:
increased hCG + normal AFP when pure
increased hCG + increased AFP if mixed
Embryonal carcinoma
gross hx:
micro hx:
gross: variegated, hemorrhagic mass w/ necrosis
micro: glandular and papillary structures or solid patterns; usually contain pleomorphic, primitive cells with ill-defined cell borders
commonly mixed w/ other tumor types
Yolk Sac Tumor: where does it arise from? is it malignant? presentation? tumor markers?
extra-embryonic mesoderm and endoderm
aggressive malignancy
usually in boys < 3yo
tumor marker: AFP
Yolk Sac Tumor:
gross hx:
micro hx:
gross: non-encapsulated; homogenous yellow-white mucinous appearance
micro: Schiller-Duval body + hyaline globules
What are Schiller-Duval bodies?
found in YOLK sac tumors; endodermal sinus – central blood vessels surrounded by multiple layers of tumor cells – it tries to recapitulate the placenta; sort of looks like primitive glomeruli
Choriocarcinoma: where does it arise from? is it malignant? presentation? tumor markers?
extra-embryonic trophoblast of the placenta
high metastatic potential via hematogenous spread to the lungs and brain (may present with hemorrhagic stroke due to bleeding into the metz)
presentation: may produce gynecomastia or symptoms of hyperthyroidism (hCG is an LH and TSH analog)
tumor marker: hCG
Choriocarcinoma
gross hx:
micro hx:
gross: areas of hemorrhage “blood filled lakes” and necrosis
micro: presence of disordered syncytio- (larger) and cyto- (smaller) trophoblastic elements, usually around a blood-filled space due to hematogenous metz
Teratoma: where does it arise from? is it malignant? presentation? tumor markers?
somatic differentiation of ectoderm, endoderm, and mesoderm
malignancy depends on age - usually the ADULT form is malignant
2 distinct age peaks: infancy and young adulthood
tumor markers: usually hCG + AFP in 50% of cases
Teratoma - ∆ btwn mature and immature forms?
mature: structures derived from all 3 germ layers
immature: resembles embryonic tissue or fetal tissue
w/ secondary malignant component
Teratoma - ∆ btwn adult and childhood forms?
Childhood: usually completely MATURE, pure, and benign (regardless of any immature element)
Adult, esp in M: almost always have some IMMATURE elements, are usually mixed, and have malignant potential due to their metastatic potential (maturity ≠ benignity)
Teratoma
gross hx:
micro hx:
gross: variegated, nodular, solid & cystic
micro: subtypes are defined by the maturity of the tissues; various structures (gut, brain, keratin)
How do you treat a Non-Seminomatous GCT?
What is critical to note in the treatment of these tumors?
NSGCT is sensitive to chemotherapy.
Residual masses + draining LN may contain microscopic tumor cells or residual teratomatous elements even after chemo; must be SURGICALLY REMOVED or else it will grow into another tumor
Sex-Cord Stromal Tumors?
Leydig Cell tumor
Sertoli cell tumor
when and where does a leydig cell tumor present?
presents 20-60yo
present outside of the seminiferous tubules
sx of Leydig Cell tumor?
usually androgens producing
associated w/ precocious puberty in boys, gynecomastia in men,
Leydig Cell tumor
gross hx:
micro hx:
Gross: well-circumscribed, small, solid, usually homogeneous (golden brown in color)
histology: reinke crystals
where does a Sertoli cell tumor usually present? how does it compare to a leydig cell tumor?
present inside of the seminiferous tubules
leydig = outside
sx of sertoli cell tumor?
usually hormonally silent and benign
Sertoli cell tumor gross presentation?
well-circumscribed, small, solid, usually homogeneous (same as leydig)
Testicular lymphoma
who does it usually affect?
how does it arise?
is it malignant?
common testicular cancer in older men
not a primary cancer but actually arises from lymphoma metz to the testes
aggressive
Hypospadias - what is it?
Arrested penile development that results in:
- urethra that doesn’t reach the tip of the penis
- chordee (fibrotic areas that run along the ventral aspect of the penis and cause curvature of the penis
Hypospadias trmt?
DO NOT CIRCUMCISE - b/c the hooded foreskin is used to reconstruct the uretrha to make the child look normal
Epispadias/Extrophy - what is it? how does it occur?
Bladder is present on the anterior abdominal wall and the penis is split on the dorsal surface; due to failure of ingrowth of mesoderm into the cloacal membrane during embryogenesis
what is a phimosis? paraphimosis?
phimosis - normal; occurs at birth where the foreskin cannot be fully retracted over the glans penis
paraphimosis - foreskin becomes trapped behind the glans penis, and cannot be reduced (pulled back to its normal flaccid position covering the glans penis)
what is Balinitis?
Inflammation under the foreskin, usually related to poor hygiene or fungal infection
trmt: hygiene + antifungals +/- circumcision
What is Lichen Sclerosis et atrophicus?
What does it look like?
trmt?
complications?
Chronic infiltrating cicatrizing skin condition -> pathological phimosis and meatal stenosis
Appears as a white patch or roughened scale on glans or prepuce
treatment: Steroids + Circumcision
complications: phimosis, carcinoma?
what is Balanitis xerotica obliterans (BXO)
Lichen Sclerosis et atrophicus in MALES
Peyronie’s disease - what is it?
What is it caused by?
when does it usually occur and in what patients?
CT d/o where a fibrotic band in the corpora albugenia of the penis that results in a bending of the penis (does not affect the erectile tissue of the corpora cavernosa)
trauma (coital trauma or urethral instrumentation) causes an inflammatory fibrotic reaction
peak incidences: 20-80 years (median, 53 years) associated with the use of β-blockers, HTN, diabetes, and immune reactions, etc
What is Priapism? what is it usually associated with?
painful sustained erection not associated with sexual stimulation or desire
associated with
- trauma
- sickle cell disease (sickled RBC are trapped in vascular channels)
- medications (anticoagulants, PDE-5 inhibitors, SARI (trazaBONE), alpha blockers, cocaine)
when does penile fractures occur?
What is done when this occur?
Sudden bending of the penis during intercourse leading to rupture of the corpora cavernosa and rapid loss of erection; may injure urethra
Treatment: repair
What is Condyloma acuminata?
What is it caused by?
histological feature?
trmt?
flat, warty, papillary growth on genital surfaces
HPV, usually 6/11 strains
papillomatosis, acanthosis, hyperkeratosis, and presence of KOILOCYTES
chemical or physical destruction, immunotherapy, surgical treatment
What is penile cancer?
What is it caused by?
histological feature?
where does it usually metz to?
papillary or flat forms that begins on the glans or inner surface of the prepuce near the coronal sulcus
HPV, usually 16/18 strains
Invasive Squamous cell carcinomas with variable keratinizatio/ keratin pearl formation
Inguinal and iliac lymph nodes, hematogenous spread is uncommon
treatment of penile cancer?
control of primary tumor: local excision, laser, or partial penectomy (usually if the tumor is too large) +/- node dissection
must assess and treat inguinal nodes to look for metz (usually cancers start off in the penis -> inguinal LN -> pelvic LN -> metz)
