case: scrotal mass

Question 1

testicular torsion

- clin presentation

Answer 1

• young (12-18 yo)
• severe, sudden pain w N/V
• high riding testis
• profound testicular swelling
• bell clapper deformity
• NO cremasteric reflex
• NO Prehns

Question 2

testicular torsion

- tx

Answer 2

• manual detorsion (meh)
• surgical emergency*
• orchipexy

Question 3

11 y.o boy with reactive hydrocele, localized tenderness, “blue-dot” sign

Answer 3

torsion of appendix

whats appendix testis? vestigial remnant of the mullerian duct

Question 4

tx of torsion of appendix?

Answer 4

NSAIDS

surgery only is persistent inflammation/ discomfort

Question 5

most common cause of scrotal pain in adults in outpatient setting

Answer 5

epididymitis

- gradual onset painful scrotal mass

Question 6

Man with 2 weeks of swelling, exquisite pain of epididymis and surrounding structures

also has fever, rigors, dysuria, urinary frequeny/ urgency

+ Prehns sign

+ Cremasteric Reflex

Answer 6

acute epididymitis

- less than 6 weeks

Question 7

Acute epididymitis

- diagnosis?

Answer 7

palpation shows induration and swelling of the epididymus with exquisite tenderness

get UA + culture

discharge? get urethral swab.

considering torsion? get US!

Question 8

Acute epididymitis

- tx?

Answer 8

if needs inpatient: IV abx, fluids

if just outpatient: NSAIDS, ice, oral abx

Question 9

chronic epididymitis

- clin presentation?

Answer 9

> 6 weeks

otherwise healthy dude but presents w scrotal pain

less severe

no spesis

maybe heavy physical exertion, biking, trauma
- d/t reflux of urine thru ejeculatory ducts –> “chemical inflammation”

Question 10

chronic epididymitis

- diagnosis?

Answer 10

epididymal tenderness (less than acute)

UA + culture

urethral swab if d/c present

US if needed

Question 11

chronic epididymitis

- tx?

Answer 11

infectious? oral abx, nsaids, ice, scrotal elevation*

noninfectious? elevation, rest, warm baths, nsaids

*lol

Question 12

most common complication of mumps infection in adult men?

Answer 12

orchitis

• gradual onset painful scrotal mass
• inflamm reaction of testes
• indistinguishable from epididymitis!!! (tx is the same)

Question 13

dilation of the pampiniform plexus of spermatic vv

Answer 13

vericocele
- LEFT gonadal v drains into left renal v first
vs right gonadal v drains directly into IVC

Question 14

Varicocele presentation & possible complication

Answer 14

• asymptomatic – dull, aching scrotal pain

complication: testicular atrophy, infertility

Question 15

Varicocele PE

Answer 15

stand for 10 mins

can do valsalva

Question 16

varicocele tx

Answer 16

asymptomatic? none!

infertile? pain? testicular atrophy? surgery.

Question 17

bacterial scrotal infection

Answer 17

scrotal cellulitis

Question 18

scrotal cellulitis clinical presentation

Answer 18

scrotal warmth, erythema, tenderness

gradual onset

F/C inguinal lymphadenopathy

Question 19

scrotal cellulitis tx

Answer 19

ABX to cover staph and strep, + MRSA

- inpatient/ outpatient depending on how sick

Question 20

what complication/ ddx do you NEVER want to miss with scrotal cellulitis?

Answer 20

FOURNIERS GANGRENE

• necrotizing fasciitis of male genitalia & perineum that primarily involves the subcutaneous tissues
• super smelly!!
• tx: broad spectrum abx; catheter, wound vac…

Question 21

collection of peritoneal fluid btwn the parietal and visceral layers of the tunica vaginalis

Answer 21

hydrocele

- painless, transilluminates

Question 22

hydrocele tx?

Answer 22

none! unless symptomatic, then surgical excision

Question 23

two types of hydrocele “special circumstances”?

Answer 23

1. Reactive Hydrocele (occurs w torsion, epididymitis, orchitis)
2. Communicating Hydrocele (infancy, diasappears when laying down, needs surgery!)