Clinical Approach To Diseases Of Contents Of The Scrotum Flashcards
What are the 4 main diagnosis of scrotum pain
1) epididymis
- shows gradual onset of posterior scrotal pain over 1-2 days
- hyperemia, swelling and hypervascular on color Doppler with US
2) testicular cancer
- can be asymptomatic but if pain its dull and chronic
- firm unilateral Nodule
- mass will show color Doppler on US (sometimes hyper vascular but sometimes normal)
3) testicular torsion
- sudden onset of severe unilateral scrotal pain
- high riding testis with absent cremaster reflex. Pain also increases with elevation of scrotum
- decreased or absent color Doppler on US (usually absent)
4) torsion of appendix testis
- sudden onset of severe diffuse scrotal pain
- shows the “blue dot” sign on scrotal examination
- hypervascular on Doppler affect of the appendix
Epididymitis
Infection of the epididymis
Symptoms
- Gradual onset of pain (1-2 days)
- usually posterior scrotal pain and swelling
- erythema of the scrotal skin
- fever and dysuria and increased urinary frequency can be present
- a (+) prehn sign = pain goes away with elevation of the scrotum
- normal cremaster reflex! (Distinguishes from a testicular torsion)
Diagnosis
- can be only clinically diagnosed, but other tests help determine pathogen
- midstream urinalysis
- urine cultures for all children and adults with a positive urinalysis
- if sexual active and under 35 or have a new sex partner = NAT test from urine looking fro gonorrhoeae or chlamydia
- ultrasound (if gotten) shows hyperemia, swelling and increased blood flow to the epididymis
Treatment:
- IM 250mg ceftriaxone 1 time period and PO 100mg doxycycline 2x daily for 10 days = all sexually active adults under age 35
- children = antibiotic treatment based on pathogen determined and referral to urologist
- adults a who had recent urinary tract surgery and/or practice anal sex = IM 250 mg ceftriaxone + oral levofloxacin 500 mg 1 time daily for 10 days
Hematocele and testicular rupture
Symptoms
- history of trauma with pains welling and usually ecchymoses as well
- is also very tender
- hematocele are usually not translucent (unlike hydrocele)
Treatment = pain control or surgery if needed
Inguinal hernias
Hernia of either bowel or abdominal muscles into he inguinal canal and scrotum
- more common in men if groin
- femoral hernia is more common in females
Symptoms
- gradual or acute pain
- **if strangulation of bowels = POOP and medical emergency to do surgery
- mass along the inguinal ligament that can bulge in the scrotum
- may feel like “dragging sensation” in groin especially at end of the day
- pain gets worse with valsalva or coughing**
- usually need to get US to confirm but not always
Treatment = surgery if incarcerated (cant reduce it) or strangulation is expected
- if asymptomatic and not incarcerated can just play “watch and see” case but even then they need surgery eventually (usually within 10 years)
Open surgery = only needs local anesthesia and is lower cost, however high complication risks
Laparoscopic surgery = low post op pain and complications but is expensive and requires general anesthesia (which may be contraindicated or bad in pulmonary patients)
Varicocele
Symptoms
- unilateral (usually) swelling mass that feels like a “bag of worms”
- is caused by swelling of the panpiniform plexus
- the mass often goes away when laying down but gets worse with standing (usually a dull ache pain)
Treatment
- surgery is most common
- may try scrotal support with NSAIDs but this often just results in needing surgery anyways
How is roster one found in the blood stream
Steroid hormone binding globulin (SHBG) = 44-66%
Albumin bound = 33-34%
Free or unbound = 1-4%
DHT, testosterone and estradiol effects in the male body
DHT
- masculinization of external genitalia
- prostate growth
- hair growth
Testosterone
- maturation of the wolffian duct
- muscle mass
- bone formation
- spermatogenesis
- erythropoiesis
Estradiol
- bone resorption
- epiphyseal closure
- hypothalamic pituitary feedback
- increase fat mass
- increases libido
- vascular and behavioral effects
What is the normal testicle size for adults?
3.5-5.5cm
In klinefelter its often normal for them to be <3.0 cm
How to conduct a testicular self-examination?
Grasp and roll the testicle between your thumbs and forefingers
- feeling for lumps,swelling, hardness or other abnormalities/asymmetries
What are the two most common causes of pain or swelling in the scrotal sac?
Orchitis or epididymitis
Testicular cancer
Most common solid tumor in 15-34yr old males
Overall 5-yr survival rate = 97% if treated
White are most common for testicular cancer by a wide margin
Risk factors
- cryptochidism
- prior history of germ-cell neoplasia in situ (GCNIS)
- age 15-34
- rare familial cases
- kleinfelter syndrome present
Are usually limited to within the tunica albuginea unless it gets really big or becomes metastatic
- also may present with a hydrocele
Usually is asymptomatic with only 10% showing with pain
What are signs and symptoms of testicular metastatic cancer
GI symptoms
- retroduodenal Mets usually
Gynecomastia
Headaches
Low back pain
Bone pain
Neck masses
- usually supraclavicular lymph nodes
Respiratory symptoms
Unilateral or bilateral extremity swelling
- Iliac or caval obstruction
any of these on top of the local scrotal symptoms (acute pain, dull ache, heaviness, swelling, etc)
Diagnostic testing and staging of testicular cancer
Scrotal ultrasound ALWAYS
- shows larger than 3.5 cm and is darker than normal
- NEVER biopsy = increases risk for metastasis!!
Get a chem panel, LFTs and tumor “markers”
- AFP = if high = NOT seminoma (high is 1000+)
- HCG = if high = Choriocarcinoma most likely (high is 5000+)
- LDH = if high = could be benign or metastatic disease (high is over 2x ULN)
**note 33% of seminomas show no lab panel increases
in high stages = all 3 can be really elevated no matter what subtype it is
Need to refer to urology for orchiectomy and recheck lab markers as needed
- then you need to get a CT abdomen/pelvis and chest xray to check for metastatic disease
- can also get brain MRI but only if signs are present brain Mets may be present
- DONT get PET
What is the biggest risk factors for seminoma and non-seminoma Germ cell tumors in testicular cancer
Seminoma
- biggest risk factor for survival is the presence of any Mets. If present = bad if not = good
NSGCT
- biggest risk factors are
- Mets
- AFP
- HCG
- LDH
- if Mets are present or any of the lab values are elevated = bad
If either are stage 2 = get chemo and take out lymph nodes (para-aortic and iliac) after orchiectomy
- stage 1 if low grade = can just monitor
- if stage 3/ = dont worry about lymph nodes and just do High dose chemo
What to do when monitoring patients post testicular cancer surgery and/or chemotherapy
Greatest risk of recurrence = 2-3 years after surgery and chemotherapy
- must follow for 5 years minimal
Follow up
- history and physical
- ultrasound and CT abdominal/pelvis if needed (as symptoms suggest)
- get lab markers for any testicular cancer that’s not seminoma stage 1-2a**
