Common testicular DOs

Question 1

Epididymitis: How does it happen?

Answer 1

Retrograde spread of urinary tract infection, STI, post-surgical constriction, or structural abnormality.

UTIs are rare. Urologic complaints, think of this.

Question 2

Epididymitis: how common is it?

Answer 2

• Uncommon in prepubertal males
• Uncommon in non–sexually active males without a history of genitourinary tract abnormalities
• 31% of all cases of scrotal pain and swelling

Question 3

Hx: what to expect with epididymitis

Answer 3

• gradual onset of pain localized in scrotum
• pain localized to epididymis, enlarged, tender and firm, hydrocele

Question 4

PE: what to expect w/epididymitis

Answer 4

• febrile > 101 F
• testicle normal
• • Prehn’s sign (elevation of testes on affected side decreases pain)
• • Chlamydia and/or Gonorrhea, pyuria, bacteriuria
• Remember GC/CT not automatically on Urine Culture

Question 5

MGMT for epididymitis

Answer 5

• STI treatment guidelines (2010) (e.g., PID)
  
  • Ceftriaxone 250 mg IM PLUS
  • Doxycyline 100mg BID x 10 days

If enteric organisms suspected (MSM insertive intercourse)

• Levofloxacin 500 mg BID OR
• Oflaxacin 300 mg BID x 10 days (E.coli & Pseudomonas)
• Motrin
• Close follow-up 48 hours
• Treat partners! Abstain until both adequately treated.

Question 6

Testing if suspect epididymitis

Answer 6

• Find source of infection through urine culture and/or culture/NAAT of urethra
• US to r/o abnormality if UTI (possible structural abnormality)

Question 7

DDx epididymitis

Answer 7

testicular torsion, tumor, abscess, infarction, testicular cancer, TB, & fungal epididymitis

Question 8

What is a varicocele?

Answer 8

distention of multiple veins and the spermatic cord which are visible and palpable in varying degrees

Teen boys: volume is most important. 2 bead difference esp.

Question 9

How and where to varicoceles happen?

Answer 9

• 90% occur on left side
• thought to be a result of incompetence of the spermatic vein, however many conflicting theories

Question 10

How are varicoceles graded?

Answer 10

• Subclinical: not palpable or visible identified on Doppler (most)
• Grade I: palpable during Valsalva only
• Grade II: palpable at rest not visible
• Grade III: palpable and visible at rest (very unusual for teen boy)

Question 11

Are varicoceles painful?

Answer 11

no

Question 12

What lab results would you expect with varicocele?

Answer 12

• FSH increased
• LH normal unless severe bilaterally
• Testosterone ? Lower usually older men
• Don’t typically do blood tests

Testosterone: usually was abnormal to begin with

Question 13

What is the treatment for varicocele?

Answer 13

surgical ligation or percutaneous testicular vein embolization if large

Question 14

What is the most common solid tumor in males 15-35yo?

Answer 14

testicular

Question 15

White vs Black - who is more likely to get a testicular tumor?

Answer 15

4(5):1 White:Black males

Question 16

Risk factors for testicular tumor

Answer 16

Cryptorchidism
Personal or FMHx of testicular cancer

Question 17

Characteristics of testicles / testicular tumor on PE

Answer 17

• Firm painless nodule that does not transilluminate (whereas fluid/hydrocele will)
• Scrotal edema affected side
• Enlargement of the testicle with/without change in consistency

Question 18

History of testicular tumor

Answer 18

Painless, fullness or heavy sensation in the scrotum

acute pain if hemorrhage or necrosis

change in sex drive

Question 19

associated sx of testicular tumor

Answer 19

Gynecomastia, change in sex drive, premature growth of body hair

Question 20

Associated S/S if disseminated cancer (testicular tumor)

Answer 20

hemoptysis, bone pain, abdominal mass or supraclavicular mass

Question 21

Types of testicular tumors

Answer 21

Seminomas
Nonseminomas

Question 22

Diagnosis of testicular tumor/ca

Answer 22

Ultrasound
Blood work for tumor markers

Question 23

MGMT of testicular tumor

Answer 23

• Surgery
• Management: Surgery, radiation, chemotherapy

Question 24

Cure rate for testicular tumor/ca

Answer 24

Early detection = > 90% cure rate - thus TSE taught to all male adolescents

Question 25

Describe the proper technique for performing a testicular self-exam to an adolescent patient and explain to the adolescent why it is important.

Answer 25

• best time is after a warm shower or while in the shower or bath when scrotum is relaxed.
• Gently roll each testicle between thumb and fingers of both hands. Hands should be warm. Normal testicle is egg-shaped and 4cm in length
• Testes may be different sizes, but have rubbery consistency and should be uniform. Left testicle usually lies slightly lower than the right
• Surfaces of your testes should be smooth with no lumps
• Check on top and slightly behind the testicle (the epididymis) → should be soft and slightly tender. Follow the epididymis up to check the spermaticcord → should be firm, smooth tubular structure
• If you feeel any lumps or hard areas, please let us know
• Teach them to come in as soon as they notice something!

Question 26

What is cryptochordism?

Answer 26

Undescended testis that cannot be drawn into the scrotum

Question 27

When does normal testicular descent occur?

Answer 27

8th month of gestation

Question 28

If testicles not drawn into scrotum by ______ then unlikely to descend later

Answer 28

3-4 months of life

Question 29

What is testicular torsion?

Answer 29

• Urologic emergency
• Pathophysiology: “bell clapper” deformity caused by the peritoneal investiture of the testis lying on the cord rather than on the lower pole of the testis
• causes ischemia and potential damage to the testis if not corrected

“infrastructure around testes not formed correctly” / Failure of the testis support structures

Question 30

Presentation of testicular torsion

Answer 30

• nausea and vomiting
• lack of urologic symptoms
• 10% may be painless
• pain begins in the abdominal area and be referred to the iliac fossa or groin before localizing in the scrotum
• 1/3 may have history of similar episode (resolved on own – partial torsion)
• usually wake up with it

Question 31

Most common age for Testicular Torsion

Answer 31

2/3 of cases occur between 12-18 years

Question 32

Anatomic variations in testicular torsion

Answer 32

• Bell-clapper –horizontal instead of vertical- can turn easily
• Loose epididymal attachment to testis: defect btwn epid & testis itself
• Torsed testis w/transverse lie: turning above

Question 33

Testicular torsion: what to expect on physical exam

Answer 33

• affected testis may be higher in the affected scrotum
• epididymis palpated in abnormal position – e.g., on medial side instead of lateral – hint may have turned
• Afebrile
• Cremastic reflex is absent (cremaster muscle does not pull up testis on effected side) – hit side of leg, won’t pull up like supposed to
• UA normal

Question 34

Treatment of testicular torsion

Answer 34

• Surgical exploration and correction necessary!
• Doppler flow studies
• Manual derotation by urologist

Question 35

Outcome for testicuar torsion

Answer 35

• 90% survival of testis
• delay of treatment by patient common

Question 36

Explain testicular torsion to a teen.

Answer 36

this happens when the chord inside your scrotum which is holding your testis gets twisted. It causes reduced blood flow to your testes and can be very painful. It needs to be fixed immediately. It is common at birth and right at puberty. It can be fixed by surgery, where the untwist the cord and make sure it is not at risk for twisting again in the future.

Question 37

Explain epididymitis to a teen.

Answer 37

This is an infection that started in your urinary tract and got deeper into your reproductive organs. It is most often caused by a UTI or an STI, and causes a fever, pain in your scrotum, and needs to be treated with antibiotics. Talk about safe sex..