Cryptorchidism and scrotal swelling

Question 1

Cryptorchidism

Answer 1

Failure of 1 or both testes to fully descend into scrotum. Low birth weight is key risk factor*

Question 2

History and exam for cryptorchidism

Answer 2

Bilateral cryptorchidism is associated with prematurity, oligospermia, congenital malformation syndromes (Prader-Willi, Noonan Syndromes), and infertility. Associated with increased risk of testicular cancer

Question 3

Dx of cryptorchidism

Answer 3

Testes cannot be manipulated into the scrotal sac with gentle pressure (vs retractile testes) and may be palpated anywhere along the inguinal canal or in the abdomen

Question 4

Tx of cryptorchidism

Answer 4

1) Orchiopexy by 6-12m (most testes will spontaneously descend by 3m)
2) If discovered later, treat with orchiectomy to avoid the risk of testicular cancer.

***Bringing testes into the scrotum does NOT lower the risk of testicular cancer

Question 5

Ddx of scrotal swelling

Answer 5

1) Hydrocele - not painful
2) Varicocele - not painful
3) Epididymitis - painful
4) Testicular torsion - painful

Question 6

Hydrocele

Answer 6

Caused by remnant of the processus vaginalis

Usually ASx, transilluminates*

Lab and rad workups are rarely indicated. Obtain an US if there is concern for inguinal hernia or testicular cancer.

Tx: usually none unless hernia is present or hydrocele persists beyond 12-18m of age (indicates patent processus vaginalis which leads to increased risk for inguinal hernia)

Question 7

Varicocele

Answer 7

Caused by dilation of the pampiniform venous plexus (bag of worms)

ASx or presents with vague, aching scrotal pain. Affects the L testicle more than the R. May disappear in supine position. Does NOT transilluminate*

Dx with US

Tx: If symptomatic or if testis makes up less than 40% of total volume, may be treated surgically with a varicocelectomy or ligation, or through embolization via IR

Question 8

Epididymitis

Answer 8

Caused by infection of the epididymis, usually from STDs, prostatitis, and/or reflux

Typically affects those over 30. Presents with epididymal tenderness, tender/enlarged testicles, fever, scrotal thickening, erythema, and pyuria. Pain may decrease with scrotal elevation (positive Prehn’s sign)

Dx with UA, culture (pyuria). Culture often shows Neisseria gonorrhoeae, E Coli or Chlamydia. Doppler US shows normal to increased blood flow to testes

Tx: ABx (tetracycline, fluoroquinolones); NSAIDs; scrotal support for pain

Question 9

Testicular torsion

Answer 9

Caused by twisting of spermatic cord, leading to ischemia and possible testicular infarction

Typically affects those under 30; presents with intense, acute-onset scrotal pain that remains the same or increases with scrotal elevation (neg Prehn’s sign). Pain is often accompanied by nausea, vomit, and dizziness. Loss of cremasteric reflex is also seen.

Dx with doppler US showing less blood flow to testes. If there is high clinical suspicion for torsion, do not wait for US and proceed straight to surgery

Tx: Attempt manual detorsion. Immediate surgery to salvage testis (the testicle is often unsalvageale after 6h of ischemia). Orthopexy of both testes to prevent future torsion.