Disorders of the scrotum and testes Flashcards
What is cryptorchidism? Related to what?
- undescended testes or absent testes (agenesis)
- occurs when 1 or both testicles fail to move down into the scrotal sac
- bilateral 10-20% of cases
- incidence is directly related to birth wt and gestational age:
1/3 of premature mailes
cause in full term infants poorly understood
3-5% of full term infants are born w/ undescended testicles:
most cases idiopathic
some may be genetic or hormonal
Pathology of cryptorchidism?
- testes develop intra-abdominally in fetus and usually descend into the scrotum through the inguinal canal during the 7th to 9th month of gestation
- undescended testicles remain in the lower abdomen or at a pt of descent into inguinal canal
- the scrotal sac is empty
- the testis either isn’t palpable or can be felt external to inguinal ring
- spontaneous descent often occurs during 1st 3 months of life
- by age 6 mo, incidence decreases to 0.8%
- spontaneous descent rarely occurs after 6mo
What pathological changes to undescended testicle can be demonstrated at 6-12 months?
- delay in germ cell development
- changes in spermatic tubules
- reduced number of leydig cells
- when the disorder is unilateral, it also may produce morphologic changes in contralateral descended testicle
Consequences of cryptorchidism?
- infertility:
increases if disorder is bilateral
decreased sperm counts
poorer quality sperm - malignancy: risk is increased (can’t examine testes)
- indirect inguinal hernias
- increased incidence of testicular torsion
Exam and dx of cryptorchidism?
- careful exam of genitalia in male infants
- diff b/t undescended testes from retractable testes:
retract into inguinal canal w/ cremasteric muscle reflex - are usually palpable by birth, careful palpation in warm room can bring them down
- usually assume a scrotal position during puberty
dx:
US occasionally
laparoscopy for dx and tx if not palpable
Tx goals of cryptorchidism and tx?
- enhance future fertility potential
- placement of gonad in favorable place for cancer detection
- improved cosmetic appearance
- orchiopexy should be considered after 6 mos of life, as rate of descent diminishes considerably after this pt:
surgical placement and fixation of testes in scrotum, 95% of orchiopexy pts will be fertile - hormone therapy w/ hCG or LHRH no longer considered useful in helping testes descend
F/U after tx of cryptorchidism?
- lifelong f/u:
infertility issues
testicular cancer issues - upon reaching puberty, instruct boys in necessity of testicular self exam, should be done monthly
What is a hydrocele? Due to what?
- excess fluid collects b/t the layers of tunica vaginalis usually peritoneal fluid due to weakness in the patent processus vaginalis
- can be unilateral or bilateral
- due to primary congenital defect or secondary condition
- palpated as cystic mass, can become quite large, mass can be mistaken for solid tumor
Primary congenital hydrocele - seen in? Tx indicated?
- male infants and kids
- assoc w/ indirect inguinal hernia
- infant hydroceles usually close spontaneously
- if persists beyond 2 yrs of age, surgical tx is indicated
Secondary causes of hydroceles?
- trauma
- epididymitis
- testicular torsion
- orchitis
- infection
- testicular cancer
- appendiceal torsion
Dx of hydrocele?
- transillumination:
shining light through scrotum for purposed of visualizing its internal structures - US:
determination of underlying conditions if not in neonate, eval if can’t transilluminate
What should be considered if hydrocele develops in young man w/o apparent cause?
- it should be considered cancer until proven otherwise
- careful eval is needed to exclude cancer or infection
Presentation of hydrocele in adult male?
- relatively benign condition
- is often asx
- feeling of heaviness in scrotum
- pain in lower back
Tx of hydrocele?
primary causes:
if it’s painful or cosmetically undesirable, surgical correction if indicated, can be done inguinally or transcrotally
- secondary causes:
tx condition causing hydrocele, if it is benign and communicating w/ peritoneal cavity then surgery is necessary to close defect
What is a hematocele? Etiologies?
- accum of blood in tunica vaginalis
- can compromise testicle
- causes scrotal skin to become dark red or purple
- etiologies:
abdominal surgical procedure
scrotal trauma
bleeding disorder
testicular tumor
Characteristics of a spermatocele?
- painless, sperm-containing cyst that forms on the epididymis
- located above and posterior to testicles
- attached to the epididymis
- separate from the testes
- may be solitary or multiple
- usually greater than 2 cm
- freely moveable and should transilluminate
- rarely cause problems
- if large, may become painful and reqr excision
What is varicocele?
- varicosities of pampiniform plexus
- network of veins that supply the testes
- if condition is persistent - damage to elastic fibers and hypertrophy of vein wall occurs (like varicose veins in legs)
- sperm concentration and motility are decreased in 65-74% of men
- rarely found b/f puberty
- highest incidence in men b/t 15-35 yo
Why is L side more common for varicoceles?
- left gonadal vein inserts in L renal vein at a R angle
- right gonadal vein enters inferior vena cava
- incompetent valves are more common in the left, causing reflux of blood back into the veins of pampiniform plexus
- force of gravity resulting from upright position also contributes to venous dilatation
Sxs and exam findings of varicoceles?
- can be asx
- dull aching, atrophy, and infertility
- an abnormal feeling of heaviness in L when stnading and relieved when recumbent (when lying down pain goes away, throughout day gets worse)
- usually readily dx on PE:
exam should be done w/ pt in standing and recumbent position
varicocele typically disappears in supine position
scrotal palpation will feel like a bag of worms
Tx of varicocele?
-surgical ligation of gonadal vein
- interventional radiology: embolization of veins
- necessary in young males who are showing testicular atrophy
- obliteration of dilated veins:
some improvement in infertility, relief of heavy feeling, cosmetic improvement
- for those who are not needing increased fertility - NSAIDs and scrotal support
What is testicular torsion? ages affected?
- twisting of spermatic cord that suspends the testis
- 2 age peaks:
Perinatal and prepubertal
Presents b/t 10-25
-acute urological emergency
What is a sign of torsion of appendix testis?
Blue dot sign
Very painful
Characteristics of testicular torsion -congenital and neonates?
-less common
- firm, smooth, painless scrotal mass
- scrotal skin appears red
- some edema
- diff simplified:
Tumors, epididymitis, orchitis are rare neonates
Hydrocele is softer and transilluminates
- PE and exclude the presence of a hernia
Testicular torsion in peds and adolescents presentation?
True EMERGENCY! Testes rotates on long axis of tunica vaginalis, rotates about distal spermatic cord Cuts off blood supply to testis Rarely seen after 30 Early recognition and tx essential
Sxs of testicular torsion?
- pts present in severe distress w/in hours of onset
- often accompanied w/ N/V
- tachycardia
- large, firm and tender testes
- pain radiates to inguinal area
- testicle is often high in the scrotum and in abdominal orientation
- cremasteric reflex is frequently absent
- degree of swelling and redness depends on duration of sxs
Imaging for testicular torsion? Manual tx?
Color Doppler US must be done right away
- referral to urology: 4-6 hr window
- attempt manual detorsion which can be attempted with pain relief as the guide for successful detorsion
- procedure similar to opening of a book when provider is standing at pt’s ft
- most torsions twist inward and toward mid line, thus manual detorsion of testicle involves twisting outward and laterally
Surgical tx for testicular torsion?
Surgical detorsion and fixation of the testicle (orchiopexy)
Orchiectomy:
Done when testes deemed nonviable after surgical detorsion
Salvage rates are directly related to duration of its torsion
- usually prophylactic fixation of opposite testicle is performed
2 major types of epididymitis?
STIs: Assoc w/ urethritis Associated with young men N. Neisseria gonorrhea Chlamydia trachomatis
Primary non-STIs: Associated with UTIs and prostatitis Assoc w/ men over 35 E. coli Pseudomonas Gram positive cocci
Post vasectomy - shouldn’t have an infection: sperm become congested - inflammation
Trauma
Presentation of epididymitis?
Unilateral pain and swelling in epididymis over a period of days
- erythema and edema of the overlying scrotal skin, can become extremely large (reactive hydrocele)
- tenderness over groin or in lower abdomen
- fever
- dysuria
- could have urethral d/c if gonococcal
Labs for suspected epididymitis?
CBC
UA and culture
Urethral culture (or urine NAAT)
Gram stain
Tx of epididymitis?
Scrotal elevation and support
Abx appropriate to age, physical findings, UA, cultures or gram stain, sexual hx
Oral analgesics and antipyretics
Sexual activity or physical strain should be avoided until sxs resolve
What is hypogonadism?
testosterone deficiency w/ assoc sxs or signs, deficiency of spermatozoa production or both
- either primary or secondary
Etiology of hypogonadism?
- primary:
failure of testes to respond to FSH and LH
testosterone is low to inhibit production of FSH and LH
MC cause: Klinefelters - secondary:
failure of hypothalamus to produce GnRH or pituitary gland to produce enough FSH and LH
Signs and sxs of congenital hypogonadism?
- 1st trimester: results in inadequate male sexual differentiation
- 2nd or 3rd trimester: results in microphallus and undescended testes
Signs and sxs of childhood onset hypogonadism?
- impairs development of secondary sexual characteristics
as adults will have:
- poor muscle development
- high pitched voice
- small scrotum
- decreased penis and testicular growth
- sparse pubic and axillary hair
Signs and sxs of adult onset hypogonadism?
- decreased libido
- ED
- depression and anger
Dx and tx of hypogonadism? SE of tx?
- dx: begins with free/total testosterone levels FSH LH -tx: - TRT: gel transdermal axillary soln or patch aub-q implants IM injections - adverse effects: erythocytosis VTE acne gynecomastia low sperm counts
Definition of, and Causes of infertility?
- inability to get pregnant after trying for at least a year, about 1/3 of cases are caused by male factor
-causes:
blockage of repro system, meds, undescended testicles, infections - male factors:
pretesticular: cushings, prolactinoma
testicular: klinefelters
posttesticular: cystic fibrosis
H and P for infertility pt?
- aks about medical hx: previous semen analysis ED or other sexual dysfxn trauma previous pregnancies - PE: testicular size vas deferens spermatic cord penis rectum body habitus
Dx infertility?
- semen analysis: semen vol 2-5 ml pH 7.2-7.8 sperm density: over 20 mill motility: 50% forward morphology: over 60% normal - antisperm ab test - hormonal analysis - TRUS: seminal vesicles - scrotal US (varicoceles?)
Tx of infertility?
- boxer shorts
- avoid hot tubs
- timing of intercourse
- avoid illegal drugs, chemical and spermicidals
- meds:
clomid (viscous semen), imipramine (retrograde ejaculation), zoloft (premature ejaculation) - surgical:
varicocelectomy
vasovastostomy
testicular bx
transuretrhal resection of ejac ducts
