Disorders of the Testes, Scrotum and Penis Flashcards
A 14 y/o boy has sudden onset excruciating pain, N&V/ abdo pain, difficult to walk.
What may you expect O/E?
SSx = testicular torsion (10-30yrs w/ peak @13-25years)
O/E:
- extremely tender testis,
- slightly swollen,
- high riding/ horizontal/ abnormal lie of testis,
- twisted/ thickening in cord,
- fever,
- loss of cremaster reflex
What are the differentials for testicular torsion e.g. sudden onset excruciating testicular pain, N&V/abdo pain, difficult to walk?
NB: children may say “belly pain” - so ALWAYS examine a childs testicles (no excuse if this is missed in a kid!!!)
differentiate ddx of testicular torsion with US unless in suspected torsion which is a clinical diagnosis - do NOT delay surgery
DDx:
-
Epididymo-orchitis (E-coli): thickened epididymis, swollen testis, normal lie - older pt, UTI symptoms, gradual onset
- Prehns sign –> Elevation of the testis eases the pain - helpful to differentiate from torsion (where elevation doesnt help)
-
Torsion of hydatid of morgagni/ appendage:
- black spot at top of testis - remnant of the Mullerian duct, typically aged 7-12yrs
- Hydrocele: not too painful, fluid in tunica vaginalis, trans-illuminates
- Varicocele: dragging, end of day, worms above testis, valsalva (cough + they fill), renal/ retroperitoneal pathology
- Testis tumour: often painless
- Kidney stone: referred pain
- Idiopathic scrotal oedema - 2-10yrs
What is the immediate Rx of testicular tosion?
- IMMEDIATE surgical exploration,
- <6h salvage rate is 90-100%, - if >6hrs since onset of pain = HIGH RISK TESTICLE
- if >24h salvage rate is 0-10%
- If torsion:
- bilateral fixation - Bell-clapper testis variant (increases liklihood of torsion), other testis may be likely to twist so attach to dartos muscle
- If infarcted: remove testis & fix other side
- NB: so no matter which testicle pain is in surgically fix both as torison can happen again
What are these differentials for?
- psoas abscess,
- neuroma of femoral nerve,
- femoral artery aneurysm,
- saphena varix,
- lymph node,
- femoral/inguinal hernia,
- hydrocele,
- varicocele,
- undescended testis
groin lump differentials
What are these differentials for?
- torsion of testicle,
- torsion of testicular appendage,
- acute epididymo-orchitis,
- idiopathic scortal oedeam,
- acute inguinal lymphadenopathy
Acute testicular pain
What can cause scrotal swellings?
- tumour - malig (teratoma) or benign (cyst)
- inflammatory - epididymoorchiditis, viral orchiditis, schistosomal epidymitis, sperm granuloma
- traumatic - scotal haematoma, haematocele (w/i tunica vaginalis), testicular haematoma (w/i tunica albuginea testis)
- varicocele - dilated veins of pampiniform plexus (left side is more commonly affected)
- epididymal cyst (spermatocele)- small and transilluminable, can get above mass… ddx = hydrocele but this surrounds the testes)
- inguinal hernia - patent processus vaginalis (when closes forms tunica vaginalist) in children
- hydrocele = fluid within tunica vaginalis - heavy and uncomfortable
- 1o = younger men; 2o trauma/infection/tumour:
- Ix: uSS to check underlying testicle
- Rx: if symptomatic - ligate patent processus vaginalis and drain
-
persistence of embryological structures
- mullarian/wolffian duct remnants
- Henoch-schonlein purpura
What is the difference between a haematocele and a testicular haematoma?
(both a cause of scrotal swelling from trauma + scrotal haematoma)
haematocele (within tunica vaginalis, parietal layer and cavity of testicle),
testicular haematoma (within tunica albuginea testis, capsule of tesis)
A patient is feeling a dragging in their testicles, especially at the end of the day.
What do you excpect O/E?
- Varicocele - dilated veins of pampiniform plexus
- L side more commonly affected
- O/E - valsalva (cough + they fill)
- bag of worms above testis
- renal/retroperitoneal pathology
A patients testicles are feeling heavy and uncomfortable (not too painful) what causes may have occured to this mans testicles?
Ix?
Rx?
hydrocele = not too painful but heavy and uncomfotable tesis - from fluid within the tunica vaginalis (the serious membrane pouch w/visceral and parietal covering the testes)
causes:
1o in younger men
2o to tumour, trauma or infection
Ix:—> US to check underlying testicle (for tumour, trauma, infection)
Rx: IF SYMPTOMATIC - ligate patent processus vaginalis (embryological remnant) & drain
What could a painless lump on the testicle be?
Testis tumour - they are often painless
Cryptorchidism = undescended testis
This may occur due to what 3 types?
What is the associated risk?
- Retractile tesis
- (exaggerated cremasteric reflex; triggers: cold, O/E, excitement or physical acitivity. Is normal and will descend when relaxed and warm, can be manipulated back into scrotum, dont neet Rx, but increase risk of becoming ascending or acquired undescended tesis)
- maldescended testis
- ~unilateral, hormonal (tesosterone/GnT) or anatomical involvement - can be arrested (stopped along path of descent) or ectopic
- ectopic testis
- descent has deviated from the normal path
maldescended and ectopic testis = increased risk of testicular cancer (?+ fertility problems w/cryptorchidism)
What condition does this describe?
- Narrowness of preputial opening, preventing retraction & exposure of glands
- Physiological in young children (normally resolves w/i first 3-4yrs of life)
- or 2o to scarring (will not resolve spontaneously)
- Circumcision can be performed as Rx
Phimosis
- Narrowness of preputial opening, preventing retraction & exposure of glands
- Physiological in young children (normally resolves w/i first 3-4yrs of life)
- or 2o to scarring (will not resolve spontaneously)
- Circumcision can be performed as Rx
What condition does this describe?
retraction of foreskin constricting lymphatic & venous drainage of distal tissues - risk progression to infection, ulceration, necrosis
Rx: Manual reduction, LA penile block, surgical management (dorsal incision, usually with circumcision)
Paraphimosis
retraction of foreskin constricting lymphatic & venous drainage of distal tissues - risk progression to infection, ulceration, necrosis
Rx: Manual reduction, LA penile block, surgical management (dorsal incision, usually with circumcision)
What is the name of this condition?
- damage to tunica albuginea penis (white membrane surrounding corpus cavernosum/spongy penis), forming inelastic penile plaques,
- local pain & deformity
Peyronie’s disease
What is the name given to this condition?
abnormally sustained erection unrelated to sexual stimulation (>4hrs)
- high flow (arterial) or low flow (veno-occlusive) -
Ix: doppler US, cavernous venous gases, FBC
PRIAPRISM
abnormally sustained erection unrelated to sexual stimulation
- high flow (arterial) or low flow (veno-occlusive) -
Ix: doppler US, cavernous venous gases, FBC
