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UROLOGY > DISORDERS OF THE TESTIS & SCROTUM > Flashcards

DISORDERS OF THE TESTIS & SCROTUM Flashcards

1
Q

Undescended testes or absent testes (agenesis)

A

CRYPTORCHIDISM

  • occurs when one or both of testicles fail to move down into scrotal sac
  • usually unilateral, but can be bilateral (10-20% of cases)
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2
Q

Incidence of cryptorchidism is directly related to (2)

A

⦁ birth weight
⦁ gestational age

premies are at increased risk

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3
Q

The cause of cryptorchidism in full term infants is poorly understood
- 3-5% of full term infants are born with undescended testicles: Most cases are

A

idiopathic, but some may be hormonal or genetic

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4
Q

Testes develop intra-_____________ in fetus

A

abdominally

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5
Q

testes usually descend into scrotum through inguinal canal during ___________ month of gestation

A

7th - 9th

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6
Q

Most common location for undescended testicle =

A

High scrotal (60%)

High scrotal (60%) > inguinal canal > abdominal

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7
Q

physical exam of cryptorchidism

A

the scrotal sac is empty;

the testes is either not palpable, or it can be felt externally to the inguinal ring

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8
Q

Spontaneous testicular descent often occurs during

A

*Spontaneous descent often occurs during the first 3 months of life so if pt is less than 3 months, tell parents to wait. if still hasn’t descended, will surgically correct

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9
Q
  • pathological changes to undescended testicle can occur at
A

6-12 months
⦁ delay in germ cell development
⦁ changes in spermatic tubules
⦁ reduced number of Leydig cells (release testosterone)

  • When the disorder is unilateral, it may also produce morphologic changes in the contralateral descended testicle
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10
Q

When the disorder is unilateral, it may also produce morphologic changes in the

A

contralateral descended testicle

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11
Q

CONSEQUENCES OF CRYPTORCHIDISM

A

⦁ Infertility
⦁ Malignancy

Infertility - because of decreased sperm counts & poorer quality sperm. Bilateral cryptorchidism increases chances of infertility

In order for proper sperm production, testes need to be kept below body temp. Also produce testosterone, so if undescended = not only poor quality sperm/low sperm count, but also may lack secondary sex characteristics

Malignancy = increased risk of testicular cancer
- testes hasn’t been able to properly develop –> can lead to abnormal cell development

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12
Q

EXAM TO CHECK FOR UNDESCENDED TESTES

A
  • need to differentiate undescended testes from retractable testes
    ⦁ use cremasteric muscle reflex –> will retract into inguinal canal (brush inner thigh - and testes will retract on that side)
    • genitofemoral & ileoinguinal nerve are what control this reflex

⦁ testes are usually palpable at birth

⦁ careful palpation in a warm room can bring them down; if an infant is crying/stressed, testes will retract (normal)

⦁ Testes usually assume a scrotal position during puberty

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13
Q

even once the testes have descended back down into scrotum or once laparoscopy was done to correct it, there is STILL an increased risk for developing

A

testicular cancer

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14
Q

DIAGNOSTIC TESTING FOR CRYPTORCHIDISM

A
  • diagnostics are usually not needed - can diagnose based on PE
  • occasionally an ultrasound is done (if not descended by 3 months, and still not by 6 months)
  • Laparoscopy for diagnosis & treatment ( refer to urology for this)
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15
Q

treatment for cryptorchidism

A

orchiopexy

fixation of testes in the scrotum

  • this procedure should be considered before 6 months of life, as the rate of descent diminishes considerably after this point
    ⦁ 95% of orchiopexy patients will be fertile
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16
Q

is hormone therapy used to help descend the testes?

A

NO

Hormone therapy with hCG or LHRH no longer considered useful in helping the testes descend
(was causing a lot of other problems)

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17
Q

follow ups in cryptorchidism

A
  • have life-long follow ups due to infertility issues & testicular cancer issues
  • Upon reaching puberty, instruct boys of the necessity of self testicular exams (monthly!)
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18
Q

excess fluid collects between the layers of the tunica vaginalis

A

hydrocele

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19
Q

hydrocele = excess fluid collects between the layers of the

A

tunica vaginalis

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20
Q

hydrocele is usually due to

A

weakness in the patent process vaginalis

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21
Q

TYPES OF HYDROCELES

A

⦁ non-communicating = testes seals off after filling up, no fluid can enter or leave, but build up of fluid remains in testes

⦁ communicating hydrocele = most common = continuous draining into scrotal layer; can lead to a hernia

⦁ Hydrocele of the cord = swelling in scrotum intself, but also have a hydrocele higher up in the spermatocord

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22
Q

most common type of hydrocele

A

communicating

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23
Q

PRIMARY CONGENITAL HYDROCELE

A
  • seen in male infants & children
  • associated with indirect inguinal hernia
  • infant hydroceles usually close spontaneously**
  • if persists beyond 2 years of age = need surgical treatment

In infants, give them time for hydrocele to heal on its own - body should absorb the fluid; if past 2 years old = surgery

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24
Q

PRIMARY CONGENITAL HYDROCELE = associated with

A

indirect inguinal hernia

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25
Q

infant hydroceles

A

usually close spontaneously**

- if persists beyond 2 years of age = need surgical treatment

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26
Q

secondary causes of hydroceles

A

⦁ trauma
⦁ epididymitis
⦁ testicular torsion
⦁ orchitis

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27
Q

DIAGNOSIS OF HYDROCELE

A

TRANSILLUMINATION

  • shine a light through scrotum to visualize internal structures. If it shines through = fluid present

If light doesn’t shine through, and just shows up as a pinpoint of light against the skin = solid mass

  • can also do an Ultrasound:
    ⦁ if cannot transilluminate
    ⦁ or if trying to determine underlying conditions in non-neonates
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28
Q

HYDROCELES IN YOUNG MEN VS ADULT MEN

A

o If a hydrocele develops in a young man without apparent cause = it should be considered cancer until proven otherwise!! Careful evaluation to exclude cancer or infection

o In an adult male, hydroceles are relatively benign conditions; are often asymptomatic, and just have a feeling of heaviness in the scrotum. May have pain in the lower back***

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29
Q

hydroceles in adult men = often asymptomatic or have a feeling of heaviness in scrotum

If symptomatic = may have

A

pain in lower back

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30
Q
  • associated with indirect inguinal hernia
A

primary congenital hydroceles

31
Q

accumulation of blood in the tunica vaginalis

A

hematocele

  • can compromise the testicle**
  • causes scrotal skin to become dark red or purple
32
Q

hematocele

A

accumulation of blood in the tunica vaginalis

  • can compromise the testicle**
  • causes scrotal skin to become dark red or purple
33
Q

causes of hematocele

A

⦁ abdominal surgical procedure
⦁ scrotal trauma
⦁ bleeding disorder
⦁ testicular tumor

trauma = most common

34
Q

most common cause of hematocele

A

trauma

35
Q

treatment of hematocele

A

Treatment = drain blood, fix underlying cause of bleeding. Then address the testicle and make sure no damage/harm to testes itself. Refer to urology, do not drain yourself!!

36
Q

Painless sperm-containing cyst that forms on the epididymis

A

spermatocele

37
Q

spermatocele

A

Painless sperm-containing cyst that forms on the epididymis

  • located above & posterior to the testes and is attached to the epididymis
  • usually > 2cm
  • freely movable and should transilluminate
  • rarely causes problems, but if large, may become painful an require excision
38
Q

usually leave spermatoceles alone unless

A

causing pain

39
Q

varicocele = varicosities of the

A

pampiniform plexus

40
Q

varicosities of the pampiniform plexus

A

varicocele

41
Q

highest incidence of varicoceles = in men between

A

15-35

rarely before puberty

42
Q

varicoceles can lead to

A

damage to the elastic fibers and hypertrophy of the vein wall (like varicose veins in the legs)

Sperm concentration and motility are decreased in 65% to 74% of men

43
Q

“BAG OF WORMS” superior to the testicle

A

varicocele

44
Q

varicoceles occur more often on the ______ side….because

A

left side

  • left pampiniform plexus = more common to have varicoceles than the right side; this is because the left gonadal vein inserts in the left renal vein at a right angle, whereas the right gonadal vein goes straight up to enter the inferior vena cava
  • Incompetent valves are more common in the left, due to more difficult route –> causes reflux of blood back into the veins of the pampiniform plexus
  • the force of gravity resulting from the upright position also contributes to venous dilation (gravity makes varicocele worse; so dilation worsens when patient is upright or with Valsalva)
45
Q

so dilation worsens when patient is upright or with Valsalva

A

varicocele

46
Q

symptoms of varicocele

A
  • can be asymptomatic
  • or can have dull aching, atrophy, and infertility
  • have an abnormal feeling of heaviness in the left side when standing that is relieved when recumbent
47
Q

exam of varicocele

A
  • usually readily diagnosed on PE
  • perform exam with patient both standing and in recumbent position; the varicocele typically disappears in the supine position
  • Scrotal palpation will feel like a “BAG OF WORMS”
48
Q

treatment of varicoceles

A
  • surgical ligation of the gonadal vein
  • interventional radiology: embolization of veins

In young males showing testicular atrophy
⦁ Varicocelectomy = obliteration of dilated veins. Will have some improvement in infertility and will relieve “heavy” feeling. Small testicular size though

  • for those not needing increased fertility = give NSAIDS & scrotal support
49
Q
  • twisting of the spermatic cord that suspends the testis
A

testicular torsion

50
Q
  • 2 age peaks of testicular torsion
A

⦁ perinatal & prepubertal

⦁ presents between ages 10-25

51
Q

testicular torsion is an acute urological emergency!!! as ____________ is at risk…

A

the viability of the testes

cuts off blood supply → necrotic testicle

52
Q

high-riding testicle

A

torsion

53
Q

blue dot on scrotum

A

torsion

husky blue dot hue to that testicle due to lack of blood supply

54
Q

Due to coiling in torsion, epididymis becomes more

A

horizontal

55
Q

CONGENITAL TORSION VS TORSION IN PEDIATRICS / ADOLESCENTS

A

CONGENITAL TORSION

  • less common
  • firm, smooth, PAINLESS scrotal mass
  • scrotal skin appears red, some edema
  • DDX = tumors, epididymitis, orchitis (all rare), hydrocele (softer & transilluminates). exclude hernia on PE

PEDIATRICS & ADOLESCENTS

  • this is a TRUE SURGICAL EMERGENCY*
  • the testes rotates on the long axis of the tunica vaginalis, rotates about the distal spermatic cord
  • cuts off blood supply to the testes
  • rarely seen after age 30
  • early recognition & early treatment = essential!
56
Q

SYMPTOMS OF TORSION

A
  • patient presents with SEVERE DISTRESS WITHIN HOURS of onset
  • often accompanied with NAUSEA & VOMITING
  • large, firm and tender testes
  • pain radiates to inguinal area
  • testicle is often high in the scrotum and in an abnormal orientation
  • CREMASTERIC REFLEX = FREQUENTLY ABSENT
  • degree of swelling & redness depends on the duration of symptoms
57
Q

IMAGING FOR TORSION

A

Color Doppler Ultrasound - must be done right away

⦁ see decreased blood flow, or avascular testicle

  • refer to urology! have a 4-6 hour window; the sooner the better
58
Q

MANAGEMENT OF TORSION

A
  • can attempt manual detorsion - using pain relief as the guide for successful detorsion
  • similar to “opening a book” - always twist outward / laterally because most torsions twist inwards and towards mid-line
  • manual detorsion often doesn’t work, but should try; often won’t be able to do in clinic, especially due to pain; if caught early and hasn’t spun much, may able to succeed manually

o Surgery

⦁ surgical detorsion & Orchiopexy (fixation of testicle); usually prophylactic fixation of opposite testicle is performed

⦁ Orchiectomy = done when testis is deemed nonviable after surgical detorsion; salvage rates are directly related to duration of torsion; usually prophylactic fixattion of opposite testicle is performed

59
Q

surgery for torsion when manual doesn’t work

A

1) surgical detorsion & Orchiopexy (fixation of testicle); usually prophylactic fixation of opposite testicle is performed
2) Orchiectomy = done when testis is deemed nonviable after surgical detorsion; salvage rates are directly related to duration of torsion; usually prophylactic fixattion of opposite testicle is performed

60
Q

salvage rates of testicle with torsion are directly related to

A

duration of torsion

61
Q

CAUSES OF EPIDIDYMITIS

A
  • 2 major causes = STI vs non-STI infection

STI (chlamydia, gonorrhea)

Primary non-STI infection (E. coli, pseudomonas, some gram positive cocci)

Post- vasectomy

Trauma

62
Q

which cause of epididymitis is associated with urethritis

A

sexually transmitted

associated with young men

63
Q

which cause of epididymitis is associated with UTIs and prostatitis

A

non-sexually transmitted

associated with men > 35

64
Q

SIGNS/SYMPTOMS OF EPIDIDYMITIS

A
  • unilateral pain & swelling in the epididymis over a period of days
  • erythema & edema of overlying scrotal skin - can become extremely large (reactive hydrocele)
  • tenderness over the groin or in the lower abdomen
  • fever
  • dysuria
  • could have urethral discharge if gonococcal
65
Q

hypogonadism

A
  • testosterone deficiency with associated symptoms or signs, deficiency of sperm production, or both
  • either primary or secondary
66
Q

most common cause of primary hypogonadism

A

Klinefelter’s syndrome

67
Q

primary vs secondary hypogonadism

A

o Primary Hypogonadism = failure of testes to respond to FSH/LH. Testosterone is too low to inhibit production of FSH & LH
⦁ most common cause = Klinefelter Syndrome

o Secondary Hypogonadism = failure of hypothalamus to produce GnRH or failure of pituitary gland to produce enough FSH & LH

68
Q

SIGNS/SYMPTOMS OF HYPOGONADISM

A

1) Congenital Hypogonadism
⦁ 1st trimester = inadequate male sexual differentiation
⦁ 2nd or 3rd trimester = results in microphallus & undescended testes

2) Childhood onset Hypogonadism
⦁ impairs development of secondary sex characteristics
⦁ as adults = have poor muscle development & high pitched voice

3) Adult onset Hypogonadism
⦁ decreased libido
⦁ ED
⦁ depression & anger

69
Q

diagnosis of hypogonadism

A

⦁ FSH
⦁ LH
⦁ free/total testosterone levels

70
Q

treatment of hypogonadism

A

⦁ testosterone replacement therapy (gel, transdermal patch, transdermal axillary solution, Sub-Q implants, IM injections (cheapest))

- Adverse effects of Testosterone replacement
⦁	erythrocytosis
⦁	venous thromboembolism
⦁	acne
⦁	gynecomastia
⦁	low sperm counts
71
Q

INFERTILITY

A
  • the inability to get pregnant after trying for at least 1 year
  • about 1/3 of cases = caused by male factor
72
Q

CAUSES OF INFERTILITY

A

⦁ blockage of reproductive system
⦁ meds
⦁ undescended testicles
⦁ infections

73
Q

DIAGNOSIS OF INFERTILITY

A 
⦁	Semen analysis 
		- Semen volume 2-5ml
		- pH level 7.2-7.8
		- Sperm density >20 million
		- Motility 50% forward progressive
		- Morphology >60% normal (<4% abnormal)
⦁	Antisperm antibody test
⦁	Hormonal analysis
⦁	Transrectal ultrasound
⦁	Scrotal ultrasound
74
Q

TREATMENT FOR INFERTILITY

A
  • Boxer shorts
  • Avoid hot tubs
  • Timing of intercourse
  • Avoid illegal drugs, chemicals, and spermicidals
  • Medications
    ⦁ Clomiphene citrate (Clomid) = for females
    ⦁ Imipramine = given when infertility is due to retrograde ejaculation
    ⦁ Zoloft (SE = ED) = but given to patients who have premature ejaculation
Surgical
⦁	Varicocelectomy
⦁	Vasovasostomy
⦁	Testicular biopsy (TESE)
⦁	Transurethral resection of ejaculatory ducts

UROLOGY (12 decks)

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