DISORDERS OF THE TESTIS & SCROTUM Flashcards
Undescended testes or absent testes (agenesis)
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)
Incidence of cryptorchidism is directly related to (2)
⦁ birth weight
⦁ gestational age
premies are at increased risk
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
idiopathic, but some may be hormonal or genetic
Testes develop intra-_____________ in fetus
abdominally
testes usually descend into scrotum through inguinal canal during ___________ month of gestation
7th - 9th
Most common location for undescended testicle =
High scrotal (60%)
High scrotal (60%) > inguinal canal > abdominal
physical exam of cryptorchidism
the scrotal sac is empty;
the testes is either not palpable, or it can be felt externally to the inguinal ring
Spontaneous testicular descent often occurs during
*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
- pathological changes to undescended testicle can occur at
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
When the disorder is unilateral, it may also produce morphologic changes in the
contralateral descended testicle
CONSEQUENCES OF CRYPTORCHIDISM
⦁ 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
EXAM TO CHECK FOR UNDESCENDED TESTES
- 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
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
testicular cancer
DIAGNOSTIC TESTING FOR CRYPTORCHIDISM
- 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)
treatment for cryptorchidism
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
is hormone therapy used to help descend the testes?
NO
Hormone therapy with hCG or LHRH no longer considered useful in helping the testes descend
(was causing a lot of other problems)
follow ups in cryptorchidism
- 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!)
excess fluid collects between the layers of the tunica vaginalis
hydrocele
hydrocele = excess fluid collects between the layers of the
tunica vaginalis
hydrocele is usually due to
weakness in the patent process vaginalis
TYPES OF HYDROCELES
⦁ 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
most common type of hydrocele
communicating
PRIMARY CONGENITAL HYDROCELE
- 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
PRIMARY CONGENITAL HYDROCELE = associated with
indirect inguinal hernia
infant hydroceles
usually close spontaneously**
- if persists beyond 2 years of age = need surgical treatment
secondary causes of hydroceles
⦁ trauma
⦁ epididymitis
⦁ testicular torsion
⦁ orchitis
DIAGNOSIS OF HYDROCELE
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
HYDROCELES IN YOUNG MEN VS ADULT MEN
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***
hydroceles in adult men = often asymptomatic or have a feeling of heaviness in scrotum
If symptomatic = may have
pain in lower back
- associated with indirect inguinal hernia
primary congenital hydroceles
accumulation of blood in the tunica vaginalis
hematocele
- can compromise the testicle**
- causes scrotal skin to become dark red or purple
hematocele
accumulation of blood in the tunica vaginalis
- can compromise the testicle**
- causes scrotal skin to become dark red or purple
causes of hematocele
⦁ abdominal surgical procedure
⦁ scrotal trauma
⦁ bleeding disorder
⦁ testicular tumor
trauma = most common
most common cause of hematocele
trauma
treatment of hematocele
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!!
Painless sperm-containing cyst that forms on the epididymis
spermatocele
spermatocele
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
usually leave spermatoceles alone unless
causing pain
varicocele = varicosities of the
pampiniform plexus
varicosities of the pampiniform plexus
varicocele
highest incidence of varicoceles = in men between
15-35
rarely before puberty
varicoceles can lead to
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
“BAG OF WORMS” superior to the testicle
varicocele
varicoceles occur more often on the ______ side….because
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)
so dilation worsens when patient is upright or with Valsalva
varicocele
symptoms of varicocele
- 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
exam of varicocele
- 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”
treatment of varicoceles
- 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
- twisting of the spermatic cord that suspends the testis
testicular torsion
- 2 age peaks of testicular torsion
⦁ perinatal & prepubertal
⦁ presents between ages 10-25
testicular torsion is an acute urological emergency!!! as ____________ is at risk…
the viability of the testes
cuts off blood supply → necrotic testicle
high-riding testicle
torsion
blue dot on scrotum
torsion
husky blue dot hue to that testicle due to lack of blood supply
Due to coiling in torsion, epididymis becomes more
horizontal
CONGENITAL TORSION VS TORSION IN PEDIATRICS / ADOLESCENTS
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!
SYMPTOMS OF TORSION
- 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
IMAGING FOR TORSION
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
MANAGEMENT OF TORSION
- 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
surgery for torsion when manual doesn’t work
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
salvage rates of testicle with torsion are directly related to
duration of torsion
CAUSES OF EPIDIDYMITIS
- 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
which cause of epididymitis is associated with urethritis
sexually transmitted
associated with young men
which cause of epididymitis is associated with UTIs and prostatitis
non-sexually transmitted
associated with men > 35
SIGNS/SYMPTOMS OF EPIDIDYMITIS
- 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
hypogonadism
- testosterone deficiency with associated symptoms or signs, deficiency of sperm production, or both
- either primary or secondary
most common cause of primary hypogonadism
Klinefelter’s syndrome
primary vs secondary hypogonadism
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
SIGNS/SYMPTOMS OF HYPOGONADISM
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
diagnosis of hypogonadism
⦁ FSH
⦁ LH
⦁ free/total testosterone levels
treatment of hypogonadism
⦁ 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
INFERTILITY
- the inability to get pregnant after trying for at least 1 year
- about 1/3 of cases = caused by male factor
CAUSES OF INFERTILITY
⦁ blockage of reproductive system
⦁ meds
⦁ undescended testicles
⦁ infections
DIAGNOSIS OF INFERTILITY
⦁ 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
TREATMENT FOR INFERTILITY
- 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
