Genital disorders Flashcards
Case
Patient is a 6 year old male from Cavite presenting at the
emergency room with right scrotal pain.
According to her teacher in school, he was seen playing during
their early morning break when he suddenly complained of scrotal
pain. She reported the incident to their school nurse, at which
time the patient’s was already inconsolable from pain.
Patient had no fever, cough or colds, diarrhea, dysuria and
hematuria
Physical examination
Irritable, uncooperative to examiner, crying inconsolably
HR 144, RR 38, T 38.C, BP 100/70, sats 99%
Anicteric sclerae, pink conjunctivae, no cervical lymphadenopathy
Equal chest expansion, clear breath sounds, no adventitious lung
sounds
Adynamic precordium, distinct heart sounds, normal rate, regular
rhythm, no murmurs
Pink nailbeds, good pulses, good CRT, no active dermatosis
Right scrotum seen with erythema and tenderness
CBC:
Hgb 145, Hct 0.48, WBC 25.1, Neuts 0.88, Lym 0.18, Plt 445
Urinalysis
Light yellow, clear, sp gr 1.020, pH 6.0, wbc 0-1, rbc 0-1, few
epithelial cells, few hyaline casts
Scrotal Ultrasound:
absence of blood flow in both the testis and epididymis,
heterogeneous echotexture with reactive hydrocele, twisting of
spermatic cord
What is your primary working impression?
Testicular torsion
Differentials
Epididymitis – acute scrotal pain; Absence of preceding UTI, no
associated fever, dysuria and other constitutional symptoms
Orchitis - Associated with other systemic symptoms from diseases
like measles, mumps, HSP, etc
UTI - Will usually present with dysuria the most common
manifestation
Lymphoma - Will present usually as mass, although it can also
manifest as lead point in a torsion
Appendicitis - Left lower quadrant abdominal pain, that may
radiate to scrotal area
Scrotal trauma - Hyper-acute in onset; Associated with
hematoma, may or may not elicit a history of trauma from the
caregivers/ children
Inguinal hernia - Acute onset of scrotal pain, sometimes with
bulging mass
Diagnostics
Diagnostics
CBC
Urinalysis
Scrotal ultrasound
Management
Management
Pain management
Place on NPO, start IVF
Emergent surgery
What is testicular torsion?
CH 545: TESTICULAR TORSION
- True surgical Emergency (Golden period: 4-8h)
- MC cause of testicular pain >12 yo
- Torsion of the spermatic cord, appendix testis, or epididymis
- Torsion of epididymis/ appendix testis (More common in prepubertal boys) vs. spermatic cord (more common in adolescents and NB)
Patho
- Caused by inadequate fixation of testis within the scrotum due to redundant tunica vaginalis (bell clapper deformity) –> twisting of the spermatic cord –>
compromised testicular blood supply
- Following 4-6h of absent blood flow to the testis,
irreversible loss of spermatogenesis can occur
What are the clinical manifestations of testicular torsion?
CM
1. Acute pain and swelling of scrotum, unilateral,
unrelenting
2. (-)cremasteric reflex
3. Nausea, vomiting
4. (-)phren sign – pain persists upon lifting scrotum. r/o
epididymitis
5. Scrotum may show varying degrees of erythema and
induration, involved testicle may be higher, transverse
orientation, or anteriorly located epididymis
6. Tender testicleH
How is testicular torsion diagnosed?
Dx
1. Testicular UTZ with doppler – coiling of the spermatic
cord. No BF to testes.
2. UA – pyuria and bacteriuria likely in epididymitis/
orchitis
Management of testicular torsion
Mgt
1. <4h – attempt manual detorsion: rotate testis
outwards (L clockwise)
2. Prompt surgical exploration and detorsion + scrotal
orchiopexy
Differentials
If 2-10yo, consider MC = torsion of the appendix testis
- Gradual scrotal pain + swelling
- 3-5mm palpable tender indurated scrotal mass
- (+) blue dot sign: through scrotal skin
- Mgt: bedrest x 24h, analgesia, nonsurgical, resolves
after 3-10d.
Epididymitis – slow onset scrotal pain and swelling that worsens
over days rather than hrs. (-)n/v
- Patho: bacteria reach epididymis in retrograde fashion
via ejaculatory ducts assoc with UTI
- Coliforms, mycoplasma; Chlamydia, gonococci in
sexually active adolescents
- (+)UCS
- Mgt: Abx
HSP vasculitis – pain, erythema, swelling of the scrotum + other
S/Sx of HSP. Usually M<7yo. R/o by Doppler
Idiopathic scrotal edema – “summer penile syndrome”.
Thickening and erythema of the scrotum, testes not involved. N
UTZ. Mgt: supportive.
What is undescended testis?
CH 545: UNDESCENDED TESTIS
- cryptorchidism
- Absence of palpable testis in the scrotum
- MC disorder of sexual differentiation in M
Patho
- Failure of testicular descent from the abdomen to the scrotum in the processus vaginalis before 28 wks AOG
1st 3 mos – majority descend spontaneously
- Due to temporary testosterone surge at 2mos resulting
to significant penile growth
At 4mos – if not descended, will remain undescended. Abnormal
at 6-12mos
Clinical manifestations of undescended testis
CM
1. Abdominal UT – nonpalpable
2. Peeping UT – can be pushed into the upper part of the
inguinal canal
3. Inguinal
4. Gliding – can be pushed into the scrotum but retract
into the pubic tubercle
5. Ectopic – superficial inguinal ring pouch
Complications
Complications
1. Poor testicular growth
2. Infertility
3. Testicular CA – germ cell, seminoma
4. Hernia
5. Testicular torsion
Management of undescended testis
- Inguinal/scrotal UTZ – if obese
- Orchiopexy at 9-15 mos (as early as 6mos) – 98%
success rate, low CA risk
What is retractile testis?
CH 545: RETRACTILE TESTIS
- May be misdiagnosed as undescended testis
CM
1. >1yo: brisk cremasteric reflex
2. In a relaxed frog-leg position, testis can be
manipulated into the scrotum comfortably
Mgt
1. Frequent monitoring q6-12 mos – may develop into
acquired undescended testis; highest risk: <7yo
2. Not an inc risk for infertility/ malignancy
What is hydrocele?
CH 545: HYDROCELE
- Accumulation of fluid in tunica vaginalis
- Communicating hydrocele: patent processus vaginalis flow of peritoneal fluid into the scrotum (indirect inguinal hernia)
- Noncommunicating hydrocele: patent processus vaginalis is present, but no communication with the peritoneal cavity
What are the clinical manifestations?
CM/Dx
1. Transillumination of scrotum shows fluid-filled mass,
palpate to r/o tumor
2. Painless scrotal swelling
What is the management of hydrocele?
Mgt
1. Observation until 1 yo
a. If resolve = noncommunicating: processus vaginalis obliterated at development
b. If persist = communicating: small in morning, progressively larger in the day.
Long term risk of inguinal hernia –> surgical repair at 12-18mos
What is varicocele?
CH 545: VARICOCELE
- Congenital. Valvular incompetence of internal
spermatic vein result to abN dilation of pampiniform
plexus “bag of worms”
- 10-15% subfertile
- MC and only surgically correctible cause of subfertility
- >10yo, puberty
CM
1. Painless paratesticular mass – dull ache
- Prominent when standing, enlarges on Valsalva,
disappears on supine
- Grade 1: palpable with Valsalva
- Grade 2: palpable on inspection
- Grade 3: visible on inspection (greatest risk of
testicular growth arrest)
Mgt
1. Varicocelectomy – for grade 3
Other differentials?
Hernia
Case
7 yr old female.
18 kg
Cc: vaginal bleeding
HPI: 1 month PTA: patient was noted to have itching of her
genital area. Patient was only advised by mother not to scratch.
2 weeks PTA: noted persistence of vaginal itchiness with
associated mucoid and occasional bloody discharge seen on her
underwear. Mother opted to use Lactacyd feminine wash with
noted slight improvement of symptoms.
Day of consult: Noted still with itching and scratching of genital
area with gross blood and hence consult at your clinic.
Past Medical History: previous consults for constipation since
symptoms started.
family History: unremarkable
Birth/Maternal Hx: born full term to a then 30 yr old G1P0
mother, no fetomaternal complications.
Immunization Hx: completed EPI in infancy, no other vaccinations
Nutritional Hx: presently eats regular table food
DevHx: at par with age
Social Hx: Patient is active in gymnastics and swimming
competitions
Physical Exam:
Awake, coherent, ambulatory. With noted gross scratching of
genital area.
Wt: 22 kg
HR 76, RR 18, afebrile
Pink conjunctivae, anicteric sclerae, no CLADS/TPC
Equal chest expansion, clear BS, no rales/wheezes
Adynamic precordium, distinct HS, normal rate, reg rhythm
Soft abdomen, nondistended, normoactive bowelsounds
Full pulses, pink nailbeds, no cyanosis, edema, no bruises
Genital exam:
See picture.
Noted minimal discharge, serosanguinous, with excoriations
around the introitus, intact hymen, no tears in the posterior
fourchette.
After specimens sent for lab studies, vulvar area was washed with
warm saline and this was noted.
Diagnosis? Differentials?
Labs to order?
LAB RESULTS
Urinalysis: normal
Wet mount (vaginal smear): no organism seen, KOH negative
Detailed vaginoscopy: no tumors, no hematoma, hymen intact
Scotch tape test: no organism seen
What is your primary diagnosis?
DIAGNOSIS
Lichen Sclerosus
What are your differentials?
Differential Diagnoses (vaginal bleeding with pruritus)
1) Withdrawal bleeding (only in neonates)
2) Foreign body
3) Sexual Abuse – would show hymenal tears esp in the
posterior fourchette
4) Vulvovaginitis – rule out infectious cause e.g. Candida,
Trichomonas, via microscopy of smear
5) Precocious puberty – if with associated accelerated
linear growth and other secondary sexual development
6) Anatomic problems – e.g. urethral prolapse,
hemangioma, neoplasms,
7) Systemic bleeding disorder – ITP, blood dyscrasia
8) Trauma – straddle injury
9) Intake of exogenous estrogen
What is the management?
MANAGEMENT
1. Corticosteroid cream in affected area for 6 to 12 weeks
2. Advise daily baths and good hygiene. Frequent
changing of soiled or wet underwear immediately after
sports activities
3. Continued screening and education to protect children
from abuse
4. Preventive measures
a. Atopy screening
b. Immunization update
c. Counseling on nutrition, hygiene, sanitation,
toxic exposure, injury prevention
d. Deworming
