Genitalia Flashcards
DDX for lump in scrotum
Testicular cancer until proven otherwise! Hydrocoel Epididymal cyst or spermatocele Hernia Varicocoel Benign tumour - lipoma Lymphoma Skin: - Idiopathic scrotal oedema - Skin cancer - Sebaceous cyst
Presentation of testicular cancer
What investigations?
Hard PAINLESS lump in scrotum, appearing over history of months (fast growing)
Young male
Past HX cryptochordism
INV:
- scrotal U/S looking for distorted architecture
- Serum tumour markers alpha fetoprotein, beta-HCG and LDH
- Abdo CT and CXR (staging - mets to lungs, and retroperitoneal lymph nodes)
+/- brain CT and bone scan (mets to brain, bone)
Markers of testicular cancer
Alpha fetoprotein
BEta-HCG
LDH is non-specific tumour market
*not always elevated but performed for surveillance and progress purposes)
Treatment of testicular cancer
Inguinal orchidectomy
Bleomycin, Etopicide and Plisplatin (BEP) x4 courses
+/- Retroperitoneal lymph node dissections
DDX for acute scrotum (new onset scrotal pain +/- swelling, tenderness, erythema)
Testicular torsion Appendage torsion Epididymitis Scrotal edema Orchitis Hernia Trauma Hydrocoel Varicocele
Investigations for acute scrotum?
Dipstick MSU urinalysis Urethral swab Testicular U/S w doppler Surgical exploration
What are factors pre-disposing to testicular torsion?
Bell-clapper deformity (Testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels)
Cryptochordism
Presentation of testicular torsion
15-20 year old males
Rapid onset unrelenting testicular pain, nausea and vomiting
Testes higher than normal, tender, firm +/- swelling
thickened spermatic cord with ABSENT cremasteric reflex
Treatment of testicular torsion
○ Urological emergency - 6 hour window before irreversible ischaemia occurs.
○ Needs surgery
Fixation +/- dartos pouch -> DO BOTH SIDES WHILE YOU’RE THERE!
Appendage torsion:
- clinical presentation
Treatment
8-10 year old boys
Testicular pain
Palpation reveals small firm nodule on upper portion of testes with characteristic “blue dot” sign
Active cremasteric reflex
Treatment:
- analgesia with self-resolution within 2-3 days
- OR surgical dissection
Presentation of epidymitis and orchitis
Sudden onset scrotal pain +/- radiation along cord to flank
Scrotal erythema, tenderness +/- lump if large abscess present
FEVER
Storage or inflammatory LUTS, purulent discharge
Resembles testicular torsion!
Causes of and investigations for epidymitis and orchitis
young people: N. gonorrhoea or chlamydia trachoma’s
older people: With penetrative anal intercourse: GI organisms (E Coli), or urinary tract pathogens (KEEPS)
Mumps, Tb
INV:
- U/A for MCS
- urethral D/C swap for gram stain and PCR
- Doppler U/S or surgical exploration if torsion is a DDX
Risk factors epididymitis and orchitis
- UTI
- Unprotected sexual intercourse
- Instrumentation/catheterisation
- Reflux
- Immunocompromised
Presentation of prostatitis
Acute bacterial: acute onset fever, chills, malaise, rectal/lower back/perineal pain and LUTS
Chronic: Pelvic pain, ejaculatory and post-ejaculatory pain + storage LUTS. Recurrent exacerbations of acute bacterial prostatitis or recurrent UTI.
Investigations and Treatment of prostatitis
Investigations: Pelvic x-ray +/- U/S, Urinalysis, blood FBE and cultures.
Supportive care
PO or IV antibiotics depending on severity
+/- catheterisation depending on level of obstruction
Consider alpha blocker with chronic prostatitis
Treatment of epidymitis
Elevation
Analgesia
Empiric antibiotics for GNB and STI coverage (Trimethoprim, cephalexin or augmentin, AND cefriazone or azithromycin)
STI screen and contact tracing
What is Fournier’s gangrene?
○ Necrotising fasciitis of testes and perineum
○ Life-threatening spreading cellulitis and necrosis of skin and subcut fat
○ Typically presents with “crackling” of skin on examination
○ Needs aggressive debridement with skin grafts etc
○ Often in diabetic patients
What is a haematocoel and how can it be caused?
Investigations and treatment?
Caused by trauma -> bleeding into space under tunica vaginalis .
Visualise any testicular rupture with U/S -> surgical exploration and evaculation/repair or orchidectomy + empirical antibiotics to prevent secondary abscess formation
What leads to hydrocoeal?
in infants - congenital Patent processus vaginalis means free fluid in abdomen can leak into the space next to the testes causing painless enlargement
In adults, can be due to infection/inflammation, or neoplasm in testes
What causes a varicocele? How does this present?
Abnormal enlargement of the pampiniform venous plexus (veins or spermatic cord) in the scrotum due to defective valves.
RARELY caused by RCC leading to venous congestion.
Presents as achy scrotal pain, worse at end of day, palpable and sometimes visible tortuous vein(s) in scrotum (‘bag of worms’) - often L side of scrotum
What are the 3 most common forms of testicular cancer?
Seminoma
Mixed germ cell
lymphoma
Why are most varicocoels on the left?
Because the L testicular vein drains into the L renal vein at a 90 degree angle which is can be difficult (vs R testicular veins drains into the R SVC at a lesser angle)
What is idiopathic scrotal oedema?
Unilateral but more often bilateral swelling, red, warmth but non-tender testes
Causes:
- Wall thickened due to allergic response to insect bite, common in boys under 10
- or due to CCF or nephrotic syndrome in older patients
