Genituurinary anorectal Flashcards
the most common cause of scrotal pain
epididymitis (posterior and inferior)
Hx of epididymitis
- Gradually increasing pain and swelling (over days)
2. Dysuria/Fever
MC ways an epididymitis get’s infected
STD
BUT not always infectious can be
Trauma”, Autoimmune dz, Vasculitis
Prehn’s Sign
Elevation of the scrotum relieves pain
This is unreliable to differentiate Testicular Torsion but is supposed to help you differentiate
Cremasteric Reflex
- Stroking the thigh on the affected side causes the ipsilateral testis to pull upwards
a. Can use for testicular torsion
predominant method of choice for dx testicular complaints
what would epididymitis look like
Ultrasound
Inflammation increases blood flow which shows up on the doppler
if blood is not getting to the testicle you might suspect something like torsion
also STD testing, ULS (hydrocele), urine culture (E.coli, pseudomonas)
Tx for epididymitis
UA, STD Testing, ?ULS (reactive Hydrocele Vs.)
Possible Urine culture (E.coli, Pseudomonas,)
Presumptive Therapy:
F/U instructions/expectations
Presumptive Therapy for epididymitis
Ceftriaxone 250 mg IM and Doxycycline or azithromyocin 100mg PO BID X days
(can’t tell if gonorrhea or chlamydia)
If over age 35, consider Levofloxacin 500 mg qd X 10 days
Analgesics, SITZ baths, Scrotal Support (jock strap so that the testicles don’t bounce)
hydrocele is a collection of fluid where
painful or nah?
Collection of fluid between the Parietal and Visceral layers of the Tunica Vaginalis.
arise over a longer period of time
usually asymptomatic BUT increasing pain w/ increasing size
hydrocele dx
Dx: Transillumination
on ULS you see tis as
tx for a hrydocele
iv. Treatment rarely needed, Aspiration doesn’t work, Surgery will.
Most large hydroceles need to go to the urologist who will decide on surgery but it’s not preferred b/c it causes recurrent hydroceles
Varicocel
dilation of the Pampiniform plexus of spermatic veins. Left hemiscrotum.
ii. 20% of men; more common on the L
iii. Occas. Dull, achy pain.
DX test for ULS
Put your hands on the scrotum and ask them to grunt or bear down (valsalva) and it should dilate the vessels or can use ULS and have them bear down
how would you treat varicocele
Scrotal Support, NSAID, Surgery for infertility.
Epididymal cysts and Spermatoceles
are found where
Arise on the head of the epididymis, when larger than 2cm called Spermatoceles
Epididymal cysts and Spermatoceles vs cancer presentation
Generally asymptomatic, found on ULS
if they do get too large they can cause discomfort
Testicular Cancer
Usually painless, unless it causes hemorrhage or infarction
Testicular cancer ULS
less homogenous on ULS
can look abnormal
want to get a CT to look for METS most commonly to the lungs
Orchitis is defined as ___
what sxs do we see associated
Extension of epididymal infection into the testes, or complication of Mumps.
More systemic symptoms:
Fever, myalgias, malaise, parotid swelling
inguinal hernia is the result of
Failure of adequate embryonic closure of the Processus vaginalis in the inguinal canal, allowing intestines to force downwards into the scrotal sac.
inguinal hernia sx
Uncomfortable but not acutely painful, usually reducible by a push or lying supine. Often gradually enlarge.
Inguinal Hernia on PE
supine, and if not palpable, standing.
- If acutely painful, think:
a. Obstructed vs. Incarcerated vs. Strangulated
“i think it is an inguinal hernia that is likely reducible. I have not reduced one before but could i practice”
dx tests for inguinal hernia
ULS/CT –> look with ULS but can’t tell where bowel gets narrow and pinched on the side so CT is very useful for this
can you push an inguinal hernia back in
Let the surgeon decide to push –>if you push dead bowel back inside, then the dead bowel gets dead-er
tx of inguinal hernia
Scrotal Support, Analgesics, Stool softeners, Surgical Referral.
CAT scan with air
necrotizing fasciitis seen as dark black hyperecohoic air
blue dot sign for
torsion
Torsion of the Appendix Testis
Caused by the infarction/necrosis of the appendix testis. Rare in adults.
Most common scrotal pathology in children
Torsion of the Appendix Testis
Torsion of the Appendix Testis sxs
7-14 y.o.
Pain usually more gradual than testicular torsion.
Tenderness localized to the anterosuperior testis and no swelling to the testis or epididymis.
tx of torsion of the appendix
Pain Control
Fournier’s Gangrene
Necrotizing Fasciitis. Mixed aerobic and anaerobic bacterial infection rapidly leading to systemic illness/Sepsis/death.j. Fournier’s Gangrene
Fournier’s Gangrene sx
who is at risk
Scrotal pain, tense edema, blisters, hemorrhagic bullae, fever, tachycardia, hypotension
IVDU
DM at risk
tx of Fournier’s gangrene
IV/Labs/broad spectrum antibiotics/CT. Immediate Surgical consult
OR – early and aggressive surgical debridement
Testicular Torsion
The testis twists on the spermatic cord causing ischemia. Irreversible damage after 12-24 hours.
sxs of testicular torsion
Sudden/acute severe pain, often a few hours after physical activity or trauma.
findings in PE
high riding’ testis on the affected side with the long axis of the testis oriented ‘sideways’.
A “Bell Clapper Deformity”.
Testicular swelling early, leading to a reactive hydrocele, and lastly scrotal redness.
The Cremasteric Reflex – absent in torsion
tx for torsion
Time is Testicle”
- Analgesics, (UA, etc.)
- Immediate Urologic/Surgical consultation
- Manual Detorsion – ‘Opening a book’ until pain relieved. Supposedly dramatic relief.?
- Color Doppler Ultrasound
- OR
Balanitis
Balanos” is Greek for “Acorn” –Inflammation of the Glans.
\Most common etiology is Candida albicans
Balanitis when the foreskin is involved.
Balanoposthitis
Balanitis sxs
Increasing tenderness, pain, swelling, and discharge over days.
DM
Balanitis
- Fingerstick glucose, STD labs
- 1-3 weeks of antifungal.
- Clotrimazole/Miconazole BID, Hydrocortisone 1% cream.
- Single dose of Fluconazole PO
- Better Hygiene
When the foreskin tightens over the glans and cannot be retracted it is
Phimosis.
Foreskin tightens over the glans and cannot be retracted
Presentation–> balanitis gone bad, foreskin adheses
If the foreskin is retracted and becomes so swollen that it constricts like a tourniquet around the glans it is
Paraphimosis.
sxs of Phimosis and Paraphimosis
Balanitis gone bad.
Foreskin adheses, glans swells
tx of Phimosis and Paraphimosis
- Phimosis doesn’t usually need treatment different from balanitis.
- Paraphimosis requires manual decompression or surgical circumcision
a. Applying sugar/glucose may be helpful
priapism lasts
A painful erection lasting more than 4 hours (without sexual excitation)
priapism pshyiology
iv. The blood in the corpora cavernosa becomes entrapped and ‘stagnates’ due to impaired relaxation of the smooth muscle.
priapism hx
Hx should include duration of erection, prior episodes,
history of Sickle Cell, Leukemia, medications
meds: antidepressants, antipsychotics, antihypertensives, impotence injectables, Atarax, Reglan, and Prilosec),
and recreational drugs… Spinal cord injuries, Black Widow and Scorpion envenomations, Malaria, etc.
dx of priapism
Doppler ULS or Cavernosal blood gas if nonischemic priapism suspected (aspirated blood is red instead of black).
CBC, HgB electrophoresis, Utox
tx of priapism
Surgical/Urologic Consult
Intracorporeal Aspiration /Irrigation and Phenylephrine 100-500 mcg per ml, injected into the corpus cavernosum every 3-5 minutes for an hour (or until 1 mg total reached)
OR, surgical shunt cut between corpus cavernosum and corpus spongiosum.
Hemorrhoids
Dilated AV channels and connective tissue with veins arising from the superior and inferior hemorrhoidal veins in the submucosal layer of the inferior rectum.
hemorrhoids tx if thormobosed
feel like a marble and is dark
sx of hrmorrhoid
Painless bleeding, Prolapse, Pain, Pruritus
PE of hemorrhoid
Risk assessment for GI bleeding (PUD, IBD)
- Position the pt. so that you can see. Light!
- If painful look for fissures, abscess, or thrombosed hemorrhoid.
- If nothing external then anoscopy.
tx of hemorrhoid
- Sitz baths. Increase Fiber, decrease Straining.
- Fiber supplementation (Methylcellulose/Psyllium, 20-30 G/d)
- Analgesic/Hydrocortisone Creams or Suppsitories
- Stool Softeners
- Surgery Referral:
a. Rubber Band Ligation, Infared Coagulation, Sclerotherapy, Cryosurgery, Surgical Hemmorhoidectomy
PeriAnal/Rectal Abscess
Infected Anal Crypt gland.
Rectal Abscess sxs
ii. 50% become fistulas!
iii. Sx: Pain, Swelling, Mass, Pus, Fever
PE with rectal abscess
Digital Exam. If palpable induration or significantly increased pain, consider CT with Contrast. Surgery Consult. Labs.
Run your finger around the anus and trying to feel for fluctuance
PeriAnal/Rectal Abscess tx
Treatment:
I&D with local anesthesia. Elliptical skin excision because of no packing, or use rubber drains… SITZ baths.Analgesics. Stool Softeners.
1. Antibiotics depending on size and comorbidities
c. Acute Prostatitis
i. Inflammation of the Prostate gland, often bacterial, can become chronic.
sxs of acute prostatis
Sx: Flu-like symptoms - Fever, chills, malaise, myalgia. Dysuria, cloudy urine.Pain in lower abd, perineum, testicles, or penis. Hematospermia.
Swelling of the Prostate can cause ‘obstructive’ symptoms: hesitancy, dribbling, acute urinary retention.
tx of prostatitis
Urine Culture and Gram Stain.
1. Labs and blood culture if toxic appearing.
- PSA not especially helpful
- Initial antibiotic therapy for gram negatives is Fluoroquinolone or Septra, for 4-6 weeks! Adjust if needed when gram stain/culture done.
- Add Aminoglycoside if toxic.
- Analgesics
Prolapse of the rectal tube thru the anus.
RF
: Female, Multiparous vaginal deliveries, Pelvic floor Anatomic defects, Prior Pelvic Surgery, Chronic Straining/Diarrhea, Cystic Fibrosis, CVA
ii. Uncommon, 1% adults over 65 y.o.
sxs of rectal prolapse
Pain is not typical. Usually pt. c/o’s mass or discharge (fecal incontinence or seepage)
Treatment: Surgery Consult. Colonoscopy referral. Fiber/Fluids/Enemas
tx of rectal foreign body
Sedation
- Imaging, Manual removal attempts
- Surgical consult
dentate line
pectinate line (dentate line) is a line which divides the upper two thirds and lower third of the anal canal. Developmentally, this line represents the hindgut-proctodeum junction.
separate internal from external hemorrhoids
