Hydrocele, varicocele, etc. Flashcards
Define hydrocele
Collection of fluid between the visceral and parietal layers of tunica vaginalis of testicle or along the spermatic cord
What is the most common cause of scrotal swelling?
Hydrocele
What % of newborn males have a patent processus vaginalis?
80% , most close within 18 months of age
Congential cause of hydrocele?
Process vaginalis does not close or closes after fluid becomes trapped in scrotal cavity
What are adult causes of hydrocele?
- Imbalance of secretion and reabsorption of fluid from tunica vaginalis
A. May be secondary to:
-Infection
-Trauma
-Tumor
-Obstruction of lymphatic or venous drainage in spermatic cord
How do you tell if the scrotum is fluid-filled?
Trans-illumination test is positive. Distinguishes fluid filled from solid mass (mass does not illuminate)
Sxs of hydrocele
- Usually painless enlarged scrotum
2, Patient may report a sensation of heaviness or fullness
Where are hydroceles often located?
Hydroceles are located superior and anterior to the testis
Where are spermatoceles often located?
superior and posterior to the testis
What other conditions are asst. with congenital hydroceles?
- Often associated with hernia
- Gets smaller and softer when supine
- Gets larger and tenser after prolonged standing
What test is always performed when the testis/scrotum are enlarged?
- Ultrasonography
Visualizes testis and presence of fluid
Important if hydrocele is result of testicular neoplasm
What is the surgical tx of hydrocele?
- Excision of hydrocele sac
- Treatment of choice for congenital hydrocele
- Herniorrhaphy: open inguinal hernia repair
What tx is reccomended with recurrent hydrocele?
Percutaneous aspiration of hydrocele fluid with installation of sclerosing agent into sac
If a hydrocele persists past the first ? months of life, it should be surgically repaired
12
Inguinal hernia in infants is usually repaired within the first ? months of life
3
What two conditions are difficult to dinstinguish from each other?
hydrocele and inguinal hernia on exam
What are some complications from hydrocele?
adversely affect fertility
Define varicocele
Mass of dilated and tortuous veins in spermatic cord
What is the prevalence of varicocele?
Occurs in 15 of 100 men
Occurs in 40 out of 100 men with infertility
What are the demographics for varicocele?
- More common in ages 15-25 years
- Found in approximately 15 – 20% of post pubertal males
- 30% of all men diagnosed with infertility have a varicocele
What are varicoceles caused by?
Caused by dilation of pampiniform plexus of spermatic veins
Which side is more affected by varicoceles and why?
Left > Right
(L) gonadal vein drains into renal vein (8-10 cm > R)
(R) drains into IVC
“Nutcracker syndrome”
What are sxs of varicoceles?
- Usually asymptomatic
- History of infertility
- May have dull, aching scrotal pain
How is a varicocele diagnosed?
- Diagnosis is usually clinical and made on physical exam
- Does NOT transilluminate
- Increases in size with valsalva: due to increased abdominal pressure
- Decreases in size when supine
When should imaging studies be done in varicocele cases? What type of imaging?
In equivocal cases or in patients with large body habitus, scrotal ultrasound with color flow doppler imaging may be useful
What is the tx for varicocele?
- Scrotal support
- Mild varicocele where fertility is not a concern - Surgical Repair
- Ligate gonadal vein
- A single vein is left open (vasal vein)
- To restore or retain fertility
Define Paraphimosis
Foreskin becomes trapped behind the corona for a prolonged period, a tight band of tissue forms around the penis
What are the results/complications of the trapped foreskin in a paraphimosis?
- Initially impairs venous blood and lymphatic flow from the glans penis and prepuce
- Edema of the glans - As the edema worsens, arterial blood flow becomes compromised
- Eventually leads to gangrene or autoamputation of the distal penis
What is the etiology of paraphimosis in infants and young children?
Usually results from self manipulation by the child or inappropriate retraction of the foreskin by the caretaker
What is the etiology of paraphimosis in sexually active adolescents and adults?
Intercourse is a potential precipitant
What is iatrogenic paraphimosis?
Follows cystoscopy or bladder catheterization if the foreskin is not reduced back over the glans penis by the medical provider
What are the sxs of Paraphimosis?
- Penile pain & swelling
- Edema & tenderness of glans
- Painful swelling of distal retracted skin
- Constricting band of tissue proximal to head of penis
- Remainder of the penile shaft is unremarkable
What is conservative tx for paraphimosis?
- Can often be reduced by manipulation by PCP, ER physician or Urologist
A. Involves compressing the glans and moving the foreskin back to its normal position
B. May need lubricant
What are the surgical tx of paraphimosis?
The foreskin may need to be cut (dorsal slit procedure) or removed by circumcision
How is paraphimosis prevented?
- Education of the patient &/or caregiver on the need to return foreskin over the glans after it has been retracted for Cleaning of the glans or After sexual activity
Define phimosis
Inability to retract the distal foreskin over the glans penis
-Irritation or bleeding from the preputial orifice
When is phimosis natural?
Physiologic phimosis occurs naturally in newborn males
When is phimosis pathological?
Pathologic phimosis refers to inability to retract the foreskin after it was previously retractable or after puberty
-Usually secondary to distal scarring of the foreskin
What is the pathophys of phimosis?
- Poor hygiene and recurrent episodes of balanitis lead to scarring of preputial orifices, leading to pathologic phimosis
- Forceful retraction of the foreskin leads to micro-tears that also lead to scarring and phimosis
Why are elderly men at risk for phimosis?
Elderly personsare at risk of phimosis secondary to loss of skin elasticity and infrequent erections.
What is the tx for phimosis?
- Rarely require emergency intervention
- Urology referral
- Topical steroid cream
- Stretching exercises with gentle retraction
Define testicular torsion
Abnormal twisting of spermatic cord of testicle, thus compromising arterial blood supply, leading to ischemia
What is the normal rotation of the testicles with contraction of the cremaster muscle?
- left testicle rotates counterclockwise 2. the right testicle rotates clockwise
Where is testicular torsion more common in adolescents?
intravaginal torsion
Where is testicular torsion more common in neonates?
Extravaginal torsion
What is the prevalence and risk of testicular torsions?
- Greatest risk is during neonatal period and between 12-18 years
- More common in boys with Hx of cryptorchidism
- Infants with torsion of one testicle are at greater risk for torsion of other testicle
What is a bell clapper deformity? What type of torsion is it asst. with?
- Incomplete attachment of testicle to scrotal wall
- Intravaginal torsion: Inappropriately high attachment of tunica vaginalis and abnormal fixation of muscle/fascia of spermatic cord
what is the etiology of extravaginal torsion?
Loose attachment of tunica vaginalis to scrotal lining
-Results in spermatic cord rotation above testicle
What are the complications of testicular torsion?
- Complete testicular infarction
2. Testicular atrophy
What are the sxs of a testicular torsion?
- Abrupt onset excruciating pain in affected testicle
-Usually middle of night or morning - Edematous, elevated, ecchymotic scrotum
(-) Prehn’s Sign (variable) - Loss of cremaster reflex on affected side
- Abdominal pain
- Nausea/vomiting
What diagnostic studies are indicated in testicular torsions?
- Doppler ultrasound of scrotum
- Emergent
- Absent blood flow and avascular testicle
- Diagnostic
What is the surgical tx for testicular torsion?
- Immediate surgical repair
- 6 hr window
- Orchiopexy: bilaterally attach testicle to the scrotum so it doesn’t move
- Orchiectomy: loose a testicle permanently
What is the conservation tx for testicular torsion?
Manual manipulation of testicle away from midline to improve blood flow before surgery
Not always possible
What are the viability rates of the testicle over time?
Detorsion within 6 hours - 90% viability
Detorsion at 12 hours - 50% viability
Detorsion at 24 hours -10% viability
Detorsion after 24 hours - 0% viability
Define orchiopexy
Fixation of a viable testicle to scrotum
Prophylactic fixation of contralateral testicle
Define Orchiectomy
Excision of nonviable testicle
Preserves fertility in other testicle
