L7 - Scrotum and foreskin conditions Flashcards
Hydrocele
Accumulation of fluid within tunica vaginalis.
Transilluminable!
Primary hydrocele
Most common
Idiopathic
Can be caused by increase serous fluid production.
Secondary hydrocele
As result of tumour or infection
Management of hydrocele
Aspiration if unfit for surgery.
Aspiration of hydrocele
Needle inserted into scrotum, directly into hydrocele.
Suction applied to remove the straw coloured fluid as much as possible.
Surgical management of hydrocele
Tunica vaginalis opened.
Fluid released.
Sac sewn onto itself, hence fluid cannot reaccumulate.
Complications of hydrocele
Haematoma formation, can occasionally become more painful than original hydrocele.
What is a varicocele?
Dilation of veins of pampiniform plexus within the spermatic cord.
Males may become subfertile. Trying to conceive takes longer than what is expected.
Why are most varicocele’s found on the left?
- Increased pressure in left testicular vein.
- As it drains perpendicular into left renal vein.
- Hence turbulent flow
Compare pressure in the left and right testicular vein.
Right testicular vein drains at a lesser angle directly into IVC.
Hence lower venous pressure than left testicular vein.
What does a varicocele feel like?
A bag of worms.
Disappears when patient is lying down.
Management of a varicocele
Conservative, reassurance
Surgery if heavy or aching variocele
Describe surgical intervention on a variocele
Affected testicular veins are divided and embolised.
Describe epididymal cyst
Transilluminable lumps.
1 or multiple swellings felt in scrotum behind testis.
Spermatocele
Not transilluminable as it contains sperm.
Describe a hernia
Indirect inguinal hernia
Has cough impulse.
Can’t feel above it.
Cough impulse
Patient coughs.
If swelling expands upon coughing then positive.
Movement without expansion IS NOT a cough impulse.
Tumour in testes
often 20-40 y/o men
Painless lump.
Often not separate from testis.
Describe testicular torsion
most common 20-40 y/o
Testes rotates around its vascular base leading to acute pain.
What is testicular torsion characterised by?
- Sudden onset severe testicular pain
- Abdominal pain
- vomiting
- retraction of testes ‘bell clapper’ position
What may be done to confirm a testicular torsion?
Doppler
Requires urgent surgical exploration !
Surgical management of testicular torsion?
Both testes sutured to tunica vaginalis to prevent further torsion.
Known as orchidopexy.
Epididimitis
Infection of epididymis. Scrotal discomfort Pain during micturition Due to chlamydia. - 2 week course of doxycycline may be given
Orchitis
Infection of testis.
Commonly has viral cause
- MUMPS
Epididymo-orchitis
If epididimitis spreads to testes
- gradual onset
- dull ache or pain
State some causes of groin lumps
Lymphocele Ectopic testes Saphena Varix Psoas Abscess Femoral aneurysm Lipoma Lymph node Inguinal and femoral hernia
Describe how a lymphocele may form?
Following femoral artery surgery in groin.
Disruption of local lymphatics.
Local collection of lymphatic fluid forms lump.
Can be aspirated.
Ectopic testes
Testes is absent from scrotum
How may you diagnose an ectopic testes?
Feel alongside line of inguinal canal ligament.
Should detect and undescended testes.
Saphena varix
Bluish tinge.
Has cough impulse.
Disappears when lying down.
Varicose veins may be present.
Psoas abscess
In psoas muscle
Caused by Crohn’s or Tb
Causes fixed flexion of hip
What would you inspect a scrotum for?
Lumps
Scars
Swelling
Get patient to cough
How would you palpate the scrotum / testes?
- Place hand over lump, get patient to repeat cough reflex, in order to feel movement.
- Check both sides for less obvious bilateral hernia
- Start on unaffected side
- Palpate along line of inguinal ligament to identify an undescended testes
What is a reducible hernia?
A hernia with a bulge that flattens out when you lie down or push against it gently.
How may you distinguish between a direct and indirect hernia?
- Ask patient to reduce lump
- Cover deep inguinal ring covered with 2 fingers.
- Ask patient to cough
IF
- Lump comes out (direct)
- Stays in place (Indirect)
What would be observed is you trans-illuminated a hernia?
Nothing.
Hernia’s do not trans-illuminate
What is the surgical difference between direct and indirect hernias?
Direct hernia arises laterally to inferior epigastric artery.
Arises through deep ring.
How would you identify an undescended testes?
Palpate along the line of inguinal ligament to identify an undescended testis.
Use the cough impulse.
You are inspecting a patient.
You can feel above the lump.
What could it be?
Hydrocele
Tumor
Varicocele
Epididymal cyst
On inspection of a patient you realise you can’t feel above the lump, this could indicate…
Presence of hydrocele of cord
Indirect inguinal hernia
What kind of lumps are transilluminable?
Hydrocele
Epididymal cyst
Hydrocele of cord
What kind of lumps are definitely not transilluminable?
Tumour
Indirect inguinal hernia
What is schistosomiasis
Water bourne parasite
- gives rise to squamous cell carcinoma
Uraemia
Characteristic fishy smell on tongue
Bruit
Abnormal sound heard over upper abdomen
Possible causes of bruit
Renal artery stenosis
Aneurysm of renal artery
Arteriovenous fistula
Describe scrotal pain
May be referred to groin or abdomen
Result of stretching of albuginea
Strangury
Repeated desire to pass urine but with little to show for it other than pain related to urethra or penile tip.
What is renal agenesis?
Kidney either absent or underveloped
Renal dysplasia
One kidney in newborn is multicystic, irregularly lobulated mass of cysts.
Usually absent ureter.
Potter’s syndrome
Bilateral renal agenesis
- can also occur due to infantile polycystic kidney disease, renal hypoplasia and obstructive neuropathy
Renal hypoplasia
One small kidney with one larger than normal
How might renal hypoplasia differ from renal dysplasia?
Kidney otherwise morphologically normal.
Normal residual parenchyma.
Smaller calyces, lobule, papillae
Supernumerary kidney
3rd kidney
Describe common position of horseshoe kidney?
Often fixed at lower pole.
Positioned lower.
Central part just below inferior mesenteric artery
Ectopic kidney
Kidney does not ascend properly, found in pelvis
Ureteral atresia
Ureter maybe absent or fail to extend to bladder
Epispadia
Rare, congenital abnormality involving the opening of urethra.
Urethra opens on top of penis as oppose to tip.
Lymphatic drainage of scrotum
Inguinal nodes
Where do the right and left testicular veins drain into?
LEFT: Pampiniform plexus drain into renal vein on the left.
RIGHT: IVC on right
State some conditions affecting foreskin
Balanoposthitis
Phimosis
Paraphimosis
Balanoposthitis
Inflammation of the head of the penis and the foreskin
Symptoms of balanoposthitis
Redness, swelling and soreness around head of penis or foreskin.
Thick discharge under foreskin.
Rash on the penis
Itchiness
Unpleasant odour
Pain when urinating
Causes of balanoposthitis
Irritation caused by smegma,
Thrush.
Bacterial infection caused by streptococcal bacteria.
Phimosis
Condition where foreskin is too tight to be pulled back over head of penis.
Paraphimosis
When foreskin cannot be returned to its original position after being retracted.
- in extreme cases penile head may become gangrenous
- emergency reduction is indicated
Difference between Epispadias and Hypospadias
Epispadias: congenital absence of upper wall of urethra, results in urethral meatus on dorsum of penis.
Hypospadias: urethral opening appearing on underside of penile shaft or on the perineum
