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GU > Lecture 11: Scrotal and Penile Disorders > Flashcards

Lecture 11: Scrotal and Penile Disorders Flashcards

1
Q

What is a hydrocele?

A

Accumulation of fluid around the testis.

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2
Q

What is the MCC PAINLESS scrotal swelling in pediatrics?

A

Hydrocele

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3
Q

What are the 3 noncommunicating hydroceles?

A
  • Testicular
  • Inguinoscrotal
  • Cord
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4
Q

What connection makes a hydrocele communicating?

A

Processus vaginalis

Usually only present in newborns.

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5
Q

What are the usual S/S of a hydrocele?

A
  • Little to no pain
  • Fluid-filled mass ANTERIOR to testis
  • +/- scrotal fullness or heaviness
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6
Q

What does a hydrocele look like on PE?

A

Like a little lightbulb on your penis

Transilluminates

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7
Q

What imaging should we order if we suspect torsion related to a hydrocele?

A

Doppler US

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8
Q

When do we treat a hydrocele?

A

If it lasts > 12months, communicating, or symptomatic.

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9
Q

What is the treatment for a hydrocele?

A
  • Needle aspiration
  • Definitive tx: Hydrocelectomy
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10
Q

Describe a variocele.

A

Dilated, engorged, tortuous veins within the pampiniform plexus of scrotal veins.

MC on the LEFT SIDE

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11
Q

What is the most surgically correctable cause of male infertility?

A

Variocele

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12
Q

What might an unilateral R variocele suggest in terms of underlying etiology?

A

IVC obstruction.

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13
Q

What are the S/S of a variocele?

A
  • Scrotal enlargement or heaviness
  • +/- dull aching pain
  • Infertility
  • Asymptomatic is possible too.

Can also be painless like a hydrocele.

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14
Q

What does a variocele feel like on PE?

A

Bag of worms that may improve with supine.

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15
Q

What is the primary imaging test that can confirm dx of a variocele?

A

Doppler US

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16
Q

What is the conservative approach to variocele treatment? Surgical tx?

A
  • Conservative: Scrotal support and NSAIDs
  • Surgical: only for severe s/s or fertility.
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17
Q

What are the surgical tx options for a variocele?

A
  • Embolization of spermatic vein
  • Injected ablation of spermatic vein
  • Surgical ligation of pampiniform plexus
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18
Q

What is a testicular torsion?

A

Twist in the spermatic cord causing compromised testicular blood supply.

EMERGENCY!

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19
Q

What age group are testicular torsion MC in?

A

12-18 yr old

65%

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20
Q

What are the risk factors for testicular torsion?

A
  • Trauma
  • Vigorous exercise or sex
  • Cryptorchidism
  • Bell-clapper deformity
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21
Q

What are the symptoms of testicular torsion?

A
  • Sudden onset of severe, unilateral scrotal pain/swelling
  • +/- lower abd pain, N/V
  • +/- hx of intermittent symptoms
  • NO VOIDING SYMPTOMS
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22
Q

What is the classic presentation of testicular torsion?

A
  • High-riding testis
  • Slightly larger than unaffected testis
  • Transverse lie in scrotum
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23
Q

What is Prehn’s sign?

A

Pain does not relieve with scrotal support

Negative Prehn’s sign

Seen in testicular torsion.
Negative prehn’s => torsion
Positive prehn’s => epididymitis

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24
Q

What is the cremasteric reflex?

A

Stroke/pinching skin or upper thigh should cause ipsilateral rise of testis.

Lack of this reflex suggests torsion.

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25
Q

What is the test of choice for testicular torsion?

A

Doppler US

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26
Q

What is the alternative to doppler US for testicular torsion?

A

Radionuclide scintigraphy

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27
Q

What is the purpose of UA in testicular torsion?

A

R/o infection

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28
Q

How do we treat testicular torsion?

A

Detorsion and fixation of testes

Either manual or surgical.

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29
Q

How is manual detorsion done?

A

Medial-to-lateral primarily.

Opening a book motion.

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30
Q

How quickly must surgical detorsion be performed?

A

6 hrs!

If > 12 hrs, you might lose your balls

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31
Q

What are the 5 criteria for the TWIST scoring system?

A
  • Testicular swelling - 2
  • Hard testicle - 2
  • Absent cremasteric reflex - 1
  • N/V - 1
  • High-riding - 1

5+ high risk, 3-4 medium: do doppler US.

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32
Q

What is the most likely testicular appendage to be twisted?

A

Appendix testes

Also MC in younger patients!

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33
Q

What are the 4 possible testicular appendages that can undergo torsion?

A
  • Appendix testis
  • Appendix epididymis
  • Paradidymis
  • Vas aberrans
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34
Q

How does testicular appendage torsion present?

A
  • Similar to testicular torsion but less severe.
  • Blue dot sign
  • Normal blood flow
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35
Q

What is the treatment for testicular appendage torsion?

A

Conservative

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36
Q

What is phimosis and the MCC?

A
  • Contracted foreskin that can’t retract.
  • MCC: chronic infection from poor hygiene.
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37
Q

What demographic is pathological phimosis common in?

A

Diabetic older men with chronic balanoposthitis

38
Q

What are the S/S of phimosis?

A
  • If infected, edema, erythema, and tenderness of prepuce can be present.
  • Ballooning of prepuce during urination
39
Q

What are the treatment options of phimosis underlying etiologies?

A
  • Fungal: topical clotrimazole or nystatin or oral fluconazole
  • Bacterial: Topical bacitracin, oral metronidazole
  • Cellulitis/shaft: cephalexin
40
Q

What are the temporary treatment options for phimosis?

A
  • Hemostat dilation
  • Catheterization
  • Topical steroids
  • Frenar stretch
  • Surgical dorsal slits
41
Q

When might circumcision be recommended for phimosis?

A
  • Recurrent/persistent
  • Chronic balanitis or balanosthitis
42
Q

What are the two dangerous complications of phimosis?

A
  • Preputial calculi
  • Squamous cell carcinoma
43
Q

What is paraphimosis?

A

Inability to reduce previously retracted foreskin.

Much more severe than phimosis.

44
Q

What parasite is a cause of paraphimosis?

A

Plasmodium falciparum (malaria)

45
Q

What happens if paraphimosis persists?

A

Necrosis, gangrene, and autoamputation.

46
Q

What are the S/S of paraphimosis?

A
  • Swollen, erythematous, tender foreskin proximal to the glans.
  • Donut sign
  • Flaccid penis proximal to foreskin

Its like a penis ring

47
Q

How do you perform manual reduction of paraphimosis?

A
  • Pressure for 5 mins on glans to reduce edema.
  • Push glans proximally while pulling prepuce distally.
48
Q

What are the 3 options after manual reduction of paraphimosis fails?

A
  • Needle decompression
  • Dorsal slit to foreskin
  • Osmotic agents

Circumcision after inflammation subsides.

49
Q

What is priapism?

A

Prolonged and painful pathologic erection

50
Q

What is the MC etiology of priapism? 2nd MC?

A
  • # 1: idiopathic
  • MC known cause is intracavernous injection ED treatment.
51
Q

What diseases can cause priapism?

A

Leukemia, SCD, cancer

In children, SCD is the MCC.

52
Q

What is high flow priapism?

A
  • Nonischemic, presenting without pain.
  • Characterized by loss of penile arterial regulation.
  • Treated with embolization for aneurysms.

High flow = arteries

53
Q

What is low flow priapism?

A
  • Ischemic, more common and painful.
  • Characterized by venous drainage
  • Results in impotence

veins = slower

54
Q

What are the S/S of each priapism?

A
  • High flow: painless, prolonged
  • Low flow: several hours of painful erection
  • Low flow: glans penis and corpus spongiosum are soft and uninvolved.
  • Low flow: Corpora cavernosa - tense, congested blood, tender.
  • Low flow: urologic emergency.
55
Q

What are the treatment options for priapism?

A
  • Anesthesia
  • SubQ terbutaline
  • Corporal aspiration of viscous blood with irrigation
56
Q

What are the treatment options for refractory priapism?

A
  • Winter procedure: fistula
  • Excision of tunica albuginea
  • Shunts

Shunt options:
Cavernosa-spongiosum
Saphenous vein-cavernous

57
Q

What is Peyronie’s disease?

A
  • Fibrosis of dorsal covering sheaths, aka tunica albuginea.
  • Makes a curved penis when erect.
  • MC in middle-aged men and older.
58
Q

What are the primary causes of Peyronie’s disease?

A
  • Trauma during sex
  • Vasculitis or CT disease
  • DM and hypercholesterolemia
  • Smoking, ETOH, Dupuytrens
  • Genetic predisposition
59
Q

How does Peyronie’s look like?

A
  • Painful erection and curved penis
  • Poor erection distal to the curvature
  • No pain if not erect.

looks like someone just bent half of it

60
Q

What is the initial treatment for Peyronie’s?

A

Observe it

61
Q

If we do decide to treat Peyronie’s, what are the options?

A
  • Vit E, colchicine, para-aminobenzoic acid
  • Intralesional injections of PTH, verapamil, etc
  • Radiation therapy
  • Excision of the plaque
  • Penile prosthesis
62
Q

What is the MCC type of penile cancer?

A

Squamous cell carcinoma

MC in underdeveloped countries.

63
Q

What age is typical for penile cancer to present?

A

Around 60 yo

64
Q

What two viruses are risk factors for penile cancer?

A
  • HPV
  • HIV
65
Q

What are the S/S of penile cancer?

A
  1. MC: skin abnormality or palpable lesions
  2. Inguinal LAN
  3. Metastatic symptoms

Symptoms:
Bone pain
Cough
Skin lesions

66
Q

How do we initially treat penile cancer? 2nd?

A
  • ABX if s/s of infection are present.
  • Biopsy if no improvement or no s/s of infection.
67
Q

What are the two surgical treatment options for penile cancer?

A
  • Low risk of recurrence: limited excision
  • High risk of recurrence: partial or total penile amputation
68
Q

Who is STD epididymitis MC in?

A
  • Men < 40, associated with urethritis.
  • N. gono
  • Chlamydia
69
Q

Who is non-STD epididymitis MC in?

A
  • Men > 40
  • Associated with UTI or prostatitis
  • G- rods
70
Q

What medication is most often implicated in causing epididymitis?

A

Amiodarone

71
Q

What are the S/S of epididymitis?

A
  • Post strain
  • Fever
  • Pain/swelling in scrotum (normal early)
  • +/- hydrocele
  • +/- inguinal LAN
  • Positive Prehn’s (elevating scrotum will help, unlike torsion)
72
Q

What would we see on an urethral swab for epididymitis if it is an STD?

A
  • Gonorrhea: G- intracellular diplococci
  • Chlamydia: WBC without visible organisms.
73
Q

What lab could we order to help confirm if a STD is causing epididymitis?

A

PCR

74
Q

What is the empiric ABX regimen for epididymitis?

A
  • Rocephin + Doxy

10d, gono + chlamydia coverage

75
Q

What is the ABX regimen for epididymitis if STD is highly UNlikely?

A
  • Levofloxacin
  • Bactrim DS

10d, G- rod coverage?

76
Q

What are the usual causes of orchitis?

A
  • Bacterial: complication of epididymitis
  • Granulomatous: autoimmune response to sperm
  • Viral: MUMPS, EBV, coxsackie, VZV, echovirus

Orchitis typically co occurs.

77
Q

What are the S/S of orchitis?

A
  • Swelling, tenderness, and erythema of testis
  • Scrotal pain (gradual onset with less pain than torsion)
  • Fever, +/- N/V
  • +/- inguinal LAN
78
Q

What is the only difference in treatment for orchitis compared to epididymitis?

A

If anal sex is occurring, rocephin + levofloxacin is used.

79
Q

What disease might predispose someone to a epididymal cyst?

A

Von-hippel lindau syndrome

80
Q

What is a spermatocele?

A

A giant epididymal cyst > 2cm.

81
Q

What cancer is the MC in males 20-35?

A

Solid testicular tumors

90-95% are germ cell tumors.

82
Q

What are the risk factors for testicular cancer?

A
  • Cryptorchidism (surgery doesn’t reduce cancer risk)
  • Exogenous estrogen during pregnancy
  • Infertility
  • Whites, but everyone else has increased mortality risk.
83
Q

What is the MC symptom of testicular tumor?

A

Painless enlargement of testis.

10% can be asymptomatic.

84
Q

Where is the MC site of metastases for testicular cancer?

A

Retroperitoneal abdominal lymph nodes

85
Q

What labs can be tested as a biomarker for testicular cancer?

A
  • AFP
  • hCG
  • LDH

Germ cell tumors can secrete hCG

86
Q

What is the initial imaging modality for testicular cancer?

A

Scrotal US

Staging is with CT or CXR.

87
Q

What is the definitive diagnostic modality for testicular tumors?

A

Radical inguinal orchiectomy.

Cannot simply biopsy.

88
Q

What are the treatment options for testicular tumors?

A
  • Inguinal exploration + vascular control of spermatic cord.
  • Radical inguinal orchiectomy
89
Q

How often should followup be for testicular cancer?

A
  • Monthly for 1st 2 years!
  • CXR/CT
  • Tumor markers at every visit

80% relapse in 1st 2 yrs

90
Q

What is the prognosis for testicular tumors?

A

90% 5-year survival rates

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