Male GU Flashcards
Anatomy
Scrotal/Testicular Pain
(3)
Testicular Torsion
Torsion of Testicular Appendices
Epididymitis/Orchitis
What is the most common cause of acute scrotal pain?
Epididymitis/Orchitis
Testicular Torsion
=
Testicle twists spontaneously on spermatic cord, cutting off blood flow to testicle
Testicular Torsion Prevalence
- Generally, a ____-degree twist is required to compromise blood flow through the testicular artery and cause ischemia
- More common in ____ testicle 1:4000 incidence in males < ___ years old
- Most common in adolescents between ages of __-__
- Older men too, so should be in ________ for every male with testicular pain
- Generally, a 720-degree twist is required to compromise blood flow through the testicular artery and cause ischemia
- More common in left testicle 1:4000 incidence in males < 25 years old
- Most common in adolescents between ages of 12-18
- Older men too, so should be in differential for every male with testicular pain
Testicular Torsion Risk Factors
(1)*
Bell Clapper Deformity
Inappropriately high attachment of the tunica vaginalis, allowing testis to rotate more freely on the spermatic cord within the tunica vaginalis
Testicular Torsion S/S
-
______ onset, ______ testicular pain and s_______
- Usually _/_ dt severe pain
- ____lateral testicular swelling, exquisitely ______
- ____ riding testicle with transverse/_____ lie
- Usually, absence of ______ reflex on ipsilateral side
-
Rapid onset, severe testicular pain and swelling
- Usually N/V dt severe pain
- Unilateral testicular swelling, exquisitely tender
- High riding testicle with transverse/horizontal lie
- Usually, absence of cremasteric reflex on ipsilateral side
Testicular Torsion S/S
Usually absence of s/s of (1) → pt typically a_____, denies dys____, would have normal (2) labs if were able to check
Unless in later stage torsion where you could see (1) r/t inflammation
Usually absence of s/s of infection → pt typically afebrile, denies dysuria, would have normal UA/WBC labs if were able to check
Unless in later stage torsion where you could see leukocytosis r/t inflammation
Testicular Torsion Diagnostic Test
Scrotal US + HP
Intermittent Testicular Torsion
Pt may report similar pain that previously resolved
- (1) present but normal (2)
- Reasonable to (1) prior to “full fledged torsion”
- Pain present but normal PE and scrotal US
- Reasonable to treat with elective procedure prior to “full fledged torsion”
Testicular Torsion Treatment
(1)*
Important to “fix” the _____ testis as well
“Bell clapper usually exists __laterally if present”
Refer immediately to ED if suspected → Surgical detorsion
Important to “fix” the unaffected testis as well
“Bell clapper usually exists bilaterally if present”
Testicular Salvage Rate
Time is Testicle
- 90-100% if < __ hours
- 20-50% if ___ - ___ hours
- 0-10% if > ___ hours
- 90-100% if < 6 hours
- 20-50% if 12 - 24 hours
- 0-10% if > 24 hours
Torsion of Testicular Appendices
=
Twisting of testicular or epididymal appendix/appendices
Torsion of Testicular Appendices S/S
____lateral testicular ___, possible s______
(1) sign (ecchymotic appendix)
Testicle ___ high riding or in transverse lie, __febrile
Unilateral testicular pain, possible swelling
Blue dot sign (ecchymotic appendix)
Testicle not high riding or in transverse lie, afebrile
Torsion of Testicular Appendices Diagnostics
(1) + (1)
First test is used to confirm what?
Scrotal US + UA
US to confirm vascular flow to testicle (hypervascular at appendix)
Torsion of Testicular Appendices Treatment
Self-Limiting
Appendix atrophies over time
Epididymitis/Orchitis
(3) Defintions
Inflammation of Epididymis
Inflammation of Testicle
Combo - Epididymo-orchitis
Epididymitis/Orchitis Etiologies
(2)-(3),(1)
- STIs N.gonorrhoeae, C. trachomatis, M.genitalium
- Non-STD enteric organisms E.coli
Epididymitis/Orchitis Other Etiologies
- Other infectious etiologies
- v_____ (m___, cox_____)
- gran_____ (T__, B___)
- Non infectious etiologies (rare)
- Beh____ disease (auto____, painful ul____)
- am____
- Other infectious etiologies
- viral (mumps, coxsackie)
- granulomatous (TB, BCG)
- Non infectious etiologies (rare)
- Behcet’s disease (autoimmune, painful ulcers)
- amiodarone
Epididymitis/Orchitis S/S
____lateral testicular pain and s_____, possibly f____ or ___uria
- ____ing and ______ness of epididymis, testicle, or both. May be hard to distinguish during acute infection
- May be able to _____ thickened spermatic cord
- Possible scrotal er____ and ed____ on affected side. Could also develop a reactive ______
Unilateral testicular pain and swelling, possibly fever or dysuria
- Swelling and tenderness of epididymis, testicle, or both.
- May be hard to distinguish during acute infection May be able to palpate thickened spermatic cord
- Possible scrotal erythema and edema on affected side. Could also develop a reactive hydrocele
Epididymitis/Orchitis Diagnostics
Imaging (1)
Labs (3)
Scrotal US (potentially confirms hypervascularity, but usually)
UA/Ucx, STI testing (more common)
Epididymitis/Orchitis Treatment
Empirically treat most likely cause → adjust abx PRN based on culture sensitivities
Epididymitis/Orchitis Treatment
For men?
Most likely cause?
Ceftriaxone 500mg* IM x1 AND Doxycycline 100mg PO BID x10 d
STIs - N.gonorrhoeae or C.trachomatis
Epididymitis/Orchitis Treatment
For men who practice insertive anal sex?
What are the most likely causes?
- *Ceftriaxone 500mg* IM**
- *x1 AND Levofloxacin**
- *500mg PO QD x10d**
N.gonorrhoea or
C.trachomatis or enteric
organisms
Epididymitis/Orchitis Treatment
For men who’s most likely cause is not STIs, most commonly (1)
Levofloxacin 500mg PO QDx10d- most commonly E.coli
Epididymitis/Orchitis Symptom Management
If ceftriaxone not available? (3)
Symptom management (3)
Gentamicin 240mg IMx1 or
Azithromycin 2g POx1 or
Cefixime 800mg POx1
NSAIDs, Scrotal elevation/support, Ice
Scrotal/Testicular Masses
(5)
Varicocele
Spermatocele
Hydrocele
Groin Hernias
Testicular Cancer
Varicocele Definition
- __% prevalence in men overall
- 40% with _____ have varicocele
- *Benign-Enlargement of**
- *pampiniform plexus veins**
- *in scrotum**
- 15% prevalence in men overall
- 40% with infertility have varicocele
Varicocele S/S
(1)* - increases with (1)
pain?
More common on what side? why?
“bag of worms” - increases with valsalva
mild, achy pain sometimes
Left side, r/t angle at which left testicle vein connects to left renal vein
Varicocele Treatment
(2) only if (2)
Surgery or Embolization
if pain is bothersome or pt is struggling with infertility
Spermatocele
=
- *Benign-Small, smooth, firm**
- *mass filled with old sperm,**
- *on epididymis anywhere**
- *from epididymal head to**
- *tail**
Spermatocele S/S
May be ______, (1) to touch, but noted along the ______ not the _____
Diagnostic
(1)
May be palpable, usually
nontender, but noted along
the epididymis (not the
testicle)
Scrotal US
Spermatocele Treatment
=
No intervention unless significant pain/bothersome
Hydrocele
=
(2) types
- *Benign- Fluid filled sac**
- *surrounding testicle**
communicating vs.
non-communicating
Hydrocele Causes
(4)
Fourth cause (2)
Which is most common?
- *Inguinal Hernia** (most common cause of secondary hydrocele)
- *Trauma**
Infection
Tumor (rhabdomyosarcoma, mesothelioma)
Hydrocele S/S
(1)*
Diagnostic
(1)
Transilluminates
Scrotal US (to r/o other causes
Hydrocele Treatment
=
- Repair ____ if cause of communicating hydrocele
- As____ + S____therapy or hydrocel____ if large or bothersome/recurrence
No intervention typically, fluid may be reabsorbed or self-limiting in some cases
- Repair hernia if cause of communicating hydrocele
- Aspiration + Sclerotherapy or hydrocelectomy if large or bothersome/recurrence
Groin Hernias Risk Factors
(Inguinal and Femoral Hernias)
- Femoral hernias more common in (1)
- Risk Factors
- P_______/F___ Hx Chronic cough
- Condition with chronic cough (1)
- Chronic con_____/st_______
- Sm______
- Frequent heavy _____ (occupational)
- ________ birth (more likely indirect inguinal hernia)
- Femoral hernias more common in women
- Risk Factors
- Personal/Fam Hx Chronic cough
- Condition with chronic cough (cystic fibrosis)
- Chronic constipation/straining
- Smoking
- Frequent heavy lifting (occupational)
- Premature birth (more likely indirect inguinal hernia)
Direct Inguinal Hernia
- More common in (1) gender >___yo
- ____ or ___ protruding into inguinal canal through ____ abdominal _____ wall
- ______ to inferior epigastric vessels
- More common in men >50yo
- Intestine or fat protruding into inguinal canal through weak abdominal muscle wall
- Medial to inferior epigastric vessels
Indirect Inguinal Hernia
- _____ COMMON TYPE OF GROIN HERNIA
- Usual cause (1)
- Intestine or fat protrude down (1) and possibly into scrotum
- ______ to inferior epigastric vessels
- MOST COMMON TYPE OF GROIN HERNIA
- Usually congenital - inguinal ring fails to close
- Intestine or fat protrude down inguinal canal and possibly into scrotum
- Lateral to inferior epigastric vessels
Benign Groin Hernia
What can we do to the hernia to help determine if intervention is needed?
____ if pain/bothersome
_____ if no pain/reducible
Reducible either when supine (direct) or with exam (potentially direct or indirect)
Imaging if pain/bothersome
Monitor if no pain/reducible
Groin Hernia Complications
(2)
Diagnostic (1) if pain/bothersome
Treatment if needed (1)
Incarceration: not easily manually reproducible
Strangulation: SURGICAL EMERGENCY! incarcerated hernia where blood supply is cut off and cause necrosis of hernia content
Imaging
Surgical repair (laparoscopic or open) by general surgeon
Testicular Cancer
Most common cancer in men between ___ - ___
- Ave age of diagnosis =
- Every 1/___ males
- Only __% of testis tumors in adults are benign*
- Most common secondary testicular cancer = ______
Most common cancer in men between 15-34
- Ave age of diagnosis 33
- Every 1/250 males
- Only 1% of testis tumors in adults are benign*
- Most common secondary testicular cancer = lymphoma
Testicular Cancer Risk Factors
- Ethnicity (1)
- P_____ hx (3-4% risk in contralateral side)
- F___ hx (father or brother)
-
(1)*
- More common on what side, therefore testicular CA is more common on that side?
- _____ the testis, higher the risk
- ___lateral → still increased risk in contralateral descended testicle
- ______ syndrome
- In____
- H_ _
- Body size (1)
- Caucasian Personal hx (3-4% risk in contralateral side)
- Fam hx (father or brother)
- Cryptorchidism - undescended testicle
- >right side → testicular CA >right side
- Higher the testis, higher the risk
- Unilateral → still increased risk in contralateral descended testicle
- Klinefelter’s syndrome
- Infertility
- HIV
- Body size (height, not weight)
Testicular Cancer S/S
Most common sign (1)
- ___, _____ pain in testicles 10%
- ____cele 5-10%
- ____ pain (metastatic)
Hard, nontender, painless lump/bump on testicle
- dull, aching pain in testicles 10%
- Hydrocele 5-10%
- Back pain (metastatic)
Testicular Cancer Diagnostics
Imaging (1)
- (1) (AFP, b-HCG, LDH)
- (2) labs
- (1) Additional imaging
Scrotal US
- Serum tumor markers (AFP, b-HCG, LDH)
- CBC, CMP (check LFTs and Creatinine)
- CXR
Testicular Cancer Treatment
(2)
Excellent prognosis with?
Refer to Urology
Radical Inguinal Orchiectomy (then based on pathology, staging, imaging/labs will decide between surveillance, chemo, RT, or RPLND, or a combo of these)
Early detection and tx
(95% 5y survival, 99% if localized vs. 73% metastasized at dx)
Testicular Self Exam
- Best done when?
- How to examine?
- Find what structure?
Penile/Urethral Conditions
(5)
Hypospadias/Epispadias
Urethral Stricture
Priapism
Peyronie’s Disease
Phimosis/Paraphimosis
Hypospadias =
Epispadias =
Hypospadias = Urethral opening on bottom of penis
Epispadias = Urethral opening on top of penis
Hypo/Epispadias Treatment
=
Surgically repaired in childhood
Narrowing of portion of urethra dt scar tissue/collagen formation
Urethral Stricture
Urethral Stricture Causes
(1) major cause (rt f____, gon_____ risk)
(1) (pelvic __ , str___ injury, traumatic catheterization)
(1) TURP, RT for prostate CA
Infection major cause (rt foley, gonococcal risk)
Trauma (pelvic fx, straddle injury, traumatic catheterization)
Post Procedure Scarring (TURP, RT for prostate CA)
Urethral Stricture S/S
- Stream =
- Urinating =
- Recurrent (1)
- _____/_____ that can damage bladder or kidney function
- Weak/Split stream
- Difficulty urinating
- Recurrent infections
- Obstruction/Retention that can damage bladder or kidney function
Urethral Stricture Treatment
(2)
Dilation
Surgical incised or repair
Priapism
=
2 types
Persistent penile erection >4h, hours beyond or unrelated to sexual stimulation
- Ischemic (low flow/veno-occlusive)
- Non-Ischemic (high flow/arterial) -Most common type
Rare form of ischemic, recurrent over extended period of time
Most common cause: sickle cell disease
Manage each episode, include prevention strategies
Stuttering Priapism
Priapism Causes
- ____pathic
- (1) trait/disease
- M_____ infiltration of corpora (ie leukemia)
- M_______ (ED tx, testosterone, alpha agonists, trazodone, bupropion, cocaine)
- T___ (esp after 20% lipid infusion - increases platelet activity)
- (1) injury
- Spinal or general an______
- Idiopathic
- Sickle cell trait/disease
- Malignant infiltration of corpora (ie leukemia)
- Medications (ED tx, testosterone, alpha agonists, trazodone, bupropion, cocaine)
- TPN (esp after 20% lipid infusion - increases platelet activity)
- Spinal cord injury
- Spinal or general anesthesia
Priapism S/S
- Corpora cavernosa will fully ____, r____, t____
- Glans penis and corpus spongiosum will be _____
- Color of the blood aspirated from corpora will be?
- Corpora cavernosa will fully erect, rigid, tender
- Glans penis and corpus spongiosum will be soft
- Color of the blood aspirated from corpora will be very dark red
Priapism Treatment
=
EMERGENCY → SEND TO ER!
IPSS
=
(7)
Score of __- __ = Mildly symptomatic
Score of __-__ = Moderately symptomatic
Score of __-__ = Severely symptomatic
International Prostatism Symptom Score
Incomplete emptying, Frequency, Intermittency, Urgency, Weak stream, Straining, Nocturia
0-7 = mildly symptomatic
8-19 = moderately symptomatic
20-35 = severely symptomatic (MUST see medical help and begin tx immediately)
Uroflow
Benign Prostatic Hypertrophy (BPH)
Most likely etiology of?
- 50% of men by age ___
- Nearly __% of all men will develop BPH - with __% receiving treatment for it
Most likely etiology of gradually worsening voiding symptoms in aging men is BPH, so often is most likely diagnosis based on H&P, and other conditions are ruled out with further testing
- 50% of men by age 50
- Nearly 80% of all men will develop BPH - with 30% receiving treatment for it
BPH Newer Minimally Invasive Treatments
(2)
Urolift: tiny implants to hold prostate lobes apart
Rezum: radiofrequency generated thermal water vapor injections
Acute Prostatitis
=
Most common cause (1)
Bacterial infection of prostate
E.coli most common cause
What is the most definitive test for Prostate Ca?
It is done trans____ via ___ guidance or transperineally
MRI ____ biopsies possible when indicated
Prostate Biopsy (most definitive test - 100%)
transrectally via US guidance or transperineally
MRI-fusion biopsies when indicated
Prostate CA Grading
What Gleason scores correlate with low, intermediate and high risk?
low risk < 6
intermediate risk 7
high risk 8-10
ED other Treatment
- (3) devices
- (1) urethral suppository (Muse, intrac injectsion system - Caverject, Edex)
- Med combos for intra______ injections (ICI): Bimix, Trimix, Quadmix
- (1): (usually try to promote vasodilation/blood flow) - Edox, L-arginine, ginseng, gingko biloba, maca, etc
- Experimental newer therapies (4): little data yet, some may be commercially available but expensive
- Vacuum erection device (VED), Penile constriction ring, Penile implant
- Alprostadil (urethral suppository)
- Intracavernosal injections
- Supplements
- Stem cell therapy, plasma rich plasma (PRP), hyperbaric oxygen, low intensity shockwave therapy (LIST)
Testosterone Deficiency Diagnosis
=
2 separate AM testosterone values <300 ng/dL
Also check hormones involved in HPG axis: LH and FSH, estradiol, prolactin
