Male GU Disorders - Cooper - Exam 2 Flashcards
2 phases of testis descent?
transabdominal descent
-dependent on insulin-like hormone 3 (INSL3)
inguinoscrotal descent
-dependent on androgens
what is cryptorchidism?
undescended testicle
cryptorchidism common in who?
premature infants/low birth weight infants
what is a prerequisite for testicular descent?
A normal hypothalamic-pituitary-gonadal axis
how does cryptorchidism occur?
in these pts gubernaculum is not firmly attached to the scrotum -> teste is not pulled into the scrotum
clinical manifestations of cryptorchidism?
empty, small scrotum
non-palpable testes
most common in inguinal canal (near internal ring)
complications of cryptorchidism?
infertility (esp if bilateral disease)
increased risk of testicular cancer (even if had surgery to fix it)
inguinal hernia - indirect -> d/t patent processus vaginalis
when should PCPs palpate testes according to AUA guidelines?
PCPs should palpate testes for quality and position at each recommended well-child visit
when should providers refer infants for cryptorchidism according to AUA guidelines?
Providers should refer infants w/ a hx of cryptorchidism (detected at birth) who don’t have spontaneous testicular descent by 6 months to an appropriate surgical specialist
should providers perform U/S or other imaging prior to referral for cryptorchidism according to AUA guidelines?
NO!!!
Providers shouldn’t perform US or other imaging studies in the evaluation of boys with cryptorchidism prior to referral as these studies rarely assist in decision making
should providers use hormonal therapy for tx of cryptorchidism according to AUA guidelines?
NO!!!
Providers shouldn’t use hormonal therapy to induce testicular descent as evidence shows low response rates and lack of evidence for long-term efficacy
when should specialists perform surgery for cryptorchidism according to AUA guidelines?
In the absence of spontaneous testicular descent by 6 months, specialists should perform surgery w/in the next year
who should providers counsel on cryptorchidism long-term risks and what risks according to AUA guidelines?
Providers should counsel boys w/a hx/of cryptorchidism and/or monorchidism and their parents regarding potential long-term risks and provide education on infertility and cancer risk
if pt has unilateral cryptorchidism w/out hypospadias, what’s the work-up?
just a consult
if pt has unilateral or bilateral cryptorchidism w/hypospadias or bilateral non-palpable testes, what’s that work-up?
- CONSULT!!!
- Sex (need to know if it’s a boy or a girl)
- 17-hydroxylase progesterone
- testosterone
- LH and FSH
(measure these hormones, but usually lead it to the specialist)
imaging for cryptorchidism?
CONSULT FIRST!!!! (if can’t do consult then do U/S)
U/S is FIRST CHOICE B/C NO RADIATION
what dx study for cryptorchidism has 100% sensitivity and specificity?
laparoscopy - also allows for concurrent surgical correction
tx for cryptorchidism before 6 months of age?
just follow the pt
tx for cryptorchidism after 6 months of age?
Orchiopexy - brings the test down and secures it to the scrotum
(ideally done before 1 y/o)
what is hydrocele?
fluid around the testicle
issue with hydrocele?
bigger scrotum than it needs to be and it also messes w/temperature regulation
pediatric hydroceles, acquired or congenital? resolve?
congenital and resolve w/in 1 year of life
adult hydroceles, acquired or congenital?
acquired
3 etiologies of hydroceles
idiopathic, non-communication, communicating
non-comunicating hydrocele d/t?
d/t minor trauma, inflammatory conditions
acute reactive hydrocele:
-epididymitis, testicular torsion, varicocele operation, testicular tumor
PROCESSUS VAGINALIS OPENS AND CLOSES IN THIS ONE
communicating hydroceles d/t to? discovered when? occur following?
Usually discovered in infancy
Due to patent processus vaginalis (STAYS OPEN ALL THE TIME)
Occur following increased intra-abdominal fluid or pressure
- Due to shunts, peritoneal dialysis, or ascites
- Likely from an imbalance of secretion and reabsorption of fluid from the tunica vaginalis
what pts have a high risk of communicating hydroceles?
pts with connective tissue disorders
signs and sx’s of hydrocele?
painless scrotal swelling
physical exam of hydrocele?
***transillumination to assess for fluid - if get glow, then there is fluid = hydrocele
palpate for masses
differentiate from hematocele, hernia, or solid mass
hydrocele evaluation?
scrotal U/S
-to evaluate for reactive hydrocele due to testicular neoplasm or other etiology
tx for idiopathic hydroceles?
Often asymptomatic or with only scrotal swelling
Observation - surgical treatment only if increased pressure, pain, or chronic irritation of scrotal skin
tx for communicating hydrocele?
Due to patent processus vaginalis -> ***requires surgical closure (similar to hernia surgery)
what is a varicocele? caused by?
cystic testicular mass of varicose veins
caused by dilation of pampiniform plexus
what side is most common for varicocele?
Left side!!!
b/c varicocele is d/t dilation of pampiniform plexus, what can occur with pt if have this?
Pampiniform plexus maintains specific temperature for sperm production -> can result in testicular growth retardation during puberty
how many grades of varicoceles?
3
grade 1 varicocele
small - palpable only w/valsalva
grade 2 varicocele
medium - palpable at rest -> invisible
grade 3 varicocele
large - easily visible
M/C sign of varicocele?
scrotal mass feels like BAG OF WORMS!!! -> disappears in supine position
physical exam for varicocele?
- Fullness, usually in spermatic cord
- Bag of worms
- Should be examined in upright position, in a warm room
dx for varicocele?
scrotal U/S
Left testicular venogram
if child has right-sided varicocele (or bilateral), what could be the cause?
a retroperitoneal mass
what is the main reason to treat a varicocele?
b/c can cause infertility
when is tx recommended for varicocele?
Varicocele is palpable on physical exam of the scrotum (may be d/t retroperitoneal mass if on right side or bilateral)
Couple has known infertility
Female partner has normal fertility or a potentially treble cause of infertility
Male partner has abnormal semen parameter or abnormal results from sperm function tests
tx for varicocele?
embolization
what is hypospadias? caused by?
abnormal urethral placement (subcoronal, mid shaft, penoscrotal)
Caused by failure of fusion of the urethral folds, endodermal differentiation, and ectodermal ingrowth in gestational weeks 8-20
hypospadias is one of the most common what?
one of the most common birth defects
hypospadias risk factor?
low birth weight
hypospadias tx?
- Maybe nothing
- Don’t circumcise
Surgical
- short procedure that’s same day
- 6-12 months old, but can be done anytime
- May need testosterone pretreatment
what is phimosis? can be normal up to?
The foreskin cannot be fully retracted over the glans penis
Foreskin fused to the gland at birth and not retractable
Can be normal up to adolescence
causes of phimosis?
- The tip of the foreskin is too narrow to pass over the glans penis
- The inner surface of the foreskin is fused with the glans penis
- The frenulum is too short to allow complete retraction -> frenulum breve
- Pathological if difficulty urinating or associated with abnormal sexual function
tx for phimosis?
Steroid creams (not recommended by Coops)
Manual stretching (overtime will pull it back)
Changing masturbation habits
(slow down - going too fast is a common cause of paraphimosis)
Preputioplasty
Circumcision
-M/C reason to do a circumcision in an adult (usually b/c can’t keep it clean)
what is the M/C reason to do a circumcision in an adult?
phimosis tx
what is paraphimosis?
Foreskin of the penis once pull back behind the glands -> cannot be retracted back -> ischemia to gland of penis
Foreskin starts to swell -> cuts off blood supply to corona of penis -> if stays this way cuses gangrene of the penis
is paraphimosis an emergency?
YES!!! it’s a urological emergency!!!
who does paraphimosis only occurs in?
Occurs only in uncircumcised or partially circumcised males
what else can lead to the same pathophysiological derangements as seen with paraphimosis?
External objects may constrict the mid to distal shaft
ex: string, metal rings, rubber rings
who is at an increased risk of paraphimosis?
uncircumcised people
signs and sx’s of paraphimosis?
- Penile pain
- Swelling/enlargement
- Congestion with edematous foreskin
- Discoloration
- N/V in adults
If prolonged ischemia -> severe paraphimosis -> distal penis has begun the process of autoamputation
In peds -> may manifest as acute urinary tract obstruction -> obstructive voiding symptoms
paraphimosis tx?
Conservative therapy initially with gentle retraction of foreskin
-If that doesn’t work, then do circumcision
Severe paraphimosis refractory to conservative therapy -> bedside emergency dorsal slit procedure to save penis
Circumcision can be performed in the operating room at a later date -> Ultimate tx
what is the ultimate tx of paraphimosis?
circumcision
if pt has severe paraphimosis refractory to conservative therapy, what’s the tx?
bedside emergency dorsal slit procedure to save penis
