Male Urology Flashcards
Causes of acute scrotum
- Testicular torsion
- Torsion of the Testicular appendage
- Epididymitis
- Orchitis
- Fournier’s Gangrene
- Priapism
- Penile Fracture
- Prostatis
- Phimosis
- Paraphimosis
- Entrapment
- Neoplasm
A 14 year old male presents with a one hour history of scrotal pain and vomiting. He denies fever or urinary symptoms but does report vomiting several times. On exam his cremasteric reflex is absent and the painful testicle has a horizontal lie.
testicular torsion
what is a bell clapper deformity
testicle lacks the normal attachment to the tunica vaginalis and rests within the scrotum, and has increased mobility as a result
when is the peak occurrence of testicular torsion
- Peak occurrences neonates and post pubertal
- average 16years old
Painful inguinal mass and empty scrotum =___
torsion
presentation of torsion
- severe pain w/ abrupt onset
- Usually starts in scrotum, but can be inguinal or abdominal
- pain can be constant or intermittent
- ~ 50% of patients have a hx of similar pain resolved* spontaneously
- Not positional (this is an ischemic event)
- Nausea, vomiting and anorexia is common
- May have a history of strenuous activity, may occur during sleep
- Can have unilateral cremasteric muscle contraction during sleep
PE of torsion
- inspect:
- Redness, swelling is inconsistent with torsion
- “High riding transverse testicle” - Loss of cremasteric reflex on the affected side is most sensitive (do this before palpating the testis)
- Palpate, evaluate penis for discharge
- Swollen, tender, firm hemiscrotum
how do you elicit the cremasteric reflex
- stroke ipsilateral inner thigh with a tongue depressor or gloved hand
- elevation of the testicle through contraction of cremasteric muscle
how do you dx torsion
- Doppler Ultrasound (sens 86-90%)**
- Test of choice in most places, looking for absent or decreased blood flow
- Non invasive, rapid
- Any procedure that delays the OR is unwise - Midstream urinalysis (consider infectious causes)
- Urethral swabs prior to urinating – or send urine for culture and GC/Cx – to evaluate for other causes
treatment of torsion
- Immediate Urologic consult
- Manual or Surgical detorsion and orchipexy (fixation of testicle of scrotal wall to prevent twisting)
- Almost 100% salvage rate if performed less than 6 hours, over 20% at 12 hours
- Manual detorsion
What way do testicles typically rotate and
how do you perform manual detorsion
- Teste usually twists lateral to medial – but 30% of cases torse laterally (so start with rotating outward–opening a book)
- Can torse 180-270 degrees
- Right testicle usually counterclockwise, left clockwise
- If pain becomes worse rotate the opposite direction
presentation of torsion of the testicular appendage
- Pain is usually more sub acute and of gradual onset
- Similar episodes not typical
- 3-5 mm nodule palpable between the epididymis and testicle
- “Blue –dot sign” visible through the skin early on
- Rarely any voiding symptoms or fever; may have a reactive hydrocoele
what is the blue dot sign
visible blue dot on the testicle
-sign of torsion of the testicular appendage
how do you dx and treat torsion of the testicular appendage
- Doppler US shows normal blood flow of the testicle
- Non surgical, appendages calcify or degenerate over 14 days
- Scrotal elevation
- Analgesics
- If pain is refractory, surgical excision may be needed
most common cause of acute scrotum
epididymitis
Key facts of epididymitis
- 75% of cases are post-pubertal
- More advanced cases present with testicular pain and swelling (epidimo-orchitis)
- Can be infectious or non infectious (often due to STDs)
untreated epididymitis may develop into a ___
scrotal abscess
presentation of epididymitis
- Usually gradual onset of pain
- Dysuria, urgency, frequency common
- Urethral discharge
- may be subtle in chlamydia - Nausea, vomiting anorexia are uncommon
- Fever, leukocytosis on 30-50%
- Can have lower abdominal, inguinal, scrotal or testicular pain
- Positive Prehn Sign- feels better when testicle is lifted up
- unilateral enlarged/angry looking testicle
most common misdiagnosis for torsion
epididymitis
how do you evaluate epididymitis
- first r/o torsion
- urinalysis (+/- GC/ chlamydia)
*Non infectious epididymitis usually has less aggressive or concerning clinical presentation, and a cause is not often identified
treatment for epididymitis for pre-pubertal
-consider underlying GU abnormality
treatment for epididymitis for sexually active males any age
ceftriaxone 250 mg IOM
AND
Doxycycline 100mg BIDx10d OR Azithromycin (1 gram for the clam)
treatment for epididymitis for MSM
ofloxacin or levofloxacin to cover enteric organisms
treatment for epididymitis for non-infectious
symptoms management: Scrotal elevation, NSAIDs, decreased activity
other considerations for treatment for epididymitis
- Abstinence from sex/safe sex/STD counseling
- Consider testing for HIV/syphilis
- Consider treatment of sexual partners
__ usually occurs as extension of epididimytis
orchitis
___ decreased the incidence of orchitis
-May occur with __ or ___
mumps vaccine
syphilis or other viral
*Should be considered in non immune adult
orchitis can cause
- testicular atrophy
2. impaired fertility
presentation of orchitis
- Testicle itself is large and tender
- Follows or is concurrent with parotitis*
- Usually presents as bilateral tenderness
differentiation of acute epididymitis and testicular torsion
testicular torsion:
- 14y/o and neonate
- sudden onset, not affected by position
- worse w/ exercise/sleep
- peaks in hours
- 20% fever
- vomiting from pain
- testicular swelling only after 12 hrs
- rare voiding compliants
- non-tender prostate
- decreased doppler blood flow
- previous episodes in past 2 weeks
- UA: 30% have WBCs/baceria
Epididymitis:
- 25y/o
- gradual onset, worse w/ standing
- rarely after sleeping
- peaks in days
- fever* (95%)
- common testicular swelling
- common dysuria/discharge
- prostate tender
- increased doppler blood flow
- UA: 50% may be normal
**imaging studies are always indicated in differentiating btwn these two
___ are always indicated in differentiating btwn testicular torsion or epididymitis
imaging studies