Penile and scrotal disorders Flashcards
1
Q
what is a hydrocele?
A
accumulation of fluid around the testis
MCC of painless scrotal swelling in peds; can also occur in adults
2
Q
what are the three types of non-comunicating hydroceles
A
- Testicular - around testicle only
- Inguinoscrotal - testicle and inguinal region
- Cord - adjacent to spermatic cord
3
Q
what are communicating hydroceles? how common is it?
A
- hydroceles that communicate with the peritoneal cavity.
- may change during the day with activity
- processus vaginalis is patent in:
- > 80% of newborns
- 40-50% of 2 year olds
- 25% of adults
4
Q
what are the s/s of hydroceles
A
- fluid filled cystic scrotal mass, anterior to testis
- usually little/no pain
- +/- scrotal fullness/heaviness
- usually gradually onset
5
Q
what is the PE for hydroceles
A
- no inflammation
- nontender
- transillumination presents with light shining through the fluid
6
Q
when are UA and US indicated in Hydroceles?
A
- UA - evaluates for signs of infection if suspicious
- US - evaluates for masses, delineates extent of fluid (can get doppler for blood flow if suspected torsion)
7
Q
what idicates whether you should treat a hydroceles?
A
- No treatment - infantile, asymptomatic, noncommunicating is physiologic and will resolve in 18-24 months
- treat - if persist >12-18 mo, is communicating or symptomatic
- treat if acute onset
8
Q
what is the treatment for hydroceles
A
- needle aspiration of fluid +/- sclerotherapy to tunica vaginalis (less invasive but high rate of recurrence)
- hydrocelectomy (excision of hydrocele sac. definitive)
9
Q
when should you refer hydroceles?
A
- sudden onset
- symptomatic
- if pt wants treatment
10
Q
what is a varicocele
A
Dilated, engorged, tortuous veins within the pampiniform plexus of scrotal veins
“varicose veins in scrotum”
This is the most surgically correctable cause of male infertility!!
11
Q
what side are vericoceles MC on? why?
A
The left side! due to testicular veins draining into the L renal vein instead of into the IVC!
Unilateral R varicocele can indicate possible IVC obstruction
12
Q
what are the symptoms of varicoceles
A
- scrotal enlargement or heaviness
- +/- dull aching pain
- may have infertility as initial complaint
- may be asymptomatic
13
Q
What will the PE show in varicoceles
A
- dilated veins in scrotal sac “bag of worms” feeling (ew)
- increased with standing and valsalva
- may improve w supine position
14
Q
what diagnostic studies are ordered for varicoceles
A
- labs to rule out other disorders
- US to confirm diagnosis
15
Q
what is the treatment for varicoceles
A
- asymptomatic = observation only
- conservative = scrotal support, NSAIDS
- severe s/s or fertility desired = surgical tx.
16
Q
what are surgical tx options for varicoceles
A
- Occlusion (balloon) or embolization of spermatic vein
- Injected ablation (sclerotherapy) of spermatic vein
- Surgical ligation of pampiniform plexus
17
Q
what are complications of varicoceles? how do we prevent varcioceles?
A
- complications - testicular atrophy, infertility
- prevention - regular TSE for early diagnosis and treatment
18
Q
what is testicular torsion
A
Twist in the spermatic cord causing compromised testicular blood supply
THIS IS AN EMERGENCY
19
Q
when is testicular torsion most common?
A
peaks in neonatal period and early puberty
65% of cases are 12-18 y/o males
20
Q
what are risk factors for testicular torsion
A
- Trauma
- Vigorous exercise or sexual intercourse
- Cryptorchidism
- Bell-clapper deformity
21
Q
what are symptoms of testicular torsion
A
- Sudden onset of severe unilateral scrotal pain and swelling
- +/- lower abdominal pain, N/V
- +/- hx of intermittent similar symptoms
- Lack of voiding symptoms
22
Q
what are PE findings in testicular torsion
A
- Classic - high-riding testis, slightly larger than unaffected testis, transverse lie in scrotum
- Often erythematous and tender
- Pain does not relieve with scrotal support (negative Prehn’s sign)
- Cremasteric reflex - stroke or pinch skin of upper thigh while observing ipsilateral testis - typically absent in torsion
23
Q
what are the diagnostic studies used for testicular torsion
A
- Doppler US (test of choice!! if inconclusive or unavailable must do surgical exploration)
- UA - r/o infection
- radionuclide scintigraphy - can also demonstrate low blood flow
24
Q
what are complications of testicular torsion
A
- infertility
- testicular necrosis and loss
25
What is the treatment for testicular torsion?
* manual (opening book method) - give anesthesia and turn affected testicle in the medial to lateral direction 180-720 degrees. success = pain relief. THIS STILL REQUIRES SURGICAL FIXATION
* surgery - detorsion and fixation of involved testis and contralateral testes. pre-lab = CBC/renal function
* pain relief with narcotics
note: 1/3 of patients require manual turning in the lateral to medial direction
26
what is the TWIST scoring system
Testicular W/U for Ischemia and Suspected Torsion
27
what is the prevention methods for testicular torsion
Avoidance of testicular trauma
Pre-emptive correction of diseases such as cryptorchidism and bell-clapper deformity
28
what is testicular appendage torsion?
torsion affecting one of the four testicular appendages which are:
appendix testis (90%), appendix epididymis (8%) , paradidymis, vas aberrans
MC in YOUNGER patients!!
29
what are the symptoms of testicular appendage torsion
* Similar but less severe than testicular torsion
* Scrotal pain, +/- swelling
* Normal, minimally tender scrotum and testicle on exam
* Might localize tenderness to upper pole of testis / epididymis
* “Blue dot sign”
* Later in course - scrotal edema +/- hydrocele
30
what would an ultrasound show in testicular appendage torsion
* normal testicular blood flow
* small hyperechoic region adjacent to testis
31
what is the treatment for testicular appendage torsion
* Scrotal support, limitation of activity
* Oral analgesics (NSAIDS)
* If unable to r/o testicular torsion - surgery
32
what is Phimosis? what is the MCC?
contracted foreskin that cant retract over the glans penis
MCC - Chronic infection from poor local hygiene
33
what is the cause of phimosis in younger children? what about in older men who are diabetic?
* Children < 2-3 yrs - often physiologic
* Diabetic older men - often due to chronic balanoposthitis
34
what are the symptoms of phimosis
* May have no s/s other than inability to retract foreskin
* Edema, erythema and tenderness of prepuce or purulent discharge if infected
* “Ballooning” of prepuce during urination
* Only emergent if urinary retention
35
what is the treatment of phimosis caused by infection
* fungal → topical clotrimazole or nystatin or oral fluconazole
* Bacterial → topical bacitracin, oral metronidazole (Flagyl)
* Cellulitis or extends to shaft → cephalexin (Keflex)
36
What is the treatment of temporary phimosis
* hemostat dilation, catheter, topical steroids
* Frenar stretch +/- steroids - gradually increase compliance
* Surgical incision - dorsal slit
* Catheter - if urinary retention present
37
what is the treatment for recurrent or persistent phimosis or balanitis/balanopsthitis?
circumcision
38
what are the complications of phimosis
* preputial calculi - dysuria, gross hematuria, foul smelling discharge, ballooning, calculi (tx is calculus removal, incision, circumcision)
* squamous cell carcinoma (asymptomatic or similar s/s of calculi, may see BIL inguinal LAD)
* urinary retention, UTI, dyspareunia, painful erections
39
what is the preventive measures for phimosis
* Proper hygiene of foreskin
* Control of systemic conditions
* Circumcision
40
what is paraphimosis
Inability to reduce previously retracted foreskin causing fixed in retracted position proximal to corona and glans
this can lead to Lymphedema and venous congestion of prepuce → arterial occlusion → necrosis, gangrene, autoamputation
41
what are causes of paraphimosis
* Pre-existing phimosis
* Failure to replace foreskin
* Sexual activity, erotic dancing
* Penile trauma
* Plasmodium falciparum
* Forceful retraction (infant foreskin)
42
what are symptoms of paraphimosis
* Swollen, erythematous, tender foreskin proximal to glans
* “Donut sign”
* Swollen, erythematous, tender glans; may be necrotic
* Flaccid penis proximal to foreskin
43
what is the treatment of paraphimosis
* emergent urology consult for manual reduction!!!! (manual pressure on glans for 5 min to reduce edema then push glans proximally while pulling prepuce distally!)
* refractory to manual reduction may need needle decompression, dorsal slit of foreskin, or osmotic agents.
* consider abx
* circumcision after inflammation subsides!
44
what are complications of paraphimosis
* penile ischemia, necrosis and gangrene
* loss of penile tissue
45
what are preventative measures for paraphimosis
* Avoidance of precipitating activities
* Proper education on care of foreskin and glans
* Treatment of phimosis
* Circumcision
46
What is priapism
A prolonged and painful pathological erection
(engorgement of the corpora cavernosa with blood, often not associated with sexual stimulation)
47
what are causes of priapism
* 60% idiopathic
* MC cause is intracavernous injection ED treatment
* diseases such as sickle cell, leukemia, cancer (in children MC cause is sickle cell and other hematologic diseases)
* trauma
* medications (anti-HTN, psych meds, oral ED meds)
48
What is the difference between high flow (nonischemic) priapism and low flow (ischemic) priapism
* high flow is rare and often painless, resulting from trauma to the perineum which causes loss of penile arterial regulation
* low flow is more common and painful, resulting from a physiologic obstruction of venous drainage.
49
How do you diagnose and treat high flow priapism
* Doppler US of penis - aneurysms of central arteries
* Aspirated blood → high O2, low CO2
* Treat with embolization of aneurysms
50
how do you diagnose low flow priapism
Aspiration of dark acidic low CO2 intracavernosal blood from corpus cavernosum
51
What are the symptoms of high and low flow priapism
* High flow - painless prolonged erection
* low flow - several hours of painful erection where the glans penis and corpus spongiosum are soft and uninvolved. The corpora cavernosa is tense and congested with blood and tender to palpation
* Low flow is a urologic emergency!!!
52
what is the treatment for priapism
* Anesthesia - narcotics; epidural or spinal
* Subcutaneous terbutaline can be used for early tx
* Corporal aspiration of viscous blood with irrigation (plain saline or alpha adrenergic agonists)
53
what is the treatment for refractory priapism
* Winter procedure - needle through glans into corpora → fistula between corpora cavernosa and corpus spongiosum
* Excision of tunica albuginea
* Cavernosa-spongiosum shunt
* Saphenous vein-cavernous shunt
54
what are the complications of priapism
* If Prolonged → interstitial edema and fibrosis of corpora cavernosa, causing impotence and permanent damage!
* possible urinary retention
55
What are the preventative measures for priapism
* Avoidance of known causative factors and trauma
* Optimal management of comorbid diseases
* Early treatment to avoid impotence
56
What is peyronie's disease
* Fibrosis of dorsal covering sheaths (tunica albuginea of corpora cavernosa)
* this does not permit involved area to lengthen with erection and causes a curved penis when erect
* mostly found in middle-aged and older men
57
what are the causes of peyronie's disease
* cause is unclear BUT, this is what the slide said
* Trauma to penis during intercourse
* Vasculitis and connective tissue disease
* DM and hypercholesterolemia
* Associated with smoking, ETOH, Dupuytren contracture
* Genetic predisposition
58
what are the symptoms of peyronie's disease? What will the PE show in these patients?
* Painful erection, penile curvature
* Poor erection distal to curved area
* Usually no pain without an erection
- PE will show raised; firm plaque to dorsal penis, often midline
59
What is the treatment for peyronie's disease
* initially observed because 50% have spontaneous remission
* oral - vitamin E, para-aminobenzoic, colchicine
* intralesional injection - verapamil, steroids, dimethyl sulfoxide, or PTH
* radiation therapy
* surgical - excision of plaque with graft of skin, vein, or tunica vaginalis graft; excision of plaque with suturing (if impotent insert penil prosthesis)
60
What are complications of peyronie's disease
* ED
* impotence
* physiological complications
61
what are preventative measures for peyronie's disease
* avoidance of penile trauma
* limit alcohol and tobacco use
* control comorbidities
62
what is the MC type of penile cancer
squamous cell carcinoomas
63
how common is penile cancer?
* rare in developed countries (<1% of cancers in men in US)
* common in underdeveloped countries (10-20% of cancers in men)
Average age of dx is 60 years but it can be much younger.
64
what are the risk factors for penile cancer
* Chronic infection/inflammation, HPV - seen in 30-50% of all penile carcinomas, HIV - increases incidence by 4-8x
* Hx of penile injury or urethral stricture
* Hx of phimosis
* Hx of tobacco use
65
what are the symptoms of penile cancer
* MC is skin abnormality or palpable lesions on the penis (25% painless lump, 13% ulcers, 6% rash)
* inguinal LAD in 30-60% (50% are malignant infiltration related, 50% are inflammatory reactions to cancer)
* metastatic symptoms (bone pain, cough, skin lesions)
66
what are diagnostics for penile cancer
* If s/s of infection (erythema, discharge) - may do 4-6 week trial of abx
* No s/s of infection or if worsening/no improvement with abx - biopsy (May also do biopsies of inguinal lymphadenopathy)
* Metastatic Symptoms - bone pain, cough, skin lesions indicate CT of chest/abd/pelvis, general lab work/up (CBC, BMP/CMP)
67
what is the treatment for penile cancer?
* if low risk of recurrence then do a limited excision. This is for _minimally_ invasive tumors. Goal is to preserve as much anatomy/function as possible. Laser therapy, topical therapy and radiation may also be used
* If higher risk recurrence do partial or total penile amputation +/- inguinal lymph node dissection and chemotherapy/radiation.
68
what is epididymitis? what are the two types?
inflammation of the epididymis!
STD related (typically men<40) - associated with urethritis, chlamydia and gonorrhoeae
non-STD related (typically men 40+) - associated with UTI, Postatitis and G- rods (e. coli, proteus, klebsiella
Other causes include medications such as amiodarone as well as reflux of urine.
69
what are signs and symptoms of epididymitis
* May present after physical strain, trauma, or sex
* +/- urethritis, prostatitis or cystitis symptoms
* Fever
* Pain and swelling in scrotum - may radiate
* Early - testicle normal or minimally tender and epididymis is tender and palpable
* Late - may be hard to distinguish from testis
* +/- reactive hydrocele
* +/- inguinal lymphadenopathy
* May see positive Prehn’s sign
70
what diagnostic studies would be used in the evaluation of epididymitis
* UA - pyuria, bacteriuria, hematuria, culture
* Urethral swab (Gonorrhea - G- intracellular diplococci. Chlamydia - WBC without visible organisms )
* PCR for gonorrhea/chlamydia
* CBC - leukocytosis and left shift
* ESR/CRP - may be increased
71
what are complications of epididymitis
* Infectious - orchitis, chronic epididymitis, sepsis, abscess
* Long-term - fibroplasia, decreased fertility
72
what is the treatment for epididymitis
* bed rest, scrotal elevation, ice packs
* analgesics (NSAIDS)
* Abx if likely STD - empiric tx is ceftriaxone + doxycycline
* if its unlikely to be an STD you can give levo or bactrim
* improvement should occur within 3 days and resolution within 2-4 weeks
73
what are preventative measures for epididymitis
* Prompt treatment of prostatitis, UTI, urethritis
* Safe sex practices
* Treatment of partners with STIs
* Minimize use of foley catheters
74
What is orchitis
Inflammation/Infection of testis (usually occurs with other illnesses)
75
what are causes of orchitis
* Bacterial - usually complication of epididymitis
* Granulomatous - autoimmune response to sperm
* Viral - M/C mumps; also EBV, coxsackie, VZV, echovirus
76
what are signs and symptoms of orchitis
* Swelling, tenderness and erythema of testis +/- urethritis, cystitis, prostatitis, epididymitis +/- reactive hydrocele
* scrotal pain - more gradual onset and less severe than torsion. May have positive prehn's sign
* fever, +/- nausea and vomiting (may have malaise, resp symptoms, parotid swelling)
* +/- inguinal LAD
77
what are diagnostic studies for evaluation of orchitis
* UA - pyuria, bacteriuria, hematuria, culture
* Urethral swab (Gonorrhea - G- intracellular diplococci. Chlamydia - WBC without visible organisms)
* PCR for gonorrhea/chlamydia
* CBC - leukocytosis and left shift
* ESR/CRP - may be increased
78
what is the treatment for orchitis
* Bed rest, scrotal elevation, ice packs
* analgesics (NSAIDs)
* Abx empiric - ceftriaxone + doxy
* Abx if practicing anal sex - ceftriaxone + levo
* abx if unlikely to be STD - levo only
* if viral, supportive care only
79
what are complications for orchitis
* Infectious - sepsis, abscess formation
* Long-term - fibroplasia, decreased fertility, testicular atrophy
80
what are preventative measures for orchitis
* Prompt treatment of UTIs - prostatitis, cystitis, urethritis, epididymitis
* Safe sex practices
* Tx of partners with STDs
* Minimize use of foley catheters
* Vaccination
81
what are the types of scrotal masses
* hydrocele
* spermatocele
* epididymal cyst
82
what is an epididymal cyst and how does it present?
* found on head of epididymus
* Asymptomatic
* Associated with DES use during pregnancy and Von Hippel-Lindau disease
* Noted on exam - US can assist diagnosis
* No specific tx needed
83
what is a spermatocele? how does it present and how do you diagnose and treat it?
* epididymal cyst >2 cm (2-5 cm) that is Superior to and distinct from testis
* rarely symptomatic; may be painful
* US - can assist diagnosis
* treatment - observation, may need surgical excision
84
what is the MCC of solid testicular tumors in men 18-40
* cancer!
* MC cancer males 20-35
* 90-95% are germ cell tumors
85
What are risk factors for testicular tumors
* Cryptorchidism (10% cancer is pts with + hx)
* Exogenous estrogen during pregnancy
* Infertility
* Family history, HIV, ethnicity
* Questionable - trauma, infection-related atrophy, high fat diet
86
What are signs and symptoms of testicular tumors
* usually a 3-6 mo delay to tx
* MC symptom is painless enlargement of testis (testicular or scrotal heaviness or painless nodules on
* acute testicular pain (10%)
* metastatic symptoms (10%)
* asymptomatic (10%)
87
what are the symptoms of metastasis for the different metastatic areas
* MC site of metastasis - retroperitoneal abdominal lymph nodes
* Back pain (retroperitoneal)
* Cough/dyspnea (pulmonary)
* Anorexia, N/V (retroduodenal)
* Bone pain (skeletal)
* LE swelling (IVC obstruction)
88
What diagnostic studies can be done in evaluation of testicular tumors
* Alpha-fetoprotein, hCG, LDH
* advanced - anemia, LFTs, renal function
* scrotal US - initial eval (after dx stage with CT abdomen/pelvis)
* definitive dx - radical inguinal orchiectomy (Transscrotal biopsy is contraindicated)
89
what is treatment for testicular tumors
* Inguinal exploration with vascular control of spermatic cord (If CA not excluded by examination, orchiectomy)
* Radical inguinal orchiectomy
* Radiation/chemo depends on subtype
90
What is the follow up protocol for testicular tumors
* Monthly for 1st 2 years, bimonthly 3rd year
* Tumor markers at each visit
* CXR and CT every 3 months
* 80% relapse in 1st 2 yrs after treatment
91
what is the prognosis for testicular tumors
* Most cancers - 90% + 5 year survival rates
* Disseminated or bulky (> 10 cm) retroperitoneal disease - 55-80%
92
that wasnt too bad
lil baby!
