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Penile and Scrotal Disorders - Exam 2 Flashcards

1
Q

Define hydrocele. What is the difference between communicating and non-communicating?

A

hydrocele: accumulation of fluid around the testis

Non-communicating: fluid that does NOT change in volume throughout the day

communicating: volume/fluid levels fluctuates throughout the day

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2
Q

When would a communicating hydrocele volume be the highest?

A

highest during the day due to activity and moving around

lowest: first thing in the morning due to laying flat during the night while you were sleeping

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3
Q

communicating hydrocele communicates with the _______ cavity. _______ is patent

A

peritoneal

processus vaginalis

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4
Q

What are the s/s of a hydrocele? What is a PE test that can be preformed in office? Also need to order _______ to check for ______

A

fluid filled cystic scrotal mass with little to NO PAIN
+/- scrotal fullness or heaviness that started gradually

transilluminate!

order US to evaluate for masses and doppler to check for suspected torsion

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5
Q

What is the tx for hydrocele?

A

if present in a kid usually will resolve between 18-24 months old

if hydrocele persists greater than 12-18 months or s/s present needle aspirating or hydrocelectomy, +/- sclerotherapy to tunica vaginalis

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6
Q

What hydrocele presentation should NOT be considered benign?

A

if hydrocele presents acutely!! NOT considered benign

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7
Q

What is the definitive tx for a hydrocele? When would you refer out for a hydrocele?

A

hydrocelectomy

sudden onset
symptomatic
pt wants tx

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8
Q

What is a varicocele? What side is it MC?

A

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

MC on the left side

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9
Q

What is the most surgically correctable cause of male infertility?

A

Varicocele

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10
Q

Why are varicocele most common on the _____ side? If a varicocele presents on the opposite side, what does that make you think?

A

left side

testicular vein drains into L renal vein instead of IVC

possible IVC obstruction

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11
Q

What is the common PE exam finding for a varicocele? What makes it better? worse?

A

Dilated veins in scrotal sac - “Bag of Worms”

better: lying supine

worse: standing or valsalva

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12
Q

What will a pt complain of with a varicocele? What test will confirm dx?

A

scrotal enlargement or heaviness
+/- dull aching pain
May have infertility as initial complaint

US will confirm dx

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13
Q

What are 2 complications of varicocele? What is the prevention?

A

complication: testicular atrophy, infertility

prevention: prevent constipation

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13
Q

What is the conservative tx for varicocele? What is the surgical tx?

A

conservative: scrotal support, NSAID

surgical: for severe s/s or desiring fertility

-Occlusion (balloon) or embolization of spermatic vein
-Injected ablation (sclerotherapy) of spermatic vein
-Surgical ligation of pampiniform plexus

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14
Q

What age range does testicular torsion peak?

A

12-18 yr old males

this is an emergency!!!!

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15
Q

What are the risk factors for testicular torsion?

A

Trauma
Vigorous exercise or sexual intercourse
Cryptorchidism
Bell-clapper deformity

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16
Q

What is a bell-clapper deformity?

A

when the tunica vaginalis layer completely covers the testes. normal is tunica vaginalis only covers half of the testes

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17
Q

Sudden onset of severe unilateral scrotal pain and swelling
+/- lower abdominal pain, N/V
+/- hx of intermittent similar symptoms
NO: urinary urgency, frequency or pain with urination
high-riding testis
erythematous and tender
negative prehn’s sign
negative cremasteris reflex

What am I?
What is a prehn’s sign?

A

testicular torsion

Prehn’s sign: cup and lift testicles closer to the body that should relief the pain (relieving pain is a positive prehn sign, no change in pain is negative prehn sign)

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18
Q

What direction does a normal testicle lay in the scrotum? abnormal?

A

normal: vertical egg

abnormal: horizontal egg

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19
Q

What is the test of choice for testicular torsion?

A

doppler US! need to eval blood flow

also order UA to rule out infection

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20
Q

What is an immediate but temporary tx for testicular torsion? Will the pt still need sx? How many degress of detorsion is needed?

A

Anesthesia (local, IV opioid, or sedation)

“opening book” motion- works for about 2/3rds of pts. 1/3 will need it twisted the other way (towards the midline)

YES!! still need sx just trying to get some temporary/minor relief

180 - 720 degrees of detorsion needed

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21
Q

**What is the magical hour number in order to completely save the testical? At what hour mark is it possible to lose the testical?

A

**need sx within 6 hours!!

Irreversible damage and possible testicular loss if > 12 hrs

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22
Q

What is the scoring system name for testicular torsion?

A

TWIST scoring system

5+ is high risk and need immediate sx

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23
Q

What does a torsed testes look like to the naked eye?

A

will be purpleish/blue due to lack of blood flow

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24
What are the 4 testicular appendages? Which one is MC to get twisted? 2nd MC? More common in younger or older pts?
appendix testis- MC- 90% appendix epididymis- 2nd MC- 8% paradidymis vas aberrans MC in younger pts
25
Which one is worse, testicular torsion or Testicular Appendage Torsion? What is a common PE finding associated with Testicular Appendage Torsion?
testicular torsion is worse!! "blue-dot sign" = Testicular Appendage Torsion
26
What will a Testicular Appendage Torsion look like on US?
normal testicular blood flow with small hyperechoic region adjacent to testis
27
What is the tx for Testicular Appendage Torsion?
Scrotal support, limitation of activity Oral analgesics (NSAIDS) If unable to r/o testicular torsion - surgery
28
What is phimosis? What is the MCC? What is the MC age?
Contracted foreskin - can’t retract over glans penis MCC - Chronic infection from poor local hygiene can occur at any age
29
What are the s/s of phimosis? What is the PE finding that often happens during urination? When is phimosis considered an emergency?
inability to retract foreskin “Ballooning” of prepuce during urination Only emergent if urinary retention
30
What is the tx for phimosis?
frenar stretch +/- steroids surgical incision cath- if urinary retention present circumcision if phimosis is recurrent or persistent
31
What is the procedure for a frenar stretch?
32
What are the complications of phimosis?
Preputial calculi Squamous cell carcinoma urine retention, UTI, dyspareunia, painful erection
33
Dysuria, gross hematuria, foul-smelling discharge, ballooning, calculi What am I? What is the tx?
Preputial calculi (complication of phimosis) calculus removal, incision, circumcision
34
What is paraphimosis?
Inability to reduce previously retracted foreskin
35
In paraphimosis the foreskin is fixed in a retracted position proximal to ______ and _____
corona and glans
36
What are some causes of paraphimosis?
Pre-existing phimosis Failure to replace foreskin Sexual activity, erotic dancing Penile trauma Plasmodium falciparum Forceful retraction (infant foreskin)
37
What are the s/s of paraphimosis? What is the common PE finding?
Swollen, erythematous, tender foreskin proximal to glans “Donut sign” flaccid penis proximal to foreskin
38
What is the tx for paraphimosis? Is it an emergency?
Manual reduction yes!!
39
What do you do if paraphimosis is refractory to manual reduction?
Needle decompression Dorsal slit to foreskin Osmotic agents-> sugar to decrease swelling circumcision after inflammation has subsided
40
What is considered priapism? What is it due to?
Prolonged and painful pathologic erection that lasts longer than 4 hours Engorgement of corpora cavernosa with blood and bloods gets trapped
41
T/F: priapism are usually associated with sexual stimulation
FALSE!! often NOT associated with sexual stimulation
42
What are the causes of priapism? What is the MC cause in children?
idiopathic -60% intracavernous injection ED treatment - MC known cause diseases: leukemia, sicle cell, cancer meds: anti-HTN, psych meds, oral ED meds kids- hematologic diseases especially sickle cell
43
What are high flow priapism caused by? What are the s/s? What is the tx? How common are they?
Trauma to perineum → loss of penile *arterial* regulation usually aneurysms of central arteries engorged penis that is often NOT painful embolization of aneurysms NOT very common
44
What are low flow priapism caused by? What are the s/s? How common are they?
Physiologic obstruction of *venous* drainage. Prolonged → interstitial edema and fibrosis of corpora cavernosa, causing impotence engorged penis that is PAINFUL more common
45
Are the CO2 levels high or low in low flow and high flow priapisms? Is pain present in each?
high flow: high O2, low CO2, NO pain low flow: high CO2, painful!!
46
In low flow priapism ______ and _____ are soft and uninvolved. _______ is tense and tender to palpation.
Glans penis and corpus spongiosum - soft, uninvolved Corpora cavernosa - tense, congested blood, tender to palpation
47
What is the tx for priapism? What is the tx for refractory priapism?
anesthesia usually epidural or spinal then corporal aspiration of viscous blood with irrigation refractory: Winter procedure Excision of tunica albuginea Cavernosa-spongiosum shunt Saphenous vein-cavernous shunt
48
What is the winter procedure? When is it used?
Winter procedure - needle through glans into corpora → fistula between corpora cavernosa and corpus spongiosum in refractory priapisms
49
What is peyronie's dz? What does it cause? What is the MC age range?
Fibrosis of dorsal covering sheaths, tunica albuginea of corpora cavernosa Does not permit involved area to lengthen with erection which causes curved penis when erect middle-aged to older men
50
peyronie's dz is _____ of dorsal covering sheaths, ______ (layer) of corpora ______
fibrosis tunica albuginea corpora cavernosa
51
What is Dupuytren contracture? What dz is it associated with?
Dupuytren contracture: scarring of CT in the hands Peyronie’s Disease
52
Painful erection, penile curvature Poor erection distal to curved area Usually no pain without an erection What am I? What is the tx? Which one did Jensen say to try first?
Peyronie’s Disease consider pentoxifylline penile traction therapy when combined with meds **Collagenase clostridium histolyticum (CCH) injection** or verapamil injection (try CCH first) radiation therapy sx removal of plaque
53
What is the prevention for peytonie's dz?
avoidance of penile trauma limit alcohol and tobacco use control of comorbidities
54
What is the MC type of penile cancer? MC in developed or underdeveloped countries? What is the average age of onset?
squamous cell carcinoma MC in UNDERdeveloped countries average age is 60, but can be younger
55
What are risk factors for penile cancer?
chronic infection/inflammation: think HPV and HIV Hx of penile injury or urethral stricture Hx of phimosis Hx of tobacco use
56
How does penile cancer usually present?
skin abnormality or palpable lesion on the penis. (think rash or ulcer on the penis that does not heal) +/- inguinal lymphadenopathy
57
What is the diagnostic work up 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
58
If there is a low risk of recurrence for penile cancer, what is the tx?
limited excision +/- Laser therapy, topical therapy, and radiation may also be used. With the goal to preserve as much anatomy and penis function as possible
59
If there is a high risk of recurrence for penile cancer, what is the tx?
partial or total penile amputation +/- inguinal lymph node dissection May also be treated with chemotherapy and/or radiation
60
What is epididymitits? What are the 2 big causes if the male is younger than 40? older than 40?
Inflammation of the epididymis younger than 40: Chlamydia trachomatis Neisseria gonorrhoeae older than 40: G- rods (E. coli, Proteus, Klebsiella)
61
epididymis for a male younger than 40 is associated with ________. Older than you, associated with ________ or _______.
younger than 40: Associated with urethritis older than 40: Associated with UTI, prostatitis
62
What are 2 non-pathogen related causes of epididymitis?
amiodarone Reflux of urine
63
+/- urethritis, prostatitis or cystitis symptoms Fever Pain and swelling in scrotum - may radiate +/- reactive hydrocele +/- inguinal lymphadenopathy May see positive Prehn’s sign What am I? According to lecture, more than likely will have ______.
Epididymitis will have urinary s/s
64
How does early epididymitis present differently from late epididymitis?
Early - testicle normal or minimally tender and epididymis is tender and palpable Late - may be hard to distinguish from testis
65
What are some labs you want to order in epididymitis? why?
UA - pyuria, bacteriuria, hematuria, culture Urethral swab Gonorrhea - G- intracellular diplococci Chlamydia - WBC without visible organisms PCR for gonorrhea/chlamydia
66
What is the non-pharm tx of epididymitis? What is the empiric abx tx if younger than 40 (think STI related)? What if insertive anal intercourse?
Bed rest, scrotal elevation, ice packs Analgesics (NSAIDs) Empiric: ceftriaxone 500 mg - 1 g IM x 1 PLUS doxycycline 100 mg PO BID x 10 d insertive anal intercourse: ceftriaxone + levofloxacin
67
What is the tx for epididymitis if unlikely to be STI related?
levofloxacin 500 mg 1 PO QD x 10 d OR TMP-SMZ DS (800/160 mg) BID x 10 days
68
When should you start to see improvement in epididymitis s/s?
Improvement within 3 d, resolution 2-4 wks
69
What is orchitis? What should this infection make you think?
Inflammation/infection of testis that usually occurs with another illness think epididymitis that did not get treated
70
What are 3 causes of orchitis? What is the major one?
bacterial granulomatous: think AI response to sperm viral: MUMPS!!!! EBV, coxsackie, chickenpox, echovirus
71
Swelling, tenderness and erythema of testis +/- urethritis, cystitis, prostatitis, epididymitis +/- reactive hydrocele gradual scrotal pain + Prehn's sign Fever, +/- nausea and vomiting +/- inguinal lymphadenopathy What am I? What is important to note about the scrotal pain?
Orchitis More gradual onset and less severe than torsion
72
What should you order in orchitis to be sure?
US because want to BE SURE that it is NOT testicular torsion
73
What is the non-pharm tx of orchitis? What is the empiric abx tx if younger than 40 (think STI related)? What if insertive anal intercourse? What is NOT STI related?
Bed rest, scrotal elevation, ice packs Analgesics (NSAIDs ceftriaxone 500 mg-1 g IM x 1 + doxycycline 100 mg PO BID x 10 d anal sex: ceftriaxone 500 mg - 1 g IM x 1 + levofloxacin 500 mg 1 PO QD x 10 d NOT STI: levo
74
What is the tx for viral orchitis?
supportive care only!
75
**What is the highlighted prevention for orchitis?
vaccinations!!
76
_______ and ______ are two common scrotal masses
Epididymal cyst and testicular tumors
77
Epididymal cyst are associated with ______ and _______. What is the tx?
Associated with DES use during pregnancy and Von Hippel-Lindau disease Diethylstilbestrol (DES) is a synthetic form of the female hormone estrogen Von Hippel-Lindau syndrome is an inherited disorder characterized by the formation of tumors and fluid-filled sacs (cysts) in many different parts of the body no specific tx needed
78
What is Von Hippel-Lindau syndrome?
Von Hippel-Lindau syndrome is an inherited disorder characterized by the formation of tumors and fluid-filled sacs (cysts) in many different parts of the bodyis an inherited disorder characterized by the formation of tumors and fluid-filled sacs (cysts) in many different parts of the body
79
Define spermatocele. Are they painful? What is the tx?
epididymal cyst >2 cm (2-5 cm) Rarely symptomatic; may be painful observation and surgical excision
80
What is the MC cause of solid testicular tumors in men? What age range? What type?
cancer MC cancer is males is 20-35 90-95% are germ cell tumors
81
What are risk factors for testicular tumors? What is the highlighted one?
**Cryptorchidism** Exogenous estrogen during pregnancy Infertility Family history HIV ethnicity
82
What is the MC symptom for testicular tumor?
painless enlargement of testis- MC Testicular or scrotal heaviness Painless nodule on testicle Acute testicular pain metastatic symptoms can also be asymptomatic in 10% of cases
83
Where is the MC site of metastasis in testicular tumors?
retroperitoneal abdominal lymph nodes (think pain the mid-back)
84
What are some labs to order when working a pt up for testicular tumor? What is the initial imaging evaluation?
Alpha-fetoprotein (AFP) hCG LDH Scrotal US
85
What imaging should you order when staging a testicular tumor? **What should you NOT do?
staging with CT of abdomen/pelvis, CXR **DO NOT order bx due to seeding risk**
86
What is the definitive dx for testicular tumor?
radical inguinal orchiectomy +/- radiation/chemo depends on the subtype
87
What are the indicated follow-up for testicular tumors? What percent of pts relapse in the first 2 years after treatment?
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
88
What is the prognosis for testicular cancer?
Most cancers - 90% + 5 year survival rates Disseminated or bulky (> 10 cm) retroperitoneal disease - 55-80%
89
What are some pt education points for a testicular self-exam?
90

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