Scrotal and Penile Disorders Flashcards
Scrotal masses that are always painful
● Epididymitis
● Orchitis
● Testicular Torsion
Scrotal masses/pain categories - HIMBIN
● Hernias (inguinal, femoral)
● Infections (epididymitis, orchitis, prostatitis, cellulitis, scrotal abscess)
● Masses (hydrocele, epididymal cysts, testis cancer)
● Blood flow issues (testicular torsion, varicocele)
● Inflammation (Non-bacterial, idiopathic, chronic inflammatory pain)
● Nerve related (Chronic, normal u/s, history of back injury, referred pain)
Hydrocele
Fluid accumulation between tunica layers of the testis
Hydrocele etiology
● Fluid accumulation between tunica layers of the testis
○ In children, fluid develops from communication directly with the abdomen
○ In adults, usually fluid accumulates through diffusion with time
○ May be associated with testicular cancer (10%) or abdominal masses
Hydrocele Presentation - Adult vs. Children
● Adult: Gradually (generally
painless) enlarging testicle
● Children: Enlarged scrotum, typically painless, that goes away in when the child lays down (the fluid drains back into the abdomen)
Hydrocele Diagnosis
● Bilateral comparison
● Transillumination – Fluid accumulation of the
anterior superior aspect of the testicle
● Ultrasound
Hydrocele Diagnosis
● Bilateral comparison
● Transillumination – Fluid accumulation of the
anterior superior aspect of the testicle
● Ultrasound
Hydrocele Management
● Observation – scrotal support
● Refer
● Drainage – needle aspiration
○ Temporary solution
● Surgical excision – Hydrocelectomy
Spermatocele
Fluid accumulation in the epididymis
● “Hydrocele” or cysts of the epididymis
● Can be confused with hydrocele on exam (if large enough)
Spermatocele Presentation
● Similar to hydrocele
○ Painless, sometimes bothersome mass of the posterior aspect of the testicle
○ Usually will be found on ultrasound for scrotal mass
Spermatocele Treatment
● Observation
● Refer
● Surgical excision
○ Less bleeding and complications than
hydroceles
Varicocele
Dilated (varicose) veins of the spermatic cord (pampiniform plexus)
Varicocele Epidemiology
● 15-20% of healthy men
● 35-40% of men with primary infertility
● Most common in ages 15-25 years-old
● Left testicle 85-90% of the time
Varicocele Etiology
● Venous insufficiency
● Tumors
● Physical activities
● Unknown
Varicocele Presentation
● Unilateral scrotal swelling superior to the testicle and
epididymis
○ Pain +/- (may have referred abdominal pain)
● Can be present for years
● Enlarged, potentially visible, veins in the scrotum – “Bag of Worms”
Varicocele Grading
○ Grade 1 – Palpable only with Valsalva
○ Grade 2 – Palpable without Valsalva
○ Grade 3 – Visible externally with or without Valsalva
Varicocele Diagnosis
● Physical exam
● Ultrasound
Varicocele Management
● Observation
● Refer
● Percutaneous embolization of
the veins
● Surgical ligation
Epididymitis/Orchitis
Bacterial infection of the epididymis or testicle
Epididymitis/Orchitis Etiology
● Children – Enteroviruses, adenoviruses, and mycoplasma pneumoniae
○ Orchitis – Mumps
● <35 years old – Most likely STI (>50%) Gonorrhea or Chlamydia
● >35 years old – More likely uropathogens – E. Coli, Klebsiella, Enterococcus,
Enterobacter, pseudomonas
Epididymitis/Orchitis Presentation
● Gradual worsening of severe scrotal pain
○ Develops over hours or days
● Typically unilateral, but can be bilateral
● Pain may radiate up the cord into the groin,
or abdomen
● Fever and chills
● May have external erythema of the scrotum
● Swelling and tenderness of the epididymis
Epididymitis/Orchitis Diagnosis
● Prehn’s sign
○ Elevation of the scrotum takes the weight off of the inflamed inflamed epididymis, alleviating the pain of epididymitis, but worsens testicular torsion
● STI testing – men < 35 years old
● Scrotal Ultrasound: Preferred imaging if unable to make diagnosis on history and physical exam alone
● Epididymitis/orchitis will not transilluminate
Prehn’s sign
Elevation of the scrotum takes the weight off of the inflamed inflamed epididymis, alleviating the pain of epididymitis, but worsens testicular torsion
Epididymitis/Orchitis management
● Suspecting STI (Gonorrhea/Chlamydia)
○ Empiric therapy with Doxycycline 100 mg PO BID x 10 days PLUS
Ceftriaxone 1 gram IM once
● Negative STI screen or unlikely Gonorrhea/Chlamydia
○ TMP/SMX or Ciprofloxacin x 10-14 days
● Supportive therapy
○ NSAIDs, scrotal elevation, rest
Epididymitis/Orchitis Referral guidelines
● If failing empiric therapy, consider repeat scrotal ultrasound to confirm or
change diagnosis
● If no resolution on empiric therapy, then refer to Urology
Testicular Torsion
Twisting of the testicle/spermatic cord restricting blood to the testicle
Testicular Torsion Epidemiology
● Accounts for 15% of the cases of “acute
scrotum” in the ER (1 in 4000 males)
● Emergent condition
● Most common ages 12-18, peak at age 14
● Rare in men over 30
Testicular Torsion Etiology
● Lack of the gubernaculum allows the testicle to “lay” sideways,
increasing the chance of torsion, resulting in ischemia
● Left > Right
Testicular Torsion Presentation
● Sudden onset of severe unilateral pain
● Significantly swollen and erythematous scrotum
● Affected testicle WILL BE higher
● Negative Prehn’s Sign
○ Elevation of the testicle offers no relief
● Refer ER
Testicular Torsion Diagnosis
● Emergent ultrasound
○ Quickly and carefully to evaluate blood flow
Testicular Torsion Management
● Surgical detorsion – restore
blood flow
○ Detorsion within 6 hours of onset of
symptoms
Phimosis
Contracted foreskin cannot be retracted over the glans
Physiologic Phimosis
○ Nearly all (96%) uncircumcised boys – resolves with time
■ Persists in 10% at age 3 and <5% at age 16
○ This doesn’t interfere with urination, cause pain, or infections
Acquired (pathologic) Phimosis
Adults, caused by poor hygiene (most often in the elderly, people with
economic situations, mental disabilities) or recurrent balanitis
Phimosis
● Tight foreskin
● Unable to retract over the corona of the glans
● Not usually painful at rest, but the cracking of the skin hurts a lot
○ Tearing of the skin where from trying to
pull foreskin back (Acquired)
Phimosis management
● Physiologic Phimosis – Allow time for the phimosis to resolve
○ Can use steroids if too tight and causing complications
● Acquired Phimosis – Medium to high-potency steroid cream
○ Only effective if able to see the ring of phimosis
Phimosis Prevention
● Hygiene, daily washing of foreskin, retracting
foreskin to completely clean will prevent this
from occurring
● Watch for this issue in elderly, patients with
mental issues, patient in low-income
situations without access to good hygiene
● Caution against leaving the foreskin
retracted over the glans to avoid
paraphimosis
Phimosis complication
Balanitis – Nearly impossible to get if circumcised
● Inflammation of the glans penis
○ Fungal infection – candida
○ Inflammatory
● Desquamation of the foreskin
Balanitis – Nearly impossible to get if circumcised
● Firm glans with inflammation causing
narrowing of the urethral meatus
○ Balanitis Xerotica Obliterans → cancer
Balanitis Treatment
antifungal cream +/- steroid
● For recurrent cases – circumcision
Paraphimosis
The foreskin becomes trapped behind the corona
Paraphimosis Etiology
● 1% of uncircumcised males over 16 years old
● Always associated with phimosis
● Tight, inflammatory band of foreskin that can
cause loss of blood flow to the distal penis
● Urological Emergency
Paraphimosis Presentation
● Edematous glans with trapped prepuce proximal to the glans
● Pain at the site of the phimotic ring and distally
Paraphimosis Management
● Urgent reduction
○ Someone with experience
● Refer to ER if you are unable to reduce in the
clinic
● Urology consult eventually to address
circumcision, to avoid future issues
Prevention of a Paraphimosis
● Caution against leaving the foreskin retracted over the glans to avoid paraphimosis
Priapism
Painful erection lasting >4 hours
Priapism etiology
● Pooling of blood in the corpora cavernosa
causing oxygen-deprived blood to
dominate the tissue, leading to ischemia,
causing cell death of the penis over time
● Drugs
○ Trazodone, alcohol, cannabis,
cocaine, nitroglycerine, injected
vasodilators, and rarely oral ED
drugs (PDE-5 meds like Viagra)
● Sickle cell disease
● Trauma
● Spinal cord injury
Priapism presentation
Painful erection
Priapism diagnosis
● If < 4 hours, but painful erection, can try ice packs and vigorous exercise to
shunt blood away from the pelvis
● If > 4 hours, needs referral to ER with Urology consultation generally
Priapism management
● Initial therapy in the ER involves penile injection of phenylephrine
● Second line – bilateral, large-bore needles with forced fluid evacuation of blood
● Last resort – surgery for distal shunt procedure to drain the blood from the penis
Priapism prevention
● High risk of recurrence
● Avoidance of inciting medications or drugs
is the principal management strategy
● Caution patients if prescribing trazodone,
nitroglycerin
Peyronies
Fibrous scar tissue on the cavernosa that causes a curvature in the penis
Occurs in 0.5% of men and 3-15% of men with Dupuytren’s contractures
Peyronies
Peyronies etiology
● Often idiopathic
● Trauma when the penis is erect (accidental withdrawal)
● Micro-trauma (various causes)
Peyronies presentation
● Curvature of the penis, generally only present while erect
● Can be quite painful, but often doesn’t cause pain
● Can impair ability to have intercourse
Peyronies Progression
Progression is 20-40-40
● 20% will resolve spontaneously
● 40% will remain stable over time
● 40% will worsen with time
Peyronies diagnosis
● Palpable plaque
● Patient reports curvature
● Hx of trauma
Peyronies Management
● Observation
● Urology referral
● Xiaflex (collagenase clostridium histolyticum) – Injection of collagenase
enzyme to break up collagen bonds in the scarred plaque
● Surgery
