Scrotal Disease Flashcards
What is the most common prostatic disease in males over 50?
Benign Prostatic Hyperplasia (BPH)
What is BPH characterised by?
Nodular prostatic hyperplasia
Not premalignant
How does BPH cause urine constriction?
Hyperplasia of prostatic epithelial, stromal cells > formation of nodules in transition zone of prostate > narrowing of urethral canal > urine flow constricted
What does testosterone + DHT do in BPH?
Testosterone + DHT estrogens act on stromal, epithelial cell androgen receptors > hyperplasia and inhibition of normal cell death
What does dysregulation of stromal growth factors do?
proliferation, hyperplasia of epithelium
Increased stem cells
Path of BPH
- inner transitional zone of prostate ( muscular gland) proliferates and narrows the urethra
Risk factors of BPH
Increased age
Family history of BPH
hEART DISEASE
Beta Blocker use
Obesity
Diabetes
Erectile dysfunction
Complications of BPH
Chronic bladder outlet obstruction
Bladder hypertrophy > formation of bladder diverticula
Urinary retention > bladder calculi
Recurrent UTIs
Hydronephrosis > renal failure
Signs and symptoms of BPH
Typical LUTS
Urinary issues - frequency, urgency, dysuria, emptying bladder feels incomplete, weak stream
Initial assessment of men presenting with LUTS involves:
Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
Abdominal examination to assess for a palpable bladder and other abnormalities
Urinary frequency volume chart, recording 3 days of fluid intake and output
Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
Diagnostic imaging for for BPH
US - Bladder size, prostate size
Cystoscopy - Reveal bladder divericula/ calculi before schedule invasive treatment
Lab investigations for BPH
Urinalysis - haematuria, Pyuria, bacteriuria
Urine culture - exclude UTIs
Blood tests - Increased PSA, electrolytes, blood urea nitrogen, creatinine
What is The international prostate symptom score (IPSS)?
scoring system that can be used to assess the severity of lower urinary tract symptoms.
Common causes of raised PSA
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
Benign vs malignant prostate
A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
Medical options for BPH
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
Surgical options for BPH
Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy
Transurethral Resection of the Prostate
most common surgical treatment of BPH. It involves removing part of the prostate from inside the urethra.
Complications of Transurethral Resection of the Prostate?
Bleeding
Infection
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
Urethral strictures
Failure to resolve symptoms
Transurethral electrovaporisation of the prostate (TEVAP / TUVP)
nvolves inserting a resectoscope into the urethra.
A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
Holmium laser enucleation of the prostate (HoLEP)
nvolves inserting a resectoscope into the urethra.
laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
What is the most common cause of scrotal enlargement?
Varicocele
Pathology of varicocele
Common testicular disorder of young adults
Dilation of pampiniform venous plexus (internal spermatic vein)
Impaired venous drainage > increased venous pressure > vein dilation
Which side does varicocele affect?
Left sided usually > due to increased flow resistance from left testicular vein drainage into left renal vein; right testicular vein drains directly into IVC
Types of varicocele
Large - easily identified by inspection as distention
Moderate - identified by palaption as bag of worms
Small - identified only by bearing down > increased abdominal pressure which impedes drainage > increased varicocele size
Causes of varicocele
Idiopathic
Retroperitoneal pathology (RCC) > can invade renal vein > left sided varicocele
Complications of varicocele
- Sperm impairments: Production, quality due to heat,
- Decreased sperm concentration
- Decreased motility
- Testicular damage
Signs and symptoms of Varicocele
Usually asymptomatic
If symptomatic - Scrotal heaviness or scrotal pain
Diagnostic imaging for varicocele
Doppler ultrasound - Characteristic reverse blood flow
Ultrasound/ CT scan
Lab investigations for varicocele
Semen analysis - impairment in semen parameters
Treatment for varicocele
Surgery
Surgical ligation/ embolization
What can varicocele result in?
testicular atrophy, reducing the size and function of the testicle.
What is the paminiform plexus?
venous plexus is found in the spermatic cord and drains the testes.
The pampiniform plexus drains into the testicular vein. It plays a role in regulating the temperature of blood entering the testes by absorbing heat from the nearby testicular artery.
The testicles need to be at an optimum temperature for producing sperm.
What are varicocele a result of
increased resistance in the testicular vein.
Incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus.
What does the right testicular vein drain into ?
IVC
What can varicocele present with?
Throbbing/dull pain or discomfort, worse on standing
A dragging sensation
Sub-fertility or infertility
Examination findings of varicocele
A scrotal mass that feels like a “bag of worms”
More prominent on standing
Disappears when lying down
Asymmetry in testicular size if the varicocele has affected the growth of the testicle
What do Varicoceles that do not disappear when lying down raise concerns about?
Retroperitoneal tumours obstructing the drainage of the renal vein.
These warrant an urgent referral to urology for further investigation.
Investigations to consider for varicocele are
Ultrasound with Doppler imaging can be used to confirm the diagnosis
Semen analysis if there are concerns about fertility
Hormonal tests (e.g., FSH and testosterone) if there are concerns about function
Define Hydrocele
Hydrocele refers to a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis
Two types of hydrocele
Communicating
Non communicating
Why does communicating hydrocele occur
failure of normal closure of the processus vaginalis. This allows the passage of peritoneal fluid into the tunica vaginalis.
What is non communicating hydrocele
There is no abnormal connection with the peritoneal cavity as seen in communicating hydroceles. Instead fluid is produced by the mesothelial lining of the tunica vaginalis.
clinical manifestations of hydrocele
SCROTAL SWELLING
- smooth
-non reducible
- non tender
- soft
What do communicating hydroceles tend to do
change size and increase when standing for prolonged periods of time
Investigations for a hydrocele
Testicular US
Management in infants of hydrocele
- may resolve with first year of life
- ongoing obs
- if surgery then open repair with high ligation of patent processuc vaginalis
management of hydrocele in adults
non communicating- spontaneous repair
communicating- aspiration of hydrocele
What is a epididymal cyst
Smooth, extra-testicular, spherical sac of fluid in the head of the epididymis (top of testicle). They are usually harmless.
Pathophysiology of a epididymal cyst
Contain clear or milky (spermatocele) fluid
They lie above and behind the testis
signs of a cyst
- Palpable lump (often multiple and bilateral)
- Well defined and will Transluminate since fluid-filled
signs of a cyst
- Can cause dragging and soreness
- May be pain if cysts are large
