Scrotal DOs Flashcards
(82 cards)
1
Q
Normal Teste =
- ____ - _____ cm in length
- Firm or soft?
- Rough or Smooth surfaces?
A
- 3-5cm in length
- FIRM
- SMOOTH Surfaces
2
Q
Why does the LT teste hang lower than the RT?
A
there is more blood on the LT side (resistance to venous return = heavier)
3
Q
Where does sperm & Testosterone formation occur?
A
Seminiferous tubules in the testes
4
Q
Describe the HPG Axis pathway that leads to Sperm & Testosterone formation
A
GnRH from Hypothalamus -> LH/FSH from the Anterior Pituitary
5
Q
Are leydig cells stimulated by LH or FSH? What do they produce?
A
- Leydig cells = LH
- Produce: Testosterone, 5 Alpha Reductase (converts Testosterone -> DHT)
6
Q
What is DHT?
A
more potent version of Testosterone
HPG Axis -> GnRH -> LH -> Leydig Cells surrounding the semiferous tubules -> 5-Alpha Reductase -> converts Testosterone to DHT
7
Q
Are Sertoli Cells stimulated by LH or FSH? What do they produce?
A
- Sertoli = FSH
- Produce: Androgen binding protein (ABP), Aormatase, Inhibin, Glycogen/Fructose
8
Q
What does Aromatase do?
A
Converts Testosterone -> Estrogen (increases tubular fluid to help support semen)
9
Q
Describe the flow of ejaculation starting with “pre-cum”
A
- Bulbourethral gland produces neutralizing “pre-cum” to prep urethra for sperm to come through
- Developing sperm travel from seminferous tubules -> epididymis -> Vas deferens -> Ejactulatory duct & Seminal vesicle -> penile urethra
10
Q
What does the seminal vesicle produce?
A
fructose for sperm energy
11
Q
- the _____ tethers the testis to the scrotum while in the retroperitoneal cavity during embryonic development
- Around 10-15Wk -> anchored testes are drawn down near entry of deep inguinal ring
- 25-35Wk -> fingerlike projection of the Peritoneum, __________ ________, pushes its way through the abd wall
A
Gubernaculum
Processus Vaginalis
12
Q
What happens if the proximal portion of the processus Vaginalis does NOT close with time?
A
open hole b/w peritoneal cavity and scrotum -> risk of Hydrocele, Hernia
13
Q
The proximal portion of the process vaginalis should close after birth. The Distal portion becomes the _____ _______
A
Tunica Vaginalis
14
Q
Which layer(s) of the scrotum have the potential to collect fluid (peritoneal fluid, Blood, Pus)?
Tunica Albuginea or Tunica Vaginalis?
A
Tunical vaginalis = 2 layered pouch
- Visceral layer covers the Tunica Albuginea
- Parietal layer is the outermost layer that lines the inner surface of scrotal sac
Tunica Albuginea = fibrous layer covering the testes
**LAYERS DEEP -> SUPERFICIAL **
Testes -> Tunica Albuginea -> Partietal layer of Tunica Vaginalis -> Cavity -> Visceral layer of Tunica Vaginilais -> Cremasteric muscle -> Skin
15
Q
List the scrotum layers DEEP -> SUPERFICIAL
Testes ->——- -> Skin
A
Testes -> Tunica Albuginea -> Partietal layer of Tunica Vaginalis -> Cavity -> Visceral layer of Tunica Vaginilais -> Cremasteric muscle -> Skin
16
Q
Cremasteric muscle function
A
raise and lower testes to regulate scrotal temp
17
Q
Where is the appendix testis?
A
anterior superior testis (0.3cm in length)
twisting risk
18
Q
the LT testicular vein drains into -> _____
RT Testicular vein drains into -> ______
A
- LT testicular vein -> LT RENAL Vein
- RT Testicular vein -> IVC
19
Q
Lymph node drainage
- Testes =
- Scrotum =
A
- Testes = para-aortic lymph nodes
- Scrotum = superficial inguinal lymph nodes
20
Q
Cryptorchidism?
A
Teste FAILS to descend
21
Q
Cryptorchidism MC affects which side?
A
RT & Unilateral
22
Q
1 risk factor for testicular torsion
A
Crytptorchidism
23
Q
Cryptorchidism Tx
- <4mo?
- 4mo-2yo?
A
- <4mo -> MONITOR
- 4mo-2yo -> ORCHIOPEXY
24
Q
MCC of 2ndary (reactive) Hydrocele?
A
STI -> Epididymo-orchitis
25
8yo boy presents with painless, unil, smooth, symmetric, soft enlarged scrotum. He describes it as "full and heavy."
PE is (+) for transillumination of scrotum. When he stands up or valsalvas, his scotum gets bigger. #1 DDx?
Hydrocele
26
Severe indications for a Sx Hydrocelectomy (rmvl of hydrocele)
* Symptomatic
* Scrotal skin compromise
* Child that does not spon resolve within 1-2yrs
27
Is a RT or LT Hydrocele more common and why?
LT
- The LT Teste vein drains into the LT RENAL VEIN at hard 90 degree angle. This makes backflow very likely. the LT renal vein is normally slightly sandwiched b/w the aorta and the superior mesenteric Artery -> backflow prob
28
Is a RT or LT Varicocele more concerning?
RT
## Footnote
the RT testicular vein drains into the IVC and is at lower risk for backflow vs the LT testicular vein, which drains into the LT Renal Vein at a 90degree angle and is sandwiched b/w the aorta and SMA.
29
What should you suspect if pt has a RT Varicocele?
TUMOR suppressing the RT veins
## Footnote
bc the SMA only compresses/affects the LT renal vein/testicular vein
30
BAG OF WORMS SCROTUM = #1 DDx?
VARICOCELE
31
Varicocele red flags
* sudden onset
* HELLA BIG
* RT SIDED
* does NOT improve when SUPINE = TUMOR (bc veins drain better when laying down, but a tumor will compress it regardless of body position)
32
- If pt has a varicocele with red flags for poss tumor, order a _____.
- MC tumor ET =
- CT Abd/Pelvis
- MCC = Renal Cell Carcinoma (RCC)
33
Dx Varicocele + WANTS KIDS -> Fertility WU q ____ - ____yr to r/o testicular atrophy
1-2
34
Testicular atrophy criteria on US
>10-15% testicular vol difference or >2mL diff on US
35
Varicocele Tx
1. Lift em up -> Briefs, jock strap
2. NSAIDs
3. Varicocelectomy
36
Sx Varicocelectomy indications
* PAINFUL & Fails Tx
- Testicular Atrophy or Abnorm semen analysis + WANTS KIDS
37
Hesselbach's Triangle is where _____ hernias can occur
| Indirect or Direct?
DIRECT
## Footnote
* Inguinal ligament (inferior)
* Inferior epigastric vessels (lateral)
* Rectus ambdominis muscle (medial)
38
Indirect hernias = _____ to the inferior epigastric
Direct hernias = _____ to the inferior epigastric
| medial or lateral?
Indirect = LATERAL
Direct = MEDIAL
39
Indirect inguinal hernias occur d/t the _____ _____ failing to close in utero, leaving a pathway open b/w peritoneal cavity and scrotum
Processus vaginalis
40
Indirect inguinal hernias are MC _____
| LT or RT?
RT
41
* Inguinal hernias are MC in ____
* Femoral hernias are MC in ____
| M or F?
Inguinal = MALE
Femoral = FEMALE
42
* Ingunal hernias are ____ the inguinal ligament
* Femoral hernias are ____ the inguinal ligament
Inguinal = ABOVE
Femoral = BELOW
43
Incarcerated vs Stangulated hernais
* Incarcerated = trapped outside
* Strangulated = cutting off blood flow -> necrosis, perforation risk
44
Groin Hernia Imaging Orders:
- Initial screen?
- eval for incarceration/strangulation?
- Initial screen = US W/Doppler
- Eval for incarceration/strangulation -> CT Abd/Pelvis W/Contrast
45
Groin Hernias Tx
- Inguinal (MILD or Asymp)?
- Induinal (MOD ss)
- Femoral?
- Incarcerated/Strangulated?
- Inguinal (MILD/Asymp) -> Monitor
- Inguinal (MOD) -> Sx repair (#1 Laprascopic)
- Femoral -> Sx repair regardless of ss
- Incarcerated/strangulated -> GI consult ASAP for Sx repair
46
MC testicular CA tumor overall?
**GERM CELL TUMORS**
- Seminomas
- Non-seminomas (more aggressive and occur at younger age)
## Footnote
Others: Leydig, Sertoli
47
Risk factors for testicular CA
* WHITE MEN (15-40yo)
* CRYPTORCHIDISM
* FMH
48
How is Testicular CA different than Hydrocele Presentation?
* Testicular CA = FIRM, FIXED MASS/Swelling, does NOT transilluminate
* Hydrocele = SMOOTH, SOFT, TRANSILLUMINATES
* BOTH = painless, unilateral, heaviness
49
What other non-testicular ss may occur if Cancerous Testicular GERM CELLS produce B-HCG?
* B-HCG can act like LH & FSH -> incr Testosterone prod -> Aromatase converts Tesosterone -> Estrogen -> **Gynecomastia**
* IF HELLA B-HCG -> it can mimic TSH (similar alpha subunit) -> **HYPERTHYROIDISM**
50
Testicular CA will MC spread to _ lymph nodes **FIRST**
**RETROPERITONEAL** Lymph nodes -> **LOW BACK PAIN**
## Footnote
Testicles originally come from the abdomen, so that's why it's retroperitoneal and NOT inguinal lymph nodes
51
**ANY MALE WITH SOLID, FIRM MASS IN THE TESTIS = ______ UNTIL PROVEN OTHERWISE**
**TESTICULAR CA (GERM CELL)**
52
Not all testicular CAs are painless, and many are accidentally Dx as ______
Epididymitis
53
Testicular CA WU
1.** Scrotal US **(hypoechoic, inhomogenous) -> refer to urology
2. CBC, CMP, Serum tumor markers (**alpha fetoprotein, HCG, LDH**)
3. **CT Abd/Pelvis** - 1st mets usu in retroperitoneal lymph nodes
4. **CXR (or CT Chest)** - pulm mets
54
When should you Bx sussy Testicular CA?
NEVERRRRRRRRRRRRRRRRRRRRRRRRRRRRR
## Footnote
also never Bx ovarian CA
55
Testicular CA Tumor Markers:
- ____ will **NEVER** be high in **Seminomas** (type of germ cell CA)
| AFP, HCG, LDH?
AFP (Alpha Fetoprotein)
56
Testicular CA Tumor Markers -> HCG, LDH, AFP
- Which are HIGH in Seminomas?
- Which are HIGH in NON-seminomas?
- Seminomas = HIGH HCG, LDH
- NON-Seminomas = HIGH HCG, LDH, **AFP**
57
Testicular CA Tx
Radical inguinal orchiectomy
- remove teste and part of spermatic cord at deep inguinal ring
## Footnote
Non-Seminomas -> +/- Retroperitoneal lymph node dissection (RPLND)
58
Is it chill to use sperm from a cancerous testicle for reproduction?
Apparently yes
59
Are monthly self-tesicle exams recommended to monitor for testicular CA?
yes, even if "average risk"
60
Sex Cord Stromal Testicular CAs (Sertoli or Leydig cell) have more ______ effects than Germ Cell CA
| body system
**Endocrine**
61
Sex Cord Stromal Testicular CAs (Sertoli or Leydig cell)
- Which age group(s) are most affected?
- Which cell type CA is MC?
- SS
- WU
- Tx
- Bimodal (6-10yo, 26-35yo)
- #1 LEYDIG CA
- SS: Gynecomastia, Early puberty (precocious puberty), decr libido, ED
- WU: US, LH, AFP, HCG, LH/FSH, Testosterone, Estrogen, Progesterone, Cortisol
- Tx: Radical Orchiectomy +/- Retroperitoneal lymph node dissection (chemo/rad fails)
62
DDx?
LOCALIZED, soft round mass in head of the epidiymis, distinct from the testicle. +/- transillumination
Epididymal cyst or Spermatocele
## Footnote
benign small fluid collections MC in the head of the epididymis
Spermatoceles are >2cm
63
#1 risk factor for epididymal cyst/Spermatocele
mom using DES (diethylstilbestrol) during pregnancy
64
epididymal cyst/Spermatocele Tx
MONITOR
+/- Excise if large/chronic pain
65
ALL MALES WITH N/V AND MOD/SEVERE ABD PAIN SHOULD GET A ______ EXAM TO R/O ______
SCROTAL EXAM
R/O TESTICULAR TORSION
66
WHAT DOES TESTICULAR TORSION LOOK LIKE ON STAT COLOR DOPPLER US?
- Decr or Incr Blood flow?
- ____ sign
- **DECREASED/ABSENT** BLOOD FLOW OR TWISTING OF THE SPERMATIC CORD
- **+/- WHIRLPOOL SIGN**
67
Testicular Torsion -> ____ Hrs until IRREVERSIBLE DAMAGE
6
68
Testicular Torsion Tx
**Sx Bilateral Orchiopexy** = Detorsion + FIXATION OF BOTH TESTES
69
Testicular Torsion Tx:
If Sx is not avail urgently, how do you do a MANUAL DETORSION?
open the testes like a book!
## Footnote
still need to go to Sx tho! this is just something to do while time passes
70
Torsion of the Appendix Testis
- MC in which age grp?
- SS?
- WU?
- Tx?
- Children 7-14yo
- SS: LOCALIZED PAIN +/- BLUE DOT SIGN
- WU: Clinical Dx +/- Doppler US
- Tx: Supportive (NSAIDs). Fails -> Sx
## Footnote
appendage will usually calcify and degenerate in several days
71
MCC of acute scrotal pain in adults
Epididymitis & Epididymo-Orchitis
## Footnote
inflammation/Infx of the epididymis
Usu d/t STIs or UTI -> back tracks to epididymis
72
Epididymitis & Epididymo-Orchitis -> MCC pathogens
- MCC Pathogens overall (bac, viral, fungal)?
- MC if <35yo (or >35yo + STI risks)?
- MC if 35yo+?
- MCC overall = **BACTERIA**
- MC if <35yo (or men >35 + STI risks) = STI (**#1 Chlamydia**, Gonorrhea, M. genitalium)
- MC if 35yo+ = UTI (**E. coli**)
73
MC Viral ET -> Epididymo-Orchitis
Mumps
74
Epididymitis & Epididymo-Orchitis SS
- painful inflamed scrotum, tender epididymis
- ss over few days
- MC = UNILATERAL
- +/- **(+) PHREN SIGN** - lifting up the scrotum relieves pain
75
Epididymitis & Epididymo-Orchitis Dx
* Clinical Dx
* Unsure -> Doppler US = ***"enlarged epididymis + INCR BLOOD FLOW" ***
* UA + Culture
* NAAT -> Chlamydia, Gonorrhea
* <35yo or STI risks -> Syphilis and HIV WU
76
Epididymitis & Epididymo-Orchitis Tx
- <35yo (or STI risk) & NO ANAL
- <35yo (or STI risk) + ANAL
- 35yo+ & NO STI risk ->
- Acutely ILL ->
- <35yo (or STI risk) & NO ANAL = Rocephin + Doxy
- <35yo (or STI risk) + ANAL = Rocephin + Levofloxacin
- 35yo+ & NO STI risk = Levofloxacin or Bactrim
- Acutely ILL = IV Fluids + IV ABX [Rocephin + (Doxy or levaquin)]
77
pt with Epididymitis & Epididymo-Orchitis. They still appear acutely ill 48Hr after being given IV ABX. Order ____ to r/o ____
Scrotal US - r/o **ABSCESS**
78
If only the testicles are swollen (ORCHITIS) and pt also has swollen parotid glands -> it is likely _______
| NO Epididymis involvement is rarer
MUMPS
- #1 ET = Viral Infx (MC in peds/YA)
- Tx: Rest, NSAIDs, Ice, Scrotal support
79
Testicular abscess is almost always a complication from _______
- Dx?
- Tx?
SEVERE or Untreated epididymo-orchitis
- Dx: Doppler US = ***"complex mixed solid/cystic structure, multiseptated, incr vascularity"***
- Tx: Sx drainage (Orchiectomy), Cultures, ABX LONG-COURSE
80
If you see Scrotal Cellulitis or Skin Abscesses -> you must R/O _______ & ______
- Testicular Abscess
- Fournier Gangrene
81
Fournier Gangrene
- what?
- ET?
- Risk?
- SS?
- Tx?
- Infx of deep soft tissues -> destroys muscle fascia, SQ FAT
- #1 Polymycrobial Infx -> Facultative organisms, Anaerobes (gas producing)
- Risks: OLD DIABETIC MEN (immunocomp)
- SS: Soft tissue infx, systemic illnes, SEVERE PAIN OUT OF PROPORTION TO PE, RAPID PROGRESSION, CREPITUS
- Dx: Clinical -> CT (airy) -> Sx exploration
- Tx: Sx debridement, Broad Spectrum ABX, Fluids, Vasopressors
82
Testicular Rupture
- ET:
- SS:
- WU:
- Tx:
- ET: Young Male Trauma (sports)
- SS: Swelling, pain, bruising, LOSS OF TESICULAR CONTOUR
- WU: Doppler US (r/o torsion) = irregular margins of tunica albuginea
- Tx: Urology consult -> Sx Exploration & Repair (best if within 72Hr)
## Footnote
if only mild scrotal hematoma -> rest, ice, supportive underwear, NSAIDs
