Scrotal DOs Flashcards
Normal Teste =
- ____ - _____ cm in length
- Firm or soft?
- Rough or Smooth surfaces?
- 3-5cm in length
- FIRM
- SMOOTH Surfaces
Why does the LT teste hang lower than the RT?
there is more blood on the LT side (resistance to venous return = heavier)
Where does sperm & Testosterone formation occur?
Seminiferous tubules in the testes
Describe the HPG Axis pathway that leads to Sperm & Testosterone formation
GnRH from Hypothalamus -> LH/FSH from the Anterior Pituitary
Are leydig cells stimulated by LH or FSH? What do they produce?
- Leydig cells = LH
- Produce: Testosterone, 5 Alpha Reductase (converts Testosterone -> DHT)
What is DHT?
more potent version of Testosterone
HPG Axis -> GnRH -> LH -> Leydig Cells surrounding the semiferous tubules -> 5-Alpha Reductase -> converts Testosterone to DHT
Are Sertoli Cells stimulated by LH or FSH? What do they produce?
- Sertoli = FSH
- Produce: Androgen binding protein (ABP), Aormatase, Inhibin, Glycogen/Fructose
What does Aromatase do?
Converts Testosterone -> Estrogen (increases tubular fluid to help support semen)
Describe the flow of ejaculation starting with “pre-cum”
- 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
What does the seminal vesicle produce?
fructose for sperm energy
- 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
Gubernaculum
Processus Vaginalis
What happens if the proximal portion of the processus Vaginalis does NOT close with time?
open hole b/w peritoneal cavity and scrotum -> risk of Hydrocele, Hernia
The proximal portion of the process vaginalis should close after birth. The Distal portion becomes the _____ _______
Tunica Vaginalis
Which layer(s) of the scrotum have the potential to collect fluid (peritoneal fluid, Blood, Pus)?
Tunica Albuginea or Tunica Vaginalis?
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
List the scrotum layers DEEP -> SUPERFICIAL
Testes ->——- -> Skin
Testes -> Tunica Albuginea -> Partietal layer of Tunica Vaginalis -> Cavity -> Visceral layer of Tunica Vaginilais -> Cremasteric muscle -> Skin
Cremasteric muscle function
raise and lower testes to regulate scrotal temp
Where is the appendix testis?
anterior superior testis (0.3cm in length)
twisting risk
the LT testicular vein drains into -> _____
RT Testicular vein drains into -> ______
- LT testicular vein -> LT RENAL Vein
- RT Testicular vein -> IVC
Lymph node drainage
- Testes =
- Scrotum =
- Testes = para-aortic lymph nodes
- Scrotum = superficial inguinal lymph nodes
Cryptorchidism?
Teste FAILS to descend
Cryptorchidism MC affects which side?
RT & Unilateral
1 risk factor for testicular torsion
Crytptorchidism
Cryptorchidism Tx
- <4mo?
- 4mo-2yo?
- <4mo -> MONITOR
- 4mo-2yo -> ORCHIOPEXY
MCC of 2ndary (reactive) Hydrocele?
STI -> Epididymo-orchitis
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
Severe indications for a Sx Hydrocelectomy (rmvl of hydrocele)
- Symptomatic
- Scrotal skin compromise
- Child that does not spon resolve within 1-2yrs
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
Is a RT or LT Varicocele more concerning?
RT
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.
What should you suspect if pt has a RT Varicocele?
TUMOR suppressing the RT veins
bc the SMA only compresses/affects the LT renal vein/testicular vein
BAG OF WORMS SCROTUM = #1 DDx?
VARICOCELE
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)
- If pt has a varicocele with red flags for poss tumor, order a _____.
- MC tumor ET =
- CT Abd/Pelvis
- MCC = Renal Cell Carcinoma (RCC)
Dx Varicocele + WANTS KIDS -> Fertility WU q ____ - ____yr to r/o testicular atrophy
1-2
Testicular atrophy criteria on US
> 10-15% testicular vol difference or >2mL diff on US
Varicocele Tx
- Lift em up -> Briefs, jock strap
- NSAIDs
- Varicocelectomy
Sx Varicocelectomy indications
- PAINFUL & Fails Tx
- Testicular Atrophy or Abnorm semen analysis + WANTS KIDS
Hesselbach’s Triangle is where _____ hernias can occur
Indirect or Direct?
DIRECT
- Inguinal ligament (inferior)
- Inferior epigastric vessels (lateral)
- Rectus ambdominis muscle (medial)
Indirect hernias = _____ to the inferior epigastric
Direct hernias = _____ to the inferior epigastric
medial or lateral?
Indirect = LATERAL
Direct = MEDIAL
Indirect inguinal hernias occur d/t the _____ _____ failing to close in utero, leaving a pathway open b/w peritoneal cavity and scrotum
Processus vaginalis
Indirect inguinal hernias are MC _____
LT or RT?
RT
- Inguinal hernias are MC in ____
- Femoral hernias are MC in ____
M or F?
Inguinal = MALE
Femoral = FEMALE
- Ingunal hernias are ____ the inguinal ligament
- Femoral hernias are ____ the inguinal ligament
Inguinal = ABOVE
Femoral = BELOW
Incarcerated vs Stangulated hernais
- Incarcerated = trapped outside
- Strangulated = cutting off blood flow -> necrosis, perforation risk
Groin Hernia Imaging Orders:
- Initial screen?
- eval for incarceration/strangulation?
- Initial screen = US W/Doppler
- Eval for incarceration/strangulation -> CT Abd/Pelvis W/Contrast
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
MC testicular CA tumor overall?
GERM CELL TUMORS
- Seminomas
- Non-seminomas (more aggressive and occur at younger age)
Others: Leydig, Sertoli
Risk factors for testicular CA
- WHITE MEN (15-40yo)
- CRYPTORCHIDISM
- FMH
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
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
Testicular CA will MC spread to _ lymph nodes FIRST
RETROPERITONEAL Lymph nodes -> LOW BACK PAIN
Testicles originally come from the abdomen, so that’s why it’s retroperitoneal and NOT inguinal lymph nodes
ANY MALE WITH SOLID, FIRM MASS IN THE TESTIS = ______ UNTIL PROVEN OTHERWISE
TESTICULAR CA (GERM CELL)
Not all testicular CAs are painless, and many are accidentally Dx as ______
Epididymitis
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
When should you Bx sussy Testicular CA?
NEVERRRRRRRRRRRRRRRRRRRRRRRRRRRRR
also never Bx ovarian CA
Testicular CA Tumor Markers:
- ____ will NEVER be high in Seminomas (type of germ cell CA)
AFP, HCG, LDH?
AFP (Alpha Fetoprotein)
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
Testicular CA Tx
Radical inguinal orchiectomy
- remove teste and part of spermatic cord at deep inguinal ring
Non-Seminomas -> +/- Retroperitoneal lymph node dissection (RPLND)
Is it chill to use sperm from a cancerous testicle for reproduction?
Apparently yes
Are monthly self-tesicle exams recommended to monitor for testicular CA?
yes, even if “average risk”
Sex Cord Stromal Testicular CAs (Sertoli or Leydig cell) have more ______ effects than Germ Cell CA
body system
Endocrine
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)
DDx?
LOCALIZED, soft round mass in head of the epidiymis, distinct from the testicle. +/- transillumination
Epididymal cyst or Spermatocele
benign small fluid collections MC in the head of the epididymis
Spermatoceles are >2cm
1 risk factor for epididymal cyst/Spermatocele
mom using DES (diethylstilbestrol) during pregnancy
epididymal cyst/Spermatocele Tx
MONITOR
+/- Excise if large/chronic pain
ALL MALES WITH N/V AND MOD/SEVERE ABD PAIN SHOULD GET A ______ EXAM TO R/O ______
SCROTAL EXAM
R/O TESTICULAR TORSION
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
Testicular Torsion -> ____ Hrs until IRREVERSIBLE DAMAGE
6
Testicular Torsion Tx
Sx Bilateral Orchiopexy = Detorsion + FIXATION OF BOTH TESTES
Testicular Torsion Tx:
If Sx is not avail urgently, how do you do a MANUAL DETORSION?
open the testes like a book!
still need to go to Sx tho! this is just something to do while time passes
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
appendage will usually calcify and degenerate in several days
MCC of acute scrotal pain in adults
Epididymitis & Epididymo-Orchitis
inflammation/Infx of the epididymis
Usu d/t STIs or UTI -> back tracks to epididymis
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)
MC Viral ET -> Epididymo-Orchitis
Mumps
Epididymitis & Epididymo-Orchitis SS
- painful inflamed scrotum, tender epididymis
- ss over few days
- MC = UNILATERAL
- +/- (+) PHREN SIGN - lifting up the scrotum relieves pain
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
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)]
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
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
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
If you see Scrotal Cellulitis or Skin Abscesses -> you must R/O _______ & ______
- Testicular Abscess
- Fournier Gangrene
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
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)
if only mild scrotal hematoma -> rest, ice, supportive underwear, NSAIDs
