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Scrotal DOs Flashcards

1
Q

Normal Teste =
- ____ - _____ cm in length
- Firm or soft?
- Rough or Smooth surfaces?

A
  • 3-5cm in length
  • FIRM
  • SMOOTH Surfaces
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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)

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3
Q

Where does sperm & Testosterone formation occur?

A

Seminiferous tubules in the testes

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4
Q

Describe the HPG Axis pathway that leads to Sperm & Testosterone formation

A

GnRH from Hypothalamus -> LH/FSH from the Anterior Pituitary

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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)
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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

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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
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8
Q

What does Aromatase do?

A

Converts Testosterone -> Estrogen (increases tubular fluid to help support semen)

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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
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10
Q

What does the seminal vesicle produce?

A

fructose for sperm energy

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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

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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

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13
Q

The proximal portion of the process vaginalis should close after birth. The Distal portion becomes the _____ _______

A

Tunica Vaginalis

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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

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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

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16
Q

Cremasteric muscle function

A

raise and lower testes to regulate scrotal temp

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17
Q

Where is the appendix testis?

A

anterior superior testis (0.3cm in length)

twisting risk

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18
Q

the LT testicular vein drains into -> _____
RT Testicular vein drains into -> ______

A
  • LT testicular vein -> LT RENAL Vein
  • RT Testicular vein -> IVC
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19
Q

Lymph node drainage
- Testes =
- Scrotum =

A
  • Testes = para-aortic lymph nodes
  • Scrotum = superficial inguinal lymph nodes
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20
Q

Cryptorchidism?

A

Teste FAILS to descend

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21
Q

Cryptorchidism MC affects which side?

A

RT & Unilateral

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22
Q

1 risk factor for testicular torsion

A

Crytptorchidism

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23
Q

Cryptorchidism Tx
- <4mo?
- 4mo-2yo?

A
  • <4mo -> MONITOR
  • 4mo-2yo -> ORCHIOPEXY
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24
Q

MCC of 2ndary (reactive) Hydrocele?

A

STI -> Epididymo-orchitis

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25
Q

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?

A

Hydrocele

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26
Q

Severe indications for a Sx Hydrocelectomy (rmvl of hydrocele)

A
  • Symptomatic
  • Scrotal skin compromise
  • Child that does not spon resolve within 1-2yrs
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27
Q

Is a RT or LT Hydrocele more common and why?

A

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

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28
Q

Is a RT or LT Varicocele more concerning?

A

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.

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29
Q

What should you suspect if pt has a RT Varicocele?

A

TUMOR suppressing the RT veins

bc the SMA only compresses/affects the LT renal vein/testicular vein

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30
Q

BAG OF WORMS SCROTUM = #1 DDx?

A

VARICOCELE

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31
Q

Varicocele red flags

A
  • 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)
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32
Q
  • If pt has a varicocele with red flags for poss tumor, order a _____.
  • MC tumor ET =
A
  • CT Abd/Pelvis
  • MCC = Renal Cell Carcinoma (RCC)
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33
Q

Dx Varicocele + WANTS KIDS -> Fertility WU q ____ - ____yr to r/o testicular atrophy

A

1-2

34
Q

Testicular atrophy criteria on US

A

> 10-15% testicular vol difference or >2mL diff on US

35
Q

Varicocele Tx

A
  1. Lift em up -> Briefs, jock strap
  2. NSAIDs
  3. Varicocelectomy
36
Q

Sx Varicocelectomy indications

A
  • PAINFUL & Fails Tx
  • Testicular Atrophy or Abnorm semen analysis + WANTS KIDS
37
Q

Hesselbach’s Triangle is where _____ hernias can occur

Indirect or Direct?

A

DIRECT

  • Inguinal ligament (inferior)
  • Inferior epigastric vessels (lateral)
  • Rectus ambdominis muscle (medial)
38
Q

Indirect hernias = _____ to the inferior epigastric
Direct hernias = _____ to the inferior epigastric

medial or lateral?

A

Indirect = LATERAL
Direct = MEDIAL

39
Q

Indirect inguinal hernias occur d/t the _____ _____ failing to close in utero, leaving a pathway open b/w peritoneal cavity and scrotum

A

Processus vaginalis

40
Q

Indirect inguinal hernias are MC _____

LT or RT?

A

RT

41
Q
  • Inguinal hernias are MC in ____
  • Femoral hernias are MC in ____

M or F?

A

Inguinal = MALE
Femoral = FEMALE

42
Q
  • Ingunal hernias are ____ the inguinal ligament
  • Femoral hernias are ____ the inguinal ligament
A

Inguinal = ABOVE
Femoral = BELOW

43
Q

Incarcerated vs Stangulated hernais

A
  • Incarcerated = trapped outside
  • Strangulated = cutting off blood flow -> necrosis, perforation risk
44
Q

Groin Hernia Imaging Orders:
- Initial screen?
- eval for incarceration/strangulation?

A
  • Initial screen = US W/Doppler
  • Eval for incarceration/strangulation -> CT Abd/Pelvis W/Contrast
45
Q

Groin Hernias Tx
- Inguinal (MILD or Asymp)?
- Induinal (MOD ss)
- Femoral?
- Incarcerated/Strangulated?

A
  • 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
Q

MC testicular CA tumor overall?

A

GERM CELL TUMORS
- Seminomas
- Non-seminomas (more aggressive and occur at younger age)

Others: Leydig, Sertoli

47
Q

Risk factors for testicular CA

A
  • WHITE MEN (15-40yo)
  • CRYPTORCHIDISM
  • FMH
48
Q

How is Testicular CA different than Hydrocele Presentation?

A
  • Testicular CA = FIRM, FIXED MASS/Swelling, does NOT transilluminate
  • Hydrocele = SMOOTH, SOFT, TRANSILLUMINATES
  • BOTH = painless, unilateral, heaviness
49
Q

What other non-testicular ss may occur if Cancerous Testicular GERM CELLS produce B-HCG?

A
  • 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
Q

Testicular CA will MC spread to _ lymph nodes FIRST

A

RETROPERITONEAL Lymph nodes -> LOW BACK PAIN

Testicles originally come from the abdomen, so that’s why it’s retroperitoneal and NOT inguinal lymph nodes

51
Q

ANY MALE WITH SOLID, FIRM MASS IN THE TESTIS = ______ UNTIL PROVEN OTHERWISE

A

TESTICULAR CA (GERM CELL)

52
Q

Not all testicular CAs are painless, and many are accidentally Dx as ______

A

Epididymitis

53
Q

Testicular CA WU

A

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
Q

When should you Bx sussy Testicular CA?

A

NEVERRRRRRRRRRRRRRRRRRRRRRRRRRRRR

also never Bx ovarian CA

55
Q

Testicular CA Tumor Markers:
- ____ will NEVER be high in Seminomas (type of germ cell CA)

AFP, HCG, LDH?

A

AFP (Alpha Fetoprotein)

56
Q

Testicular CA Tumor Markers -> HCG, LDH, AFP
- Which are HIGH in Seminomas?
- Which are HIGH in NON-seminomas?

A
  • Seminomas = HIGH HCG, LDH
  • NON-Seminomas = HIGH HCG, LDH, AFP
57
Q

Testicular CA Tx

A

Radical inguinal orchiectomy
- remove teste and part of spermatic cord at deep inguinal ring

Non-Seminomas -> +/- Retroperitoneal lymph node dissection (RPLND)

58
Q

Is it chill to use sperm from a cancerous testicle for reproduction?

A

Apparently yes

59
Q

Are monthly self-tesicle exams recommended to monitor for testicular CA?

A

yes, even if “average risk”

60
Q

Sex Cord Stromal Testicular CAs (Sertoli or Leydig cell) have more ______ effects than Germ Cell CA

body system

A

Endocrine

61
Q

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

A
  • 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
Q

DDx?
LOCALIZED, soft round mass in head of the epidiymis, distinct from the testicle. +/- transillumination

A

Epididymal cyst or Spermatocele

benign small fluid collections MC in the head of the epididymis
Spermatoceles are >2cm

63
Q

1 risk factor for epididymal cyst/Spermatocele

A

mom using DES (diethylstilbestrol) during pregnancy

64
Q

epididymal cyst/Spermatocele Tx

A

MONITOR
+/- Excise if large/chronic pain

65
Q

ALL MALES WITH N/V AND MOD/SEVERE ABD PAIN SHOULD GET A ______ EXAM TO R/O ______

A

SCROTAL EXAM
R/O TESTICULAR TORSION

66
Q

WHAT DOES TESTICULAR TORSION LOOK LIKE ON STAT COLOR DOPPLER US?
- Decr or Incr Blood flow?
- ____ sign

A
  • DECREASED/ABSENT BLOOD FLOW OR TWISTING OF THE SPERMATIC CORD
  • +/- WHIRLPOOL SIGN
67
Q

Testicular Torsion -> ____ Hrs until IRREVERSIBLE DAMAGE

A

6

68
Q

Testicular Torsion Tx

A

Sx Bilateral Orchiopexy = Detorsion + FIXATION OF BOTH TESTES

69
Q

Testicular Torsion Tx:
If Sx is not avail urgently, how do you do a MANUAL DETORSION?

A

open the testes like a book!

still need to go to Sx tho! this is just something to do while time passes

70
Q

Torsion of the Appendix Testis
- MC in which age grp?
- SS?
- WU?
- Tx?

A
  • 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

71
Q

MCC of acute scrotal pain in adults

A

Epididymitis & Epididymo-Orchitis

inflammation/Infx of the epididymis
Usu d/t STIs or UTI -> back tracks to epididymis

72
Q

Epididymitis & Epididymo-Orchitis -> MCC pathogens
- MCC Pathogens overall (bac, viral, fungal)?
- MC if <35yo (or >35yo + STI risks)?
- MC if 35yo+?

A
  • MCC overall = BACTERIA
  • MC if <35yo (or men >35 + STI risks) = STI (#1 Chlamydia, Gonorrhea, M. genitalium)
  • MC if 35yo+ = UTI (E. coli)
73
Q

MC Viral ET -> Epididymo-Orchitis

A

Mumps

74
Q

Epididymitis & Epididymo-Orchitis SS

A
  • painful inflamed scrotum, tender epididymis
  • ss over few days
  • MC = UNILATERAL
  • +/- (+) PHREN SIGN - lifting up the scrotum relieves pain
75
Q

Epididymitis & Epididymo-Orchitis Dx

A
  • Clinical Dx
  • Unsure -> Doppler US = **“enlarged epididymis + INCR BLOOD FLOW” **
  • UA + Culture
  • NAAT -> Chlamydia, Gonorrhea
  • <35yo or STI risks -> Syphilis and HIV WU
76
Q

Epididymitis & Epididymo-Orchitis Tx
- <35yo (or STI risk) & NO ANAL
- <35yo (or STI risk) + ANAL
- 35yo+ & NO STI risk ->
- Acutely ILL ->

A
  • <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
Q

pt with Epididymitis & Epididymo-Orchitis. They still appear acutely ill 48Hr after being given IV ABX. Order ____ to r/o ____

A

Scrotal US - r/o ABSCESS

78
Q

If only the testicles are swollen (ORCHITIS) and pt also has swollen parotid glands -> it is likely _______

NO Epididymis involvement is rarer

A

MUMPS
- #1 ET = Viral Infx (MC in peds/YA)
- Tx: Rest, NSAIDs, Ice, Scrotal support

79
Q

Testicular abscess is almost always a complication from _______
- Dx?
- Tx?

A

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
Q

If you see Scrotal Cellulitis or Skin Abscesses -> you must R/O _______ & ______

A
  • Testicular Abscess
  • Fournier Gangrene
81
Q

Fournier Gangrene
- what?
- ET?
- Risk?
- SS?
- Tx?

A
  • 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
Q

Testicular Rupture
- ET:
- SS:
- WU:
- Tx:

A
  • 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

GU (3 decks)

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