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GU: Clin Med IIA > Scrotal & penile disorders > Flashcards

Scrotal & penile disorders Flashcards

1
Q

Accumulation of fluid around the testis
what scrotal disorder is this?

A

hydrocele

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2
Q

MCC painless scrotal swelling in peds; may occur in adults
what scrotal disorder is this?

A

hydrocele

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3
Q

what are the 3 noncommunicating hydroceles

A
  1. Testicular - around testicle only
  2. Inguinoscrotal - testicle and inguinal region
  3. Cord - adjacent to spermatic cord
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4
Q

what is a Communicating hydrocele

A
  1. Communicates with peritoneal cavity
  2. May change during the day, with activity
  3. Processus vaginalis is patent in:
    - >80% of newborns
    - 40-50% of 2 year olds
    - 25% of adults
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5
Q
  1. Fluid-filled cystic scrotal mass, anterior to testis
  2. Has little or no pain
  3. some scrotal fullness or heaviness
  4. Exam - no inflammation, nontender
    - Transillumination - light shines through fluid

what is this scrotal disorder

A

hydrocele

+/- scrotal fullness or heaviness
Usually gradual onset

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6
Q

work-up for hydroceles (labs, imaging)

A
  1. UA - evaluate for signs of infection (if suspicious)
  2. US - evaluate for masses, delineate extent of fluid
    - Doppler for blood flow - if suspected torsion
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7
Q

tx for hydrocele

A
  1. Infantile, asx, noncommunicating
    - Physiologic - usually resolve by 18-24 months
  2. Tx - if persist >12-18 mo, communicating, or sx
    - can grow if not treated
    - r/o underlying causes and correct
    - Acute (sudden onset) - do not consider benign
    - Needle aspiration - < invasive, high rate of recurrence
    — +/- sclerotherapy to tunica vaginalis
    - Hydrocelectomy
    — Definitive tx - excision of hydrocele sac
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8
Q

what is a common ddx of hydroceles?

A

inguinal hernia

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9
Q

referral and prevention for hydroceles?

A
  1. Referral - if hydrocele is:
    - Sudden onset
    - Symptomatic
    - Or if pt wants tx
  2. Prevention
    - Little to directly prevent
    - Proper prenatal care, avoidance of injury
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10
Q

Dilated, engorged, tortuous veins within the pampiniform plexus of scrotal veins

what scrotal disorder is this?

A

Varicocele
“Varicose veins in scrotum”

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11
Q

what scrotal disorder is the Most surgically correctable cause of male infertility

A

varicocele

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12
Q

varicocele Mc happens on which side of the body? why?

A

left side

  1. testicular vein drains into L renal vein instead of IVC
  2. Unilateral R varicocele - possible IVC obstruction
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13
Q
  1. scrotal enlargement or heaviness
  2. some dull aching pain
  3. May have infertility as initial complaint
  4. Exam - Dilated veins in scrotal sac - “Bag of Worms”
    - Increased with standing, Valsalva
    - sometimes improves with supine position

what is this scrotal disorder?

A

varicocele

May be asx

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14
Q

work-up for varicocele

A
  • Differential - hydrocele, mass, infection, trauma
  • Labs - rule out other disorders
  • US - can confirm dx
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15
Q

tx for varicocele

A
  1. asx → observation
  2. Conservative → scrotal support, NSAID
  3. Surgical tx - severe s/s or desiring fertility
    - Occlusion (balloon) or embolization of spermatic vein
    - Injected ablation (sclerotherapy) of spermatic vein
    - Surgical ligation of pampiniform plexus
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16
Q

complications and prevention for varicoceles

A
  1. Complications - testicular atrophy, infertility
  2. Prevention
    - No clear-cut preventive measures
    - Regular TSE - early diagnosis and treatment
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17
Q

Twist in the spermatic cord causing compromised testicular blood supply

what scrotal disorder is this

A

Testicular Torsion
Surgical/urologic emergency

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18
Q

Testicular Torsion MC happens at what age?

A

12-18 yr olds
Peaks in neonatal period and early puberty

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19
Q

risk factors for testicular torsion

A

Trauma
Vigorous exercise or sexual intercourse
Cryptorchidism
Bell-clapper deformity

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20
Q

s/s of testicular torsion

A
  1. Sudden onset of severe unilateral scrotal pain and swelling
  2. +/- lower abdominal pain, N/V
  3. +/- hx of intermittent similar sx
  4. Lack of voiding sx
  5. Classic - high-riding testis, slightly larger than unaffected testis, transverse lie in scrotum
  6. Often erythematous and tender
  7. Pain does not relieve with scrotal support (negative Prehn’s sign)
  8. Cremasteric reflex - absent
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21
Q

work-up for testicular torsion

A
  1. Test of choice - doppler US
    - If US not available or inconclusive - surgical exploration
  2. UA - rule out infection
  3. Radionuclide scintigraphy - also can demonstrate low blood flow
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22
Q

tx for testicular torsion

A

Immediate detorsion and fixation of testes

  1. Manual - “opening book” motion - temporary fix
    - Anesthesia (local, IV opioid, or sedation)
    - 180 - 720 degrees of detorsion needed
    - ⅓ of pts actually need detorsion in the
    lateral-to-medial direction
    - Success → pain relief, lowering of testis,
    doppler US normal
    - Still requires permanent surgical fixation
  2. Surgery - detorsion and fixation of involved testis and contralateral testis
    - < 6 hrs - salvage rates nearly 100%
    - >12 hrs - Irreversible damage, possible testicular loss
  3. Pain relief - narcotics often needed
  4. Prep for surgery - NPO, CBC/Renal Function, IV access
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23
Q

prevention for testicular torsion

A
  1. Avoidance of testicular trauma
  2. Pre-emptive correction of diseases such as cryptorchidism and bell-clapper deformity
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24
Q

what are the Four testicular appendages

A
  1. appendix testis
  2. appendix epididymis
  3. paradidymis
  4. vas aberrans
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25
Q

which one of the testicular appendages is MC affected by torsion? least?

A

MC - appendix testes (90%)
least - appendix epididymis (8%)

MC in younger patients

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26
Q

s/s of Testicular Appendage Torsion

A

Similar but less severe < testicular torsion

  1. Scrotal pain, +/- swelling
  2. Normal, minimally tender scrotum and testicle on exam
  3. Might localize tenderness to upper pole of testis / epididymis
  4. “Blue dot sign”
  5. Later in course - scrotal edema +/- hydrocele
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27
Q

during an US of the scrotum it showed a normal testicular blood flow with a small hyperechoic region adjacent to testis

what could this possibly be?

A

Testicular Appendage Torsion

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28
Q

tx for Testicular Appendage Torsion

A

conservative

  • Scrotal support, limitation of activity
  • Oral analgesics (NSAIDS)
  • If unable to r/o testicular torsion - surgery
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29
Q

Contracted foreskin - can’t retract over glans penis

what penile disorder is this

A

phimosis

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30
Q

MCC of phimosis

A

Chronic infection from poor local hygiene

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31
Q

phimosis MC happens at what age?

A

Can occur at any age

  • Children < 2-3 yrs - often physiologic
  • DM older men - chronic balanoposthitis
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32
Q

s/s of phimosis

A
  • asx other than inability to retract foreskin
  • Edema, erythema and tenderness of prepuce or purulent discharge if infected
  • “Ballooning” of prepuce during urination
  • Only emergent if urinary retention
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33
Q

tx for phimosis

A
  1. Treat infection if present
  • Fungal → topical clotrimazole or nystatin or oral fluconazole
  • Bacterial → topical bacitracin, oral metronidazole (Flagyl)
  • Cellulitis or extends to shaft → cephalexin (Keflex)
  1. Temporary - hemostat dilation, catheter, topical steroids
  • Frenar stretch +/- steroids - gradually increase compliance
  • Surgical incision - dorsal slit
  • Catheter - if urinary retention present
  1. Circumcision - if recurrent or persistent phimosis or balanitis/balanoposthitis
34
Q

complications of phimosis

A
  1. Preputial calculi
    - Dysuria, gross hematuria, foul-smelling discharge, ballooning, calculi
    - Tx - calculus removal, incision, circumcision
  2. Squamous cell carcinoma
    - asx (other than mass), or similar s/s to calculi
    - Bilateral inguinal lymphadenopathy
  3. Others - urine retention, UTI, dyspareunia, painful erection
35
Q

prevention for phimosis

A

Proper hygiene of foreskin
Control of systemic conditions
Circumcision

36
Q

Inability to reduce previously retracted foreskin

what penile disorder is this

A

paraphimosis

  • Fixed in retracted position proximal to corona and glans
  • Lymphedema and venous congestion of prepuce → arterial occlusion → necrosis, gangrene, autoamputation
37
Q

causes of paraphimosis

A
  • Pre-existing phimosis
  • Failure to replace foreskin
  • Sexual activity, erotic dancing
  • Penile trauma
  • Plasmodium falciparum
  • Forceful retraction (infant foreskin)
38
Q

Swollen, erythematous, tender foreskin proximal to glans
“Donut sign”
Swollen, erythematous, tender glans; may be necrotic
Flaccid penis proximal to foreskin

these s/s are of what penile disorder?

A

paraphimosis

39
Q

tx for paraphimosis

A

Emergent urology consult

  • Manual reduction - manual pressure on glans for 5 min to reduce edema, then push glans proximally while pulling prepuce distally
  1. Refractory to manual reduction
    - Needle decompression
    - Dorsal slit to foreskin
    - Osmotic agents
  2. Consider administering abx
  3. Circumcision - after inflammation has subsided
40
Q

complications with paraphimosis

A

penile ischemia, necrosis and gangrene
loss of penile tissue

41
Q

prevention of paraphimosis

A

Avoidance of precipitating activities
Proper education on care of foreskin and glans
Treatment of phimosis
Circumcision

42
Q

Prolonged and painful pathologic erection

what is this penile disorder

A

priapism

Engorgement of corpora cavernosa with blood
Often not associated with sexual stimulation

43
Q

causes of priapism

A
  1. 60% idiopathic
  2. MC known cause - intracavernous injection ED tx
  3. Diseases - leukemia, sickle cell, cancer
    - Children - MC hematologic disease, esp sickle cell
  4. Trauma
  5. meds - anti-HTN, psych meds, oral ED meds
44
Q

what are the types of priapism

A
  1. High flow (nonischemic) - rare, often painless
    - Trauma to perineum → loss of penile arterial regulation
    - Doppler US of penis - aneurysms of central arteries
    - Aspirated blood → high O2, low CO2
    - tx with embolization of aneurysms
  2. Low flow (ischemic) - MC, painful
    - Aspiration of dark acidic low CO2 intracavernosal blood from corpus cavernosum
    - Physiologic obstruction of venous drainage
    - Prolonged → interstitial edema and fibrosis of corpora cavernosa → impotence
45
Q

s/s of priapism

A
  1. High flow - painless prolonged erection
  2. Low flow - several hrs of painful erection
    - Glans penis and corpus spongiosum - soft, uninvolved
    - Corpora cavernosa - tense, congested blood, tender to palpation
    - Urologic emergency
46
Q

tx for priapism

A
  1. Anesthesia - narcotics; epidural or spinal
  2. Subcutaneous terbutaline can be used for early tx
  3. Corporal aspiration of viscous blood with irrigation (plain saline or alpha adrenergic agonists)
  4. Refractory priapism
    - Winter procedure - needle through glans into corpora → fistula between corpora cavernosa and corpus spongiosum
    - Excision of tunica albuginea
    - Cavernosa-spongiosum shunt
    - Saphenous vein-cavernous shunt
47
Q

complications and prevention for prirapism

A
  1. Complications
    - Impotence and permanent damage
    - Possible urinary retention
  2. Prevention
    - Avoidance of known causative factors and trauma
    - Optimal management of comorbid diseases
    - Early tx to avoid impotence
48
Q
  • Fibrosis of dorsal covering sheaths
  • Does not permit involved area to lengthen with erection → curved penis when erect
  • MC middle-aged and older men

what is this penile disorder

A

Peyronie’s Disease

49
Q

causes of Peyronie’s Disease

A

unclear

  • Trauma to penis during intercourse
  • Vasculitis and connective tissue disease
  • DM and hypercholesterolemia
  • Associated with smoking, ETOH, Dupuytren contracture
  • Genetic predisposition
50
Q
  • Painful erection, penile curvature
  • Poor erection distal to curved area
  • Usually no pain without an erection
  • PE - raised, firm plaque to dorsal penis, often midline

these s/s are indicative of what penile disorder?

A

Peyronie’s Disease

51
Q

tx for Peyronie’s Disease

A
  1. Initially - observation
    - Spontaneous remission in about 50%
  2. Oral - vitamin E, para-aminobenzoic acid, colchicine
  3. Intralesional injection - verapamil, steroids, dimethyl sulfoxide, or PTH
  4. Radiation therapy
  5. Surgical - excision of plaque with graft of skin, vein or tunica vaginalis graft; excision of plaque with suturing
    - If impotent - penile prosthesis
52
Q

complications and prevention of peyronie’s disease

A
  1. Complications - ED, impotence, psychological
  2. Prevention
    - avoidance of penile trauma
    - limit alcohol and tobacco use
    - control of comorbidities
53
Q

what cancer is MC in penile cancer?

A

squamous cell carcinoma

54
Q

penile cancer is rare and common where?

A

rare - developed countries - <1%
common - underdeveloped - 10-20%

55
Q

MC age for penile cancer

A

average age at dx 60 yrs, but can be much younger

56
Q

risk factors for penile cancer

A
  1. Chronic infection/inflammation
    - HPV - seen in 30-50% of all penile carcinomas
    - HIV - increases incidence by 4-8x
  2. Hx of penile injury or urethral stricture
  3. Hx of phimosis
  4. Hx of tobacco use
57
Q

s/s of penile cancer

A
  1. MC - skin abnormality or palpable lesion on penis
    - 25% - painless lump, 13% - ulcer, 6% - rash
    - Usually seen on glans, in coronal sulcus, or on prepuce
  2. Inguinal LAN - 30-60%
    - 50% - malignant infiltration
    - 50% - inflammatory reaction to cancer
  3. Metastatic sx - bone pain, cough, skin lesions
58
Q

how to diagnose penile cancer?

A
  1. If s/s of infection (erythema, discharge) - may do 4-6 week trial of abx
  2. No s/s of infection or if worsening/no improvement with abx - biopsy
    - May also do biopsies of inguinal lymphadenopathy
  3. Metastatic sx - bone pain, cough, skin lesions
    - CT of chest/abd/pelvis, general lab work/up (CBC, BMP/CMP)
59
Q

tx for low risk penile cancer recurrence

A

limited excision

  • Minimally invasive tumors
  • Goal is to preserve as much anatomy and function of the penis as possible
  • Laser therapy, topical therapy, and radiation may also be used
60
Q

tx for higher risk of recurrence of penile cancer

A

partial or total penile amputation

  • +/- inguinal LN dissection
  • May also be treated with chemotherapy and/or radiation
61
Q

epididymitis is MC at what ages and what are their MCC?

A
  1. STD - <40 y
  • Associated with urethritis
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  1. Non-STD - 40+
  • Associated with UTI, prostatitis
  • G- rods (E. coli, Proteus, Klebsiella)
62
Q

s/s of epididymitis

A
  1. May present after physical strain, trauma, or sex
  2. +/- urethritis, prostatitis or cystitis symptoms
  3. Fever
  4. Pain and swelling in scrotum - may radiate
    - Early - testicle normal or minimally tender and epididymis is tender and palpable
    - Late - may be hard to distinguish from testis
  5. +/- reactive hydrocele
  6. +/- inguinal LAN
  7. May see positive Prehn’s sign
63
Q

work-up for epididymitis

A
  1. UA - pyuria, bacteriuria, hematuria, culture
  2. Urethral swab
    - Gonorrhea - G- intracellular diplococci
    - Chlamydia - WBC without visible organisms
  3. PCR for gonorrhea/chlamydia
  4. CBC - leukocytosis and left shift
  5. ESR/CRP - may be increased
64
Q

complications with epididymitis

A
  1. Infectious - orchitis, chronic epididymitis, sepsis, abscess
  2. Long-term - fibroplasia, decreased fertility
65
Q

tx for epididymitis

A
  1. Bed rest, scrotal elevation, ice packs
  2. Analgesics (NSAIDs)
  3. abx
    - Empiric - ceftriaxone + doxycycline
    - Unlikely to be STD
    — levofloxacin
    — TMP-SMZ DS
  4. Improvement within 3 d, resolution 2-4 wks
66
Q

prevention for epididymitis

A

Prompt treatment of prostatitis, UTI, urethritis
Safe sex practices
Treatment of partners with STIs
Minimize use of foley catheters

67
Q

Inflammation/infection of testis

what is this GU infection

A

Orchitis

Usually occurs with other illness

68
Q

causes of orchitis

A
  1. Bacterial - usually complication of epididymitis
  2. Granulomatous - autoimmune response to sperm
  3. Viral - M/C mumps; also EBV, coxsackie, VZV, echovirus
69
Q

s/s of orchitis

A
  1. Swelling, tenderness and erythema of testis
    - +/- urethritis, cystitis, prostatitis, epididymitis
    - +/- reactive hydrocele
  2. Scrotal pain
    - More gradual onset and less severe than torsion
    - May have (+) Prehn’s sign
  3. Fever, +/- nausea and vomiting
    - May have malaise, rsp sx, parotid swelling
    - +/- inguinal LAN
70
Q

work up for orchitis

A
  1. UA - pyuria, bacteriuria, hematuria, culture
  2. Urethral swab
    - Gonorrhea - G- intracellular diplococci
    - Chlamydia - WBC without visible organisms
  3. PCR for gonorrhea/chlamydia
  4. CBC - leukocytosis and left shift
  5. ESR/CRP - may be increased
71
Q

tx for orchitis

A
  1. Bed rest, scrotal elevation, ice packs
  2. Analgesics (NSAIDs)
  3. abx
    - Empiric - ceftriaxone + doxycycline
    - Men practicing insertive anal sex - ceftriaxone + levofloxacin
    - Unlikely to be STD - levofloxacin
  4. Viral - supportive
72
Q

complications and prevention with orchitis

A
  1. complications
  • Infectious - sepsis, abscess formation
  • Long-term - fibroplasia, decreased fertility, testicular atrophy
  1. Prevention
  • Prompt treatment of UTIs - prostatitis, cystitis, urethritis, epididymitis
  • Safe sex practices
  • Tx of partners with STDs
  • Minimize use of foley catheters
  • Vaccination
73
Q

3 types of scrotal masses

A

Hydrocele, Spermatocele, Epididymal Cyst

74
Q

presentation and tx for epididymal cyst

A

head of epididymis

  1. asx
  2. Associated with DES use during pregnancy and Von Hippel-Lindau disease
  3. Noted on exam - US can assist diagnosis
  4. No specific tx needed
75
Q

presentation and tx of Scrotal Masses

A
  1. Spermatocele - epididymal cyst >2 cm (2-5 cm)
    - Superior to and distinct from testis
  2. Rarely symptomatic; may be painful
  3. US - can assist diagnosis
  4. tx - observation
    - Surgical excision
76
Q

Cancer is MCC solid testicular tumor in men at what ages?

A

18-40

  • MC cancer males 20-35
  • 90-95% are germ cell tumors
77
Q

factors of testicular tumors

A
  1. Cryptorchidism
    - ~10% cancer is in pts with + hx
    - Corrective surgery does not change CA risk
  2. Exogenous estrogen during pregnancy
  3. Infertility
  4. FHx, HIV, ethnicity
    - MC in whites
    - later dx and ￪ death in other ethnicities
  5. Questionable - trauma, infection-related atrophy, high fat diet
78
Q

s/s of testicular tumors

A
  1. Usually a 3-6 mo delay to treatment
  2. MC sx - painless enlargement of testis
    - Testicular or scrotal heaviness
    - Painless nodule on testicle
  3. Acute testicular pain - 10%
  4. Metastatic sx - 10%
    - MC site of metastasis - retroperitoneal abd LN
    - Back pain (retroperitoneal)
    - Cough/dyspnea (pulmonary)
    - Anorexia, N/V (retroduodenal)
    - Bone pain (skeletal)
    - LE swelling (IVC obstruction)
  5. asx - 10%
79
Q

work-up for testicular tumors

A
  1. Labs
    - Alpha-fetoprotein (AFP), hCG, LDH
    - Advanced - anemia, LFTs, renal function
  2. Imaging and Diagnosis
    - Scrotal US - initial evaluation
    — After dx - staging with CT of abdomen/pelvis, CXR
    - Definitive dx - radical inguinal orchiectomy
    — Transscrotal bx is contraindicated
80
Q

tx for testicular tumors

A
  1. Inguinal exploration with vascular control of spermatic cord
    - If CA not excluded by examination, orchiectomy
  2. Radical inguinal orchiectomy
  3. Radiation/chemo depends on subtype
81
Q

f/u for testicular tumors

A
  1. Monthly for 1st 2 years, bimonthly 3rd year
  2. Tumor markers at each visit
  3. CXR and CT every 3 months
  4. 80% relapse in 1st 2 yrs after treatment
82
Q

prognosis of testicular tumors

A
  1. Most - 90% + 5 year survival rates
  2. Disseminated or bulky (> 10 cm) retroperitoneal disease - 55-80%

GU: Clin Med IIA (13 decks)

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