Scrotal & penile disorders Flashcards
Accumulation of fluid around the testis
what scrotal disorder is this?
hydrocele
MCC painless scrotal swelling in peds; may occur in adults
what scrotal disorder is this?
hydrocele
what are the 3 noncommunicating hydroceles
- Testicular - around testicle only
- Inguinoscrotal - testicle and inguinal region
- Cord - adjacent to spermatic cord
what is a Communicating hydrocele
- Communicates with peritoneal cavity
- May change during the day, with activity
- Processus vaginalis is patent in:
- >80% of newborns
- 40-50% of 2 year olds
- 25% of adults
- Fluid-filled cystic scrotal mass, anterior to testis
- Has little or no pain
- some scrotal fullness or heaviness
- Exam - no inflammation, nontender
- Transillumination - light shines through fluid
what is this scrotal disorder
hydrocele
+/- scrotal fullness or heaviness
Usually gradual onset
work-up for hydroceles (labs, imaging)
- UA - evaluate for signs of infection (if suspicious)
- US - evaluate for masses, delineate extent of fluid
- Doppler for blood flow - if suspected torsion
tx for hydrocele
- Infantile, asx, noncommunicating
- Physiologic - usually resolve by 18-24 months - 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
what is a common ddx of hydroceles?
inguinal hernia
referral and prevention for hydroceles?
- Referral - if hydrocele is:
- Sudden onset
- Symptomatic
- Or if pt wants tx - Prevention
- Little to directly prevent
- Proper prenatal care, avoidance of injury
Dilated, engorged, tortuous veins within the pampiniform plexus of scrotal veins
what scrotal disorder is this?
Varicocele
“Varicose veins in scrotum”
what scrotal disorder is the Most surgically correctable cause of male infertility
varicocele
varicocele Mc happens on which side of the body? why?
left side
- testicular vein drains into L renal vein instead of IVC
- Unilateral R varicocele - possible IVC obstruction
- scrotal enlargement or heaviness
- some dull aching pain
- May have infertility as initial complaint
- Exam - Dilated veins in scrotal sac - “Bag of Worms”
- Increased with standing, Valsalva
- sometimes improves with supine position
what is this scrotal disorder?
varicocele
May be asx
work-up for varicocele
- Differential - hydrocele, mass, infection, trauma
- Labs - rule out other disorders
- US - can confirm dx
tx for varicocele
- asx → observation
- Conservative → scrotal support, NSAID
- 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
complications and prevention for varicoceles
- Complications - testicular atrophy, infertility
- Prevention
- No clear-cut preventive measures
- Regular TSE - early diagnosis and treatment
Twist in the spermatic cord causing compromised testicular blood supply
what scrotal disorder is this
Testicular Torsion
Surgical/urologic emergency
Testicular Torsion MC happens at what age?
12-18 yr olds
Peaks in neonatal period and early puberty
risk factors for testicular torsion
Trauma
Vigorous exercise or sexual intercourse
Cryptorchidism
Bell-clapper deformity
s/s of testicular torsion
- Sudden onset of severe unilateral scrotal pain and swelling
- +/- lower abdominal pain, N/V
- +/- hx of intermittent similar sx
- Lack of voiding sx
- Classic - high-riding testis, slightly larger than unaffected testis, transverse lie in scrotum
- Often erythematous and tender
- Pain does not relieve with scrotal support (negative Prehn’s sign)
- Cremasteric reflex - absent
work-up for testicular torsion
- Test of choice - doppler US
- If US not available or inconclusive - surgical exploration - UA - rule out infection
- Radionuclide scintigraphy - also can demonstrate low blood flow
tx for testicular torsion
Immediate detorsion and fixation of testes
- 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 - Surgery - detorsion and fixation of involved testis and contralateral testis
- < 6 hrs - salvage rates nearly 100%
- >12 hrs - Irreversible damage, possible testicular loss - Pain relief - narcotics often needed
- Prep for surgery - NPO, CBC/Renal Function, IV access
prevention for testicular torsion
- Avoidance of testicular trauma
- Pre-emptive correction of diseases such as cryptorchidism and bell-clapper deformity
what are the Four testicular appendages
- appendix testis
- appendix epididymis
- paradidymis
- vas aberrans
which one of the testicular appendages is MC affected by torsion? least?
MC - appendix testes (90%)
least - appendix epididymis (8%)
MC in younger patients
s/s of Testicular Appendage Torsion
Similar but less severe < testicular torsion
- Scrotal pain, +/- swelling
- Normal, minimally tender scrotum and testicle on exam
- Might localize tenderness to upper pole of testis / epididymis
- “Blue dot sign”
- Later in course - scrotal edema +/- hydrocele
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?
Testicular Appendage Torsion
tx for Testicular Appendage Torsion
conservative
- Scrotal support, limitation of activity
- Oral analgesics (NSAIDS)
- If unable to r/o testicular torsion - surgery
Contracted foreskin - can’t retract over glans penis
what penile disorder is this
phimosis
MCC of phimosis
Chronic infection from poor local hygiene
phimosis MC happens at what age?
Can occur at any age
- Children < 2-3 yrs - often physiologic
- DM older men - chronic balanoposthitis
s/s of phimosis
- 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
tx for phimosis
- 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)
- Temporary - hemostat dilation, catheter, topical steroids
- Frenar stretch +/- steroids - gradually increase compliance
- Surgical incision - dorsal slit
- Catheter - if urinary retention present
- Circumcision - if recurrent or persistent phimosis or balanitis/balanoposthitis
complications of phimosis
- Preputial calculi
- Dysuria, gross hematuria, foul-smelling discharge, ballooning, calculi
- Tx - calculus removal, incision, circumcision - Squamous cell carcinoma
- asx (other than mass), or similar s/s to calculi
- Bilateral inguinal lymphadenopathy - Others - urine retention, UTI, dyspareunia, painful erection
prevention for phimosis
Proper hygiene of foreskin
Control of systemic conditions
Circumcision
Inability to reduce previously retracted foreskin
what penile disorder is this
paraphimosis
- Fixed in retracted position proximal to corona and glans
- Lymphedema and venous congestion of prepuce → arterial occlusion → necrosis, gangrene, autoamputation
causes of paraphimosis
- Pre-existing phimosis
- Failure to replace foreskin
- Sexual activity, erotic dancing
- Penile trauma
- Plasmodium falciparum
- Forceful retraction (infant foreskin)
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?
paraphimosis
tx for paraphimosis
Emergent urology consult
- Manual reduction - manual pressure on glans for 5 min to reduce edema, then push glans proximally while pulling prepuce distally
- Refractory to manual reduction
- Needle decompression
- Dorsal slit to foreskin
- Osmotic agents - Consider administering abx
- Circumcision - after inflammation has subsided
complications with paraphimosis
penile ischemia, necrosis and gangrene
loss of penile tissue
prevention of paraphimosis
Avoidance of precipitating activities
Proper education on care of foreskin and glans
Treatment of phimosis
Circumcision
Prolonged and painful pathologic erection
what is this penile disorder
priapism
Engorgement of corpora cavernosa with blood
Often not associated with sexual stimulation
causes of priapism
- 60% idiopathic
- MC known cause - intracavernous injection ED tx
- Diseases - leukemia, sickle cell, cancer
- Children - MC hematologic disease, esp sickle cell - Trauma
- meds - anti-HTN, psych meds, oral ED meds
what are the types of priapism
- 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 - 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
s/s of priapism
- High flow - painless prolonged erection
- Low flow - several hrs of painful erection
- Glans penis and corpus spongiosum - soft, uninvolved
- Corpora cavernosa - tense, congested blood, tender to palpation
- Urologic emergency
tx for priapism
- Anesthesia - narcotics; epidural or spinal
- Subcutaneous terbutaline can be used for early tx
- Corporal aspiration of viscous blood with irrigation (plain saline or alpha adrenergic agonists)
- 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
complications and prevention for prirapism
- Complications
- Impotence and permanent damage
- Possible urinary retention - Prevention
- Avoidance of known causative factors and trauma
- Optimal management of comorbid diseases
- Early tx to avoid impotence
- 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
Peyronie’s Disease
causes of Peyronie’s Disease
unclear
- Trauma to penis during intercourse
- Vasculitis and connective tissue disease
- DM and hypercholesterolemia
- Associated with smoking, ETOH, Dupuytren contracture
- Genetic predisposition
- 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?
Peyronie’s Disease
tx for Peyronie’s Disease
- Initially - observation
- Spontaneous remission in about 50% - Oral - vitamin E, para-aminobenzoic acid, colchicine
- Intralesional injection - verapamil, steroids, dimethyl sulfoxide, or PTH
- Radiation therapy
- Surgical - excision of plaque with graft of skin, vein or tunica vaginalis graft; excision of plaque with suturing
- If impotent - penile prosthesis
complications and prevention of peyronie’s disease
- Complications - ED, impotence, psychological
- Prevention
- avoidance of penile trauma
- limit alcohol and tobacco use
- control of comorbidities
what cancer is MC in penile cancer?
squamous cell carcinoma
penile cancer is rare and common where?
rare - developed countries - <1%
common - underdeveloped - 10-20%
MC age for penile cancer
average age at dx 60 yrs, but can be much younger
risk factors for penile cancer
- Chronic infection/inflammation
- HPV - seen in 30-50% of all penile carcinomas
- HIV - increases incidence by 4-8x - Hx of penile injury or urethral stricture
- Hx of phimosis
- Hx of tobacco use
s/s of penile cancer
-
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 - Inguinal LAN - 30-60%
- 50% - malignant infiltration
- 50% - inflammatory reaction to cancer - Metastatic sx - bone pain, cough, skin lesions
how to diagnose penile cancer?
- If s/s of infection (erythema, discharge) - may do 4-6 week trial of abx
- No s/s of infection or if worsening/no improvement with abx - biopsy
- May also do biopsies of inguinal lymphadenopathy - Metastatic sx - bone pain, cough, skin lesions
- CT of chest/abd/pelvis, general lab work/up (CBC, BMP/CMP)
tx for low risk penile cancer recurrence
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
tx for higher risk of recurrence of penile cancer
partial or total penile amputation
- +/- inguinal LN dissection
- May also be treated with chemotherapy and/or radiation
epididymitis is MC at what ages and what are their MCC?
- STD - <40 y
- Associated with urethritis
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Non-STD - 40+
- Associated with UTI, prostatitis
- G- rods (E. coli, Proteus, Klebsiella)
s/s of epididymitis
- May present after physical strain, trauma, or sex
- +/- urethritis, prostatitis or cystitis symptoms
- Fever
- 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 - +/- reactive hydrocele
- +/- inguinal LAN
- May see positive Prehn’s sign
work-up for epididymitis
- UA - pyuria, bacteriuria, hematuria, culture
- Urethral swab
- Gonorrhea - G- intracellular diplococci
- Chlamydia - WBC without visible organisms - PCR for gonorrhea/chlamydia
- CBC - leukocytosis and left shift
- ESR/CRP - may be increased
complications with epididymitis
- Infectious - orchitis, chronic epididymitis, sepsis, abscess
- Long-term - fibroplasia, decreased fertility
tx for epididymitis
- Bed rest, scrotal elevation, ice packs
- Analgesics (NSAIDs)
- abx
- Empiric - ceftriaxone + doxycycline
- Unlikely to be STD
— levofloxacin
— TMP-SMZ DS - Improvement within 3 d, resolution 2-4 wks
prevention for epididymitis
Prompt treatment of prostatitis, UTI, urethritis
Safe sex practices
Treatment of partners with STIs
Minimize use of foley catheters
Inflammation/infection of testis
what is this GU infection
Orchitis
Usually occurs with other illness
causes of orchitis
- Bacterial - usually complication of epididymitis
- Granulomatous - autoimmune response to sperm
- Viral - M/C mumps; also EBV, coxsackie, VZV, echovirus
s/s of orchitis
- Swelling, tenderness and erythema of testis
- +/- urethritis, cystitis, prostatitis, epididymitis
- +/- reactive hydrocele - Scrotal pain
- More gradual onset and less severe than torsion
- May have (+) Prehn’s sign - Fever, +/- nausea and vomiting
- May have malaise, rsp sx, parotid swelling
- +/- inguinal LAN
work up for orchitis
- UA - pyuria, bacteriuria, hematuria, culture
- Urethral swab
- Gonorrhea - G- intracellular diplococci
- Chlamydia - WBC without visible organisms - PCR for gonorrhea/chlamydia
- CBC - leukocytosis and left shift
- ESR/CRP - may be increased
tx for orchitis
- Bed rest, scrotal elevation, ice packs
- Analgesics (NSAIDs)
- abx
- Empiric - ceftriaxone + doxycycline
- Men practicing insertive anal sex - ceftriaxone + levofloxacin
- Unlikely to be STD - levofloxacin - Viral - supportive
complications and prevention with orchitis
- complications
- Infectious - sepsis, abscess formation
- Long-term - fibroplasia, decreased fertility, testicular atrophy
- Prevention
- Prompt treatment of UTIs - prostatitis, cystitis, urethritis, epididymitis
- Safe sex practices
- Tx of partners with STDs
- Minimize use of foley catheters
- Vaccination
3 types of scrotal masses
Hydrocele, Spermatocele, Epididymal Cyst
presentation and tx for epididymal cyst
head of epididymis
- asx
- Associated with DES use during pregnancy and Von Hippel-Lindau disease
- Noted on exam - US can assist diagnosis
- No specific tx needed
presentation and tx of Scrotal Masses
- Spermatocele - epididymal cyst >2 cm (2-5 cm)
- Superior to and distinct from testis - Rarely symptomatic; may be painful
- US - can assist diagnosis
- tx - observation
- Surgical excision
Cancer is MCC solid testicular tumor in men at what ages?
18-40
- MC cancer males 20-35
- 90-95% are germ cell tumors
factors of testicular tumors
- Cryptorchidism
- ~10% cancer is in pts with + hx
- Corrective surgery does not change CA risk - Exogenous estrogen during pregnancy
- Infertility
- FHx, HIV, ethnicity
- MC in whites
- later dx and ￪ death in other ethnicities - Questionable - trauma, infection-related atrophy, high fat diet
s/s of testicular tumors
- Usually a 3-6 mo delay to treatment
- MC sx - painless enlargement of testis
- Testicular or scrotal heaviness
- Painless nodule on testicle - Acute testicular pain - 10%
- 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) - asx - 10%
work-up for testicular tumors
- Labs
- Alpha-fetoprotein (AFP), hCG, LDH
- Advanced - anemia, LFTs, renal function - 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
tx for testicular tumors
- Inguinal exploration with vascular control of spermatic cord
- If CA not excluded by examination, orchiectomy - Radical inguinal orchiectomy
- Radiation/chemo depends on subtype
f/u for testicular tumors
- Monthly for 1st 2 years, bimonthly 3rd year
- Tumor markers at each visit
- CXR and CT every 3 months
- 80% relapse in 1st 2 yrs after treatment
prognosis of testicular tumors
- Most - 90% + 5 year survival rates
- Disseminated or bulky (> 10 cm) retroperitoneal disease - 55-80%
