scrotal & testicular disorders Flashcards
what is the prehn sign
lifting the scrotum improves the pain
condition? dx? treatment?
- rotation of testicle around spermatic cord that constricts the testicular artery & cause ischemia
- RF: cryptorchidism, genetic defects like bell clapper deformity; most times no risk factors
- acute onset, severe unilateral scrotal pain +/- edema, N/V
- firm tender high-riding horizontal lie of testicle in shortened spermatic cord; epididymis not posterior to testis
- absent cremasteric reflex & absent prehn sign
testicular torsion
dx– suspicion, color US, emergent referral
tx: emergent bilateral orchiopexy or manual detorsion if tx delayed before surgery
condition? dx? tx?
- testicular appendix twisted causing acute unilateral testicular pain
- pain localized in upper pole of testicle (makes it different from other condition)
- appendix testis torsion
- dx- blue dot sign (blue nodule in upper scrotum), US to r/o testicular torsion or epididymitis
- tx: conservative– NSAID, bed rest
condition? labs? imaging? tx (3)?
- inflammation of epididymitis (& testis)
- most common cause of acute scrotum
- mostly d/t bacterial infefction (also viral, fungual and non-infectious)
- presents similar to testicular torsion but pain is progressive or gradual; indurated, tender or swollen epidiymis
- (+) positive cremasteric reflex will help r/o torsion.
epididymitis & epididymo-orchitis
Labs– get UA & C/S, STI screening, WBC
imaging: increased blood flow on US
tx: “RICE” + NSAIDs + Abx
most common cause of epididymitis & epididymoorchitis in UNDER 35? how is it treated?
STI– chlamydia & gonorrhea
tx: Ceftriaxone 250 mg IM + doxy 100 mg PO BID x 10 days OR azithromycin 1g PO
tx partners!
most common cause of epididymitis & epididymoorchitis in OVER 35?
- URI or bladder stasis secondary to bladder outlet obstruction(BOO)– ecoli, pseudo, gram pos cocci
- tx: cipro 500 mg BID or levofloxacin 500mg x 10 days; TMP-SMX if allergy
if someone has anal intercourse hx with epididymitis & epididymoorchitis, how would you treat
ceftriaxone 250 mg IM + levofloxacin 500 mg x 10 days
after treating epididymitis & epididymoorchitis, what gets resolved?
- swelling w/in 3 days but pain may be chronic– REFER TO UROLOGY
condition? dx? tx?
- necrotizing fascitis of male genitalia and perineum; life threatening
- pain, swelling, erythema of scrotal skin; skin necrosis, hemorrhagic bullae, sx of septic shock; crepitus from gas producing bacteria; probably no urinary sx
- RF: obesity, DM, chronic indwelling catheters, EtOH, IVDU, immunocompromised
- Ecoli is most common pathogen
fournier’s gangrene
CT pelvis– gas in scrotum/perineum
IV ampicillin or clindamycin; C/S to guide tx; emergent surgical debridement
- protrusion in inguinal canal d/t fascial defect, mostly in males
- variable presentation- no sx/benign to life threatening and painful)
- groin pain/pressure, swelling, will not transilluminate
- if incarcerated can cause ischemia and bowel death
inguinal hernia
examine pt in standing position!
US can distinguis from scrotal masse
tx: observe if reducible, emergent if irreducible
- inguinal hernia lateral to inferior epigastric vessels to enter deep inguinal ring; most common time
- congenial patency of processus vaginalis; mostly pediatric
- worse with lifting
- turn head & cough– hernia touches TIP of finger
indirect inguinal hernia
- inguinal hernia medial to inferior epigastric vessels
- acquired– heavy lifting
- turn head & cough– hernia touches MEDIAL to finger
direct inguinal hernia
condition? tx?
irreducible trapped hernias with high risk of impaired blood supply
may have fever, N/V, pain, hernia erythemia
incarcerated hernia
surgery
important mimic to inguinal hernia; an inguinal/paratesticular mass
liposarcoma
what is this? what is the most common type? workup?
- most common malignancy in males 15-35 yo; “young mans cancer”
- RF: cryptorchidism, HIV, fam hx, genetic d/o of testicular dev (Klinefelter), testicular feminization over 30 yo
- painless, firm, fixed mass “rock” IN the testicle; typically NOT acute
testicular cancer
most common is germ cell– seminoma & non-seminoma
check for LAD in P.E; scrotal doppler US as initial study (urgent referral to urology if anything sus)
these are what type of testicular cancer?
- embyonal carcinoma
- yolk sac
- choriocarcinoma
- teratoma
- mixed germ cell
non-seminoma germ cell
4 tx of testis cancer
- radical INGUINAL orchiectomy
- cyropreservation (sperm banking)
- +/- retroperitoneal lymph node dissection (RPLND)
- +/- chemo or radiation
what is this? how is it diagnosed?
undescended testicle
increased risk for testis cancer, infertility, torsion, psychological
cryptorchidism
dx: US/CT
true types: abdominal , inguinal & suprascrotal
condition? labs (3)? imaging (1)? tx (3)?
- peritoneal fluid accumulation w/in processus vaginalis (mostly in tunica) surrounding testicle & cord
- common in new borns; multiple etiologies
- can rarely harbor a tumor
- PE shows edematous, fluctuant scrotum; transillumination
hydrocele
labs: UA, CBC, semen analysis
tx: observe, aspirate +/- sclerotherapy w/ doxy or alcohol, hydrocelectomy
- dilation of the pampiniform plexus resulting in blood pooling in veins; most common cause of male infertility worldwide
- mostly bilateral; 20% in post pubertal males
- inguinal or scrotal pain, infertility, testicular atrophy; bag of worms
- L side is more common- dull ache
- R side rapid onset or is irreducible in supine position- worrisome
varicocele
US– > 3mm; reverse flow w/ valsalva
tx: observe, varicocelectomy/ligation, embolization +/- sclerotherapy
if not having pain, can still treat it because it could affect fertility
– check sperm counts to see if thats a concern at that time
why are R varicocele more worrisome? what should you get if its that side?
the R gonadal veins drain directly into IVC; possible retroperitoneal pathology as cause of spermatic vein compression
R side requires CT abdomen to r/o!
Gr 1 vs 2 vs 3 of varicoceles
1: palpable w/ valsalva only
2: w/o valsalva
3: visible
condition? tx (3)?
- retention cyst of epididymis (superior & posterior to testis)
- traveling sperm blocks efferent ducts leading to epididymis that forms diverticulum
- **growing painless mass (smooth, spherical, transilluminates); mostly no sx but can be issue as it grows
spermatocele
tx: observation, aspiration +/- sclerotherapy, spermatocelectomy
