Scrotal & Testicular Disorders Flashcards
Describe conditions that may produce acute scrotal pain or swelling?
- Testicular torsion
- torsion of testicular appendices
- epidiymitis
- orchitis
- testicular tumor
- scrotal trauma
- hernia
- fournier’s gangrene
non-acute scrotum masses
- varicocele
- hydrocele
- spermatocele
- epididymal cyst
- early stage testicular cancer
- urological emergency= Emergent urology consult
- rotation of the testicle along its vertical axis around the spermatic cord can constric the testicular artery and cause ischemia
- risk factors: Cryptochidism, genetic structural defects such a “bell clapper deformity (tunica vaginalis covers the entire testicle and epididymis, preventing fixation to the posterior wall and causing the testicle to rotate freely
Testicular torsion
signs and symptoms of testicular torsion
- acute onset; severe, unilateral scrotal pain +/- edema, N/V
- possible history of previous intermittent torsion
- firm tender, high-riding horizontal lie of testicle from the shortened spermatic cord
- absent cremasteric reflex (does not raise)
- absent prehn sign (pain does not improve)
- epididymis is not posterior to the testis
- can be intermittent and spontaneously resolve
diagnosis and treatment of testicular torsion
- clinical suspicion, mostly a diagnosis based on exam
- imaging: Color Doppler ultrasound- preferred initial diagnostic test
- Surgery is the definitive treatment
Treatment
- emergent bilateral orchiopexy
- if treatment delayed- attempt manuel detorsion (twist affected testicle in outward motion)
- pain is localized in the upper pole of the testicle
- acute unilateral testicular pain
- diagnosis: blue dot sign, a nodule with blue discoloration in the upper scrotum, especially in light skinned pts.
- ultrasound is useful to rule out concurrent testicular torsion or epididymitis
- tx: conservative: NSAID and bed rest if dx can not be made with confidence, surgical intervention may be necessary
Appendix testis
- inflammation of the epididymis or epididymo-orchitis
- most common cause of acute scrotum
- etiology: infectious most common bacterial (most common)
- < 35 y/o most common causes are chlamydia trichromatic and Neisseria gonorrhea
- > 35 y/o: most common cause of epididymitis is UTI or bladder stasis secondary to BOO, which may present in combo with prostatitis (e. coli, psedomonas, and gram + cocci)
- anal intercourse history- consider coliform bacteria from the rectum
Noninfectious- malignancy, trauma, chemical
Epidiymitis & epididymoorchitis
diagnosis of epididymitis & epididymo-orchiits
diagnosis
- the clinical presentation is similar to testicular torsion- unilateral scrotal pain, erythema, and edema; however, the onset of pain is usually progressive or gradual, not acute
- positive cremasteric reflex
- indurated, tender, or swollen epididymis
- labs: UA & urine C/S (pyuria/bacteriuria); STI screening (urethral swab PCR vs urine) WBC- leukocytosis, elevated CRP/ESR
How can you distinguis epididymitis from testicular torsion via ultrasound?
- increased blood flow/ hyperemia to the epididymis
treatment of epididymitis & epididymo-orchitis?
- RICE + NSAIDs + antibotics based on most likely etiology
- < 35 y/o ceftriaxone 250mg IM + doxycycline 100mg PO bid x 10d or azithromycin 1g PO
- > 35y/o cipro 500mg bid x 10d or levofloxacin 500mg x 10d; TMP-SMX if allergy
- if anal intercourse- ceftriaxone 250mg IM + levofloxacin 500mg x 10 days
- septic presentation –> admit for IV antibiotics
swelling typically improves within 3 days, pain may linger weeks/mon
- necrotizing fasciitis of male genitalia and perineum
- life threatening urological emergency
- pain, swelling and erythema of the scrotal skin and surrounding affected areas; those with more severe infection will have skin necrosis, hemorrhagic bullae and symptoms of septic shock
- crepitus from gas producing bacteria
- pathogens include e.coli (most common) streptococcus pyogenes, staph aureus and MRSA
Fournier’s gangrene
risk factors and treatment for fournier’s gangrene?
Risk factors:
Obesity, DM, chronic indwelling catheters
EtOH, IV drug users
immunocompromise (HIV, immunosuppressants, chemo, surgical pts)
Treatment
- IV ampicillin or clindamycin. A gram stain and C&S-to guide therapy, emergent surgical debridement is crucial to explore the extent of necrosis and debride affected sites to limit extent
- protrusion in the inguinal canal due to fascial defect
- variable presentation (asymptomatic/benign to life-threatening and painful. incarcerated=ischemia= bowel death
inguinal hernia
- lateral to the inferior epigastric vessels to enter the deep inguinal ring
- most common (2/3)
- congenital patency to the processus vaginalis
- mostly pediatric
indirect hernia
- medial to the inferior epigastric vessels
- acquired- heavy lifting
Direct hernia
signs and symptoms of inguinal hernia
- groin pain/pressure, swelling
- worse with lifting (indirect)
- will not transilluminate
- exam variable- grossly normal scrotum to large mass
- turn your head and cough: “indirect hernia will touch tip of the finger, direct will touch medial to finger
*
treatment of hernias?
reducible
- can observe
irreducible
- Emergency
Incarcerated
- may be present with fever, nausea, vomiting and pain and hernia erythema- do not reduce, repair surgically
Presentations: variable
- painless, firm mass “rock” IN the testicle, fixed- most common
- +- dull achy scrotal pain/ heaviness
- typically NOT ACUTE pain
- +/- hydrocele
- gynecomastia seen in HCG producing GST (5%)
- up 10% present with meetastatic dz (cough from pulmonary met, GI, LBP (retroperitoneal) bone pain
Testis cancer
Work Up for testicular cancer
- Complete PE- check for LAD
- Scrotal ultrasound with color Doppler- preferred initial study
- if intratesticular concerning lesion noted–> obtain tumor markers and URGENT referral to urology +/- staging CT
Treatment for Testicular cancer
- Radical INGUINAL orchiectomy
- +/- retroperitoneal lymph node dissection
- +/- chemotherapy or radiation
- cyropreservation (sperm banking); given pt population, fertility risk with orchiectomy/chemo/radiation
- peritoneal fluid accumulation within the processus vaginalis (most commonly the tunica)- surrounds testicle and cord
- common in newborn males- congenital patency of the processus vaginalis (communicating hydrocele)
- multiple etiologies- idiopathic or reactive
- US- fluid around the testicle
- can rarely harbor a tumor, don’t hesitate to get an US
Hydrocele
what would PE and Labs look like in a pt presenting with hydrocele?
PE
- edematous, fluctuant scrotum
- can easily palpate cord above swelling
- testicles palpable
- LAD?
- transillumination
Labs
- UA, CBC
- semen analysis (younger patients)
Treatment of hydrocele
- observe
- aspiration +/- sclerotherapy with doxyclince or alcohol
- hydrocelectomy
- dilation of the pampiniform plexus, a network of veins supplying the testes, resulting in blood pooling in the veins
- presentation- Inguinal or scrotal pain, infertility, testicular atrophy - most common cause of infertility
- left side more common- due to the differences in the right and left testicular vein anatomy- presents as a dull ache
- right side, rapid onset or irreducible in supine position is more worrisome
Varicocele
treatment of varicocele?
- consider monitoring for testicular atrophy or semen parameters in young patients
- varicocelectomy/ ligation
- embolization +/- scleropathy
- retention cyst of the epididymis (superior and posterior to the testis
- efferent ducts that lead into epididymis can become obstructed by the traveling sperm and form diverticulum in the tubules, creating a cyst, the cyst will grow and typically result in a painless mass
- most commonly asypmptomatic
- smooth, spherical, transilluminates
- can cause bother/pain as enlarges
Spermatocele
Treatment of spermatocele
- observation- common
- aspiration +/- sclerotherapy
- spermatocelectomy