SM_241b: Benign Male Genital Disorders Flashcards
Describe abdominal wall and corresponding scrotal wall layers
Abdominal wall and corresponding scrotal wall layers
Abdominal wall - scrotum
- Skin - skin
- Scarpa’s fascia - dartos and smooth muscle
- External oblique fascia - external spermatic fascia
- Internal oblique muscle and aponeurosis - cremasteric fascia and muscle
- Transversus abdominis muscle and aponeurosis - cremasteric fascia and muscle
- Transversalis fascia - internal spermatic fascia
- Peritoneum - tunica vaginalis
Describe scrotal disorders
Scrotal disorders
- Hydrocele
- Testicular tumor
- Cyst of epididymis
- Spermatocele
- Cyst of hydatid of morgagni
- Epididymitis
- Varicocele
___, ___, ___, and ___ are scrotal masses that exhibit (+) transillumination
Scrotal masses that exhibit (+) transillumination
- Hydrocele
- Spermatocele
- Epididymal cyst
- Indirect inguinal hernia (containing fluid)
____ is a diagnostic procedure commonly used to diagnose scrotal pathology
Scrotal ultrasound is a diagnostic procedure commonly used to diagnose scrotal pathology
____, ____, ____, ____, and ____ are scrotal masses that do NOT transilluminate
Scrotal masses that do NOT transilluminate
- Testicular tumor
- Epididymal tumor
- Spermatic cord tumor
- Varicocele
- Abscess
Describe varicocele
Varicocele
- Examine patient supine and standing with concurrent Valsalva maneuver
- Grade 1: palpable only with concurrent venous malformation
- Grade 2: easily palpable w/o venous malformation
- Grade 3: visible through scrotal skin
Solitary right varicocele should prompt consideration of imaging studies to rule out a ___
Solitary right varicocele should prompt consideration of imaging studies to rule out a retroperitoneal mass
This is ___
This is orchitis and pyocele
This is a ___
This is a large scrotal abscess
Non-communicating hydrocele can be managed with ___, ___, or ___
Non-communicating hydrocele can be managed with observation, aspiration / sclerosis, and surgery
____ is the site of a direct inguinal hernia
Inguinal (Hasselbach’s) triangle is the site of a direct inguinal hernia
For inguinal hernia repair, ____ is the site of nerve block and ____ is the incision site
For inguinal hernia repair, anterior superior iliac spine is the site of nerve block and pubic tubercle area is the incision site
Describe steps of inguinal hernia repair
Steps of inguinal hernia repair
- Dissection of cord and indirect sac
- Plug placement into internal ring
- Suture placement into rectus sheath
Describe predisposing factors for testicular torsion
Predisposing factors for testicular torsion
- Hypermobile testis
- High-riding testis
- Transverse orientation
- Bell clapper deformity
- Undescended testis
- Family history
- Sudden movement, trauma, cold temperature
Testicular torsion can be ____, ____, or ____
Testicular torsion can be intravaginal, extravaginal, or long mesorchium
Describe extravaginal torsion
Extravaginal torsion
- Neonatal or perinatal event
- Vanishing testis syndrome
- Purple, blue scrotum, firm testicle
- Often no distress
- 5-22% bilateral
- 33% synchronous presentation
- Risk factors: prolonged labor, large birth weight, breech presentation
- Almost never salvageable
Describe intravaginal testicular torsion
Intravaginal testicular torsion
- All age groups at risk but most common in early puberty
- Spermatic cord twists inside tunica vaginalis due to its insertion on the cord -> allows testis to turn freely within the scrotum
- Prompt surgical exploration to detorse testis (if salvageable) with bilateral orchidopexy vs removal of necrotic testis and contralateral orchidopexy
Describe differential diagnosis for testicular torsion
Differential diagnosis for testicular torsion
The most likely differential diagnoses are ____, ____, and ____
Obtain ____
The most likely differential diagnoses are testicular torsion, epididymitis + orchitis, and testicular tumor
Obtain scrotal US with color doppler (not perfect)
This is ___
This is epididymo-orchitis
Male 12-16 years old presenting with sudden severe unilateral pain, nausea / vomiting, no cremasteric reflex, and no relief with lifting (Prehns’ sign) has ___
Male 12-16 years old presenting with sudden severe unilateral pain, nausea / vomiting, no cremasteric reflex, and no relief with lifting (Prehns’ sign) has intravaginal torsion
Describe presentation of intravaginal torsion
Intravaginal torsion: presentation
- Peak in age 12-16 years
- Pain: sudden, severe, unilateral
- NOT active at the onset of pain
- Early presentation: nausea / vomiting, no cremasteric reflex, no relief with lifting (Prehn’s sign)
- Late presentation: swollen, redness can seem to cross midline
- Very late presentation: non-tender (nerves are dead), swollen, purple, eggplant
Describe workup for intravaginal torsion
Intravaginal torsion workup
- Urinalysis
- Doppler US (not perfect)
- Clinical diagnosis: if there is suspicion, do emergent exploration (do NOT delay for US)
Describe management of intravaginal torsion
Intravaginal torsion
- Preoperative manual detorsion (will almost always salvage testis if performed in < 6 hours)
- Surgery: bilateral orchidopexy
Describe prognosis of intravaginal torsion
Intravaginal torsion prognosis
- Compartment syndrome theory
- Total ischemia time > 6 hours -> very poor prognosis
- Trick question: patient comes in and is now 8 hours from onset and looks bad -> still explore because have to try
- Paternity usually ok if contralateral testicle is normal
Describe torsed appendages
Torsed appendages
- Mullerian duct remnants: appendix testis, prostatic utricle
- Wolffian duct remnant: appendix epididymis
- Physical exam: blue dot sign
- Duppler US: inflammatory blob above testicle
- Supportive care: rest, ice, NSAIDs
