Testicular concerns

Question 1

refractory scrotal pain despite adequate therapy for epididymitis should be evaluated for:

Answer 1

testicular torsion, testicular abscess or testicular infarction

Question 2

can you tell the difference based on history or physical exam about the difference between testicular torsion, testicular abscess or testicular infarction?

Answer 2

no must get a additional imaging like a testicular U/S

Question 3

testicular abscess

Answer 3

may not show fluctuance

Question 4

testicular torsion is associated with

Answer 4

no cremasteric reflex but this is more common in boys <12 yrs cremasteric reflex test not reliable for ruling in or out testicular torsion in men

Question 5

scrotal pain and swelling that is decreased with sac elevation may be

Answer 5

consistent with epididymitis but not specific to epididymitis

Needs to get U/S and urologist or radionucleotide scrotal imaging to see cause of pain to determine if he needs surgical management.

Question 6

testicular cancer can present as

Answer 6

acute testicular pain.

Question 7

bacterial causes of epididymitis based on age

Answer 7

<35 years see chlamydia and neisseria gonorrhea

>35 yrs see E coli and these are in men who engage in anal intercourse

Question 8

common causes of epididymitis would be

Answer 8

chlamydia trachomatis - ok to treat with quinolones, macrolides, and doxycycline (low levels of in vivo resistance to these antibiotics)

Question 9

when should pts start to feel better after being treated with epididymitis?

Answer 9

1-3 days and so continued pain should get further exploration of cause of pain.

Question 10

does HIV and syphilis cause epididymitis pain?

Answer 10

no. more likely chlamydia but also consider other causes.

Question 11

acute severe onset of pain, profound testicular swelling high riding testis bell clapper deformity

Answer 11

think testicular torsion which has pain in location of testis

Question 12

screening test for testicular torsion?

Answer 12

U/S

Question 13

epididymitis presentation

Answer 13

fever,

urinary frequency, urgency (acute)

induration, swelling, and exquisite tenderness of involved epididymis

pyuria and bacteruria on urinalysis

urine culture recommended

Question 14

what do you order for someone who has epididymitis?

Answer 14

get urine culture

Question 15

severe pain from anterior abdomen into scrotum and penis see skin edema and crepitus and blisters and bulla

Answer 15

fournier’s gangrene pain is diffuse scrotum

Question 16

best way to evaluate for fournier’s gangrene?

Answer 16

need surgical management and evaluation CT/MRI is preferred.

Question 17

chart of acute testicular pain

Answer 17

Question 18

anatomy of testicle and testicular torsion chart

Answer 18

Question 19

what are the associated characteristics of a varicocele?

Answer 19

Question 20

varicocele pathophysiology

Answer 20

Question 21

When should we get a CT scan for varicocele?

Answer 21

CT scan is suggested, not indicated when

when there’s a right sided varicocele as they are rare and can indicate an inferior vena cava compression (with renal cell carcinoma) or obstruction (thrombus)

Sudden onset of left sided varicocele that does not diminish with lying in the recumbent position may also indicate obstruction

Question 22

a varicocele is (definition)

Answer 22

tortuous dilation of pampiniform plexus of veins surrounding the spermatic cord and testis of the scrotum.

Occur in about 20% of men usually age 15-25 yrs and are left sided but 30% are bilateral.

Left spermatic gonadal vein enters the left renal vein at a right angle. the aorta and superior mesenteric artery can compress the left renal vein and increase intravascular pressure within the left renal vein and gonadal veins and this can cause incompetence in valves retrograde blood flow and venous dilation.

Question 23

varicocele symptoms

Answer 23

asymptomatic but can have dull ache with standing, or pain is worsened with standing and relieved with sitting. See a soft mass on exam that is enlarged with standing and valsalva maneuvers but diminishes when supine.

U/S can show retrograde venous flow and dilation of pampiniform plexus.

Question 24

how to treat varicocele?

Answer 24

asymptomatic pts don’t need treatment

scrotal discomfort pts can get NSAIDS and scrotal support.

Potential complications are infertility and testicular atrophy with the increased temperature.

Don’t need annual U/S but if there’s a solid mass need to get one.

Question 25

viral orchitis without epididmyitis is

Answer 25

MUMPS rubella andparvo see scrotal swelling, pain and tenderness with erythema but seen in kids and adults - have more of a cross over between epididmymo orchitis

Question 26

sharp left testicular pain that worsens when he takes a step down with left foot. Left testicle is more swollen nad has severe tenderness with palpation in the posterior aspect. NO inguinal hernias and no urethral discharge

Answer 26

**Epididymitis** - presents with acute onset testicular pain, fever, and possible urinary symptoms and exquisite pain with palpation Urinalysis can be normal without urinary symptoms. _Diagnosis is clinically made_ but doppler u/s of testes is done in equivocal cases to document increased flow to affected epididymis. Tx is outpatient with **testicular elevation, NSAIDs and antibiotics with close follow up.**

Question 27

first line therapy for symptomatic left sided varicocele that is not associated with testicular atrophy or infertility is:

Answer 27

**analgesic agents and scrotal support** varicoceles are leading cause of infertility; 40% of men who are infertile have varicocels dilation of pampiniform plexus of spermatic veins and cause symtpoms from dull to aching scrotal fullness see left sided bag of worms soft scrotal mass. the bag of worms improves with lying down and worsens with standing.

Question 28

right sided varicoceles should merit a

Answer 28

**deeper examination - get a CT abd/pel** uncommon and may be a _sign of a significant abnormality_ - inferior vena cava obstruction due to **tumor or thrombosis** because right gonadal vein empties directly into the inferior vena cava

Question 29

when do you get surgery for treatment of varicocoele?

Answer 29

when there's **presence of testicular atrophy** or **infertility** ligation or embolizaiton of gonadal vein prevents retrograde flow of blood into the pampiniform in the scrotum.