Testis & Scrotum Disorders Flashcards
Define Cryptorchidism
Undescended testes or absent testes (agenesis)
Pathology of Cryptorchidism
Undescended testicles remain in the lower abdomen or at a point of descent into the inguinal canal
Scrotal sac is empty
Spontaneous decent in first 3 months
Pathologic Changes to the Undescended Testicle Demonstrated at 6-12 Months
Delay in germ cell development
Changes in spermatic tubules
Reduces number of Leydig cells
Morphologic changes in contralateral descended testicle
Consequences of Cryptorchidism
Infertility
Increased risk of malignancy
Indirect inguinal hernias
Increased incidence of testicular torsions
Cryptorchidism & Infertility
Increases if disorder is bilateral
Decreased sperm counts
Poorer quality sperm
Exam & Diagnosis of Cryptorchidism
Careful exam of genitalia in male infants
Differentiate from retractable testes
Diagosis: ultrasound, laparoscopy
Treatment Goals of Cryptorchidism
Enhance future fertility potential
Placement of the gonad in a favorable place for cancer detection
Improved cosmetic appearance
Treatment of Cryptorchidism
Orchiopexy after 6 months of life
Lifelong follow-up: infertility & testicular cancer issues
Define Hydrocele
Excess fluid collects between the layers of the tunica vaginalis usually peritoneal fluid due to a weakness in the patent processes vaginalis
Causes of Hydrocele
Primary congenital defect
Secondary condition
Primary Congenital Defect with a Hydrocele
Associated with indirect inguinal hernia
Persist beyond 2 years: surgical treatment indicated
Secondary Causes of Hydrocele
Trauma Epididymitis Testicular torsion Orchitis Infection Testicular cancer Appendiceal torsion
Hydrocele on Palpation
Palpated a cystic masses
Can become quite large
Mass can be mistaken for a solid tumor
Diagnosis of Hydrocele
Ultrasound
Trans-illuminate
Define Trans-illumination
Shining a light through the scrotum for the purposed of visualizing its internal structures
Ultrasound in Diagnosis of Hydrocele
Determination of underlying conditions
Evaluate if can not transilluminate
Hydrocele in a Young Man
Should be considered cancer until proven otherwise
Careful evaluation needed to exclude cancer or infection
Hydrocele in an Adult Male
Relatively benign condition
Often asymptomatic
Feeling of heaviness in scrotum
Pain in the lower back
Treatment of Primary Causes of a Hydrocele
If painful or cosmetically undesirable, surgical correction is indicated
Inguinally or transcrotally
Treatment of Secondary Causes of a Hydrocele
Treat condition causing hydrocele
If communicating with peritoneal cavity then surgery is necessary to close the defect
Define Hematocele
Accumulation of blood in the tunica vaginalis
Can compromise testicle
Etiologies of a Hematocele
Abdominal surgical procedure
Scrotal trauma
Bleeding disorder
Testicular tumor
Define Spermatocele
Painless, sperm-containing cyst that forms on the epididymis
Where is a spermatocele located?
Above & posterior to the testes
Attached to epididymis
Define Varicocele
Varicosities of the pampiniform plexus
Highest incidence of Varicoceles
15-35 years old
Rare before puberty
Which side are varicoceles more common?
Left due to left gonadal vein inserts into the left renal vein
Symptoms of Varicocele
Asymptomatic Dull aching Atrophy Infertility Abnormal feeling of heaviness in the left when standing and relieved when recombent
Diagnosis of Varicocele
Exam with patient in standing & recumbent position
Disappears in supine position
Feels like “a bag of worms”
Treatment of Varicocele
Surgical ligation of the gonadal vein Embolization of veins Obliteration of the dilated veins NSAIDs Scrotal support
Benefits of Obliteration of the Dilated Veins
Some improvement in infertility
Relief of the “heavy” feeling
Cosmetic improvement
Define Testicular Torsion
Twisting of the spermatic cord that suspends the testis
2 Age Peaks of Testicular Torsion
Perinatal
Prepubertal
Testicular Torsion in Neonates
Less common
Firm, smooth painless scrotal mass
Scrotal skin appears red
Some edema
Testicular Torsion in Pediatrics & Adolescents
True surgical emergency
Rotates on long axis of the tunica vaginalis
Cuts off blood supply to the testis
Early recognition & treatment essential
Symptoms of Testicular Torsion
Severe distress within hours of onset Accompanied with N/V Tachycardia Large, firm & tender testes Pain radiates to inguinal area Testicle high inscrotum & in abnormal orientation Cremasteric reflex frequently absent Degree of swelling & redness depends on duration of the symptoms
Imaging in Testicular Torsion
Color doppler ultrasonography
Attempt manual detorsion: “opening a book”
Referral to urology
Treatment of Testicular Torsion
Surgical detorsion
Orchiopexy
Orchiectomy: when deemed nonviable
Two Major Types of Epididymitis
STIs
Primary non-sexually transmitted infections
Epididymitis Due to STIs
Associated with young men, urethritis
Gonorrhea
Chlamydia
Epididymitis Due to Primary Non-sexually Transmitted INfections
Associated with UTIs, prostatitis, & men over 35
E. coli
Pseudomonas
Gram-positive cocci
Other Causes of Epididymitis
Post vasectomy: congestion in epididymis
Trauma
Define Epididymitis
Unilateral pain & swelling in the epididymis over a period of days
Inflammation of the epididymis
Symptoms of Epididymitis
Erythema & edema of overlying scrotal skin
Tenderness over the groin or lower abdomen
Fever
Dysuria
Urethral discharge (gonococcal)
Labs to Identify Epididymitis
CBC UA & culture Urethral culture Urine NAAT Gram stain
Treatment of Epididymitis
Scrotal elevation & support
Antibiotics appropriate to age, physical findings, UA, cultures or gram’s stain, sex history
Oral analgesics & antipyretics
Sexual activity or physical strain should be avoided
Define Hypogonadism
Testosterone deficiency with associated symptoms or signs, deficiency of spermatozoa production or both
Etiology of Primary Hypogonadism
Failure of testes to respond to FSH & LH
Testosterone is low to inhibit FSH & LH
Klinefelters syndrome
Etiology of Secondary Hypogonadism
Failure of hypothalamus to produce gonadotropin-releasing hormone (GnRH) or pituitary gland to produce enough FSH & LH
3 Categories of Hypogonadism
Congenital
Childhood-onset
Adult-onset
Congenital Hypogonadism Signs & Symptoms
1st trimester: results in inadequate male sexual differentiation
2nd & 3rd trimester: results in microphallus & undescended testes
Childhood-onset Hypogonadism Signs & Symptoms
Impairs development of secondary sexual characteristics
Signs & Symptoms of Childhood-onset Hypogonadism as Adults
Poor muscle development High-pitched voice Small scrotum Decreased penis & testicular growth Sparse pubic & axillary hair
Adult-Onset Hypogonadism Signs & Symptoms
Decreased libido
Erectile Dysfunction
Depression & anger
Diagnosis of Hypogonadism
FSH
LH
Free/total testosterone levels
Treatment of Hypogonadism
Testosterone replacement therapy (TRT)
Adverse Effects of Hypogonadism
Erythrocytosis Venous thromboembolism Acne Gynecomastia Low sperm counts
Administration of Testosterone Replacement Therapy (TRT)
Gel Transdermal axillary solution Transdermal patch Sub-Q implants IM injections
Define Infertility
Inability to get pregnant after trying for at least 1 year
Causes of Infertility
Blockage of the reproductive system
Medicines
Undescended testicles
Infections
Male Factors of Infertility
Pre-testicular
Testicular
Post-testicular
Medical History of Infertility
Previous semen analysis
Erectile dysfunction or other sexual dysfunction
Trauma
Previous pregnancies
Physical Exam to Determine Infertility
Testicular size Vas deferens Spermatic cord Penis Rectum Body habitus
Diagnosis of Infertility
Semen analysis Antisperm antibody test Hormonal analysis Transrectal ultrasound Scrotal ultrasound
Semen Analysis
Semen volume: 2-5 mL pH level: 7.2-7.8 Sperm density: 20M/mL Motility: >50% forward progressive Morphology: >60%
Treatment of Infertility
Boxer shorts Avoid hot tubs Timing of intercourse Avoid illegal drugs, chemicals & spermicidals Medications Surgical
Medications for Infertility
Clomiphene citrate (Clomid)
Imipramine: retrograde ejaculation
Zoloft: premature ejaculation
Surgical Options for Infertility
Varicocelectomy
Vasovasostomy
Testicular biopsy (TESE)
Transurethral resection of ejaculatory ducts
