the BALLS!!!!!! Flashcards
low testosterone
< 150-200 ng/dL
Hypogonadism
Hypogonadism etiology
Primary: testicular failure
Mumps orchitis
Secondary: hypogonadotropic hypogonadism
Age-related (ADAM), chronic opiates
Hypogonadism epidemiology
increasingly diagnosed
Hypogonadism presentation
decreased energy/fatigue, ED, decreased force of ejaculation, decreased libido
Hypogonadism work - up
Free and total testosterone
Exam
If low – DEXA scan (< 100 ng/dL)
Hypogonadism tx
Androgen (testosterone) supplementation
Gels, injections, pellets
Hypogonadism follow up monitoring
PSA, hemogram (H&H), testosterone, review of urinary symptoms, DRE
3, 6 and 12 months after initiating, then annual
Counsel prostate Ca monitoring; CV risks, infertility.
basic questionnaire can be very useful for men to describe the kind
and severity of their low testosterone symptoms.
ADAM Questionnaire
testis (testes) not in scrotum
Possibly absent; possibly non-palpable (20%); if palpable, won’t come down
Cryptorchidism
Cryptorchidism etiology
not well understood
Normal descent is androgen-independent, mediated by “descendin;” passage through inguinal canal begins 28 weeks
Cryptorchidism epidemiology
rare
Cryptorchidism work up
good physical exam (don’t forget penis), possible scrotal U/S, urologist may pursue further studies (MRI, diagnostic laparoscopy)
Cryptorchidism tx
hormonal manipulation (GnRH injection); orchidopexy
testi at Inguinal canal -
between internal and external rings
testi Intra-abdominal (10%) -
proximal to inguinal ring
Absent testis (20%)-
truly absent, probable vascular event
Ectopic testis -
below the internal ring but out of normal path
Retractile testis -
reflects exuberant cremasteric reflex
Follow patient until puberty
Most descend spontaneously in first __ months
3
If undescended at __months, descent is unlikely
6
what percent of term infants have cryptorchidism
3
what percent of premes have cryptorchidism
30
what percent of Cryptorchidism is bilateral
10
3 percent have one or both missing
Cryptorchidism risk factors
Twins, low birth weight, pre-term delivery, family history, Prune Belly syndrome
Cryptorchidism cancer risk
Increased risk of testicular cancer (1/2500 versus 1/100,000)
Cancer risk may be reduced by orchidopexy, certainly facilitates examination
Contralateral testis at increased risk also, even if descended (10-25% of cancers on this side)
Cryptorchidism fertility effect
decreased
t/f torsion risk is 10 x higher
t
benign accumulation of serous fluid between layers of tunica vaginalis
Hydrocele
infant Hydrocele presentation
infant/toddler with hemiscrotal enlargement; volume/size waxes and wanes during day
infant Hydrocele etiology
patent processus vaginalis (communicating hydrocele)
infant Hydrocele work up
clinical diagnosis; scrotal sonogram may be helpful
infant Hydrocele tx
if persistent after one year, repair via inguinal incision
Adult Hydrocele presentation
scrotal discomfort; scrotal enlargement; possible h/o trauma or infection
Adult Hydrocele etiology
idiopathic; post-traumatic; post-infectious
Adult Hydrocele work-up
careful physical examination; transillumination; possible scrotal sonogram
Adult Hydrocele tx
Expectant management if asymptomatic
Aspiration/sclerosis associated with recurrence
Scrotal excision (hydrocelectomy)
congestion of veins around the testis
Varicocele
Varicocele etiology
reflects valvular anomaly exacerbated (or caused?) by gonadal venous anatomy; rare malignant etiology (consider if right-sided, or in man > 40 years)
Varicocele presentation
asymptomatic; dull ache; infertility; scrotal enlargement; majority on left
Varicocele work up
Clinical diagnosis; “bag of worms” due to dilatation of veins in pampiniform plexus; examine both standing and supine; generally no need for imaging; ?SA
Varicocele tx
varicocelectomy; embolization; 2/3 surgically treated have fertility improvement
Varicocele epidemiology
age 15-30 years; rarely over 40 years
careful dissection of spermatic cord, with ligation of veins (preserve the artery, lymphatics, vas deferens)
Varicocelectomy
twisting of spermatic cord causing ischemia of testis
Testicular Torsion
Testicular Torsion epidemiology
bimodal distribution
Neonatal (extravaginal) v. pubertal (intravaginal)
Testicular Torsion etiology
anatomic predisposition (Bell-clapper deformity; cryptorchidism); trauma; sex
Testicular Torsion presentation
Sudden severe onset unilateral scrotal pain; nausea/emesis; abdominal pain; symptoms may be intermittent (intermittent torsion)
Testicular Torsion work up
Difficult exam; high-riding testis; ?negative cremasteric reflex on affected side; scrotal edema and tenderness; pain unrelieved by scrotal elevation
Sonogram often equivocal or may be misleading, could delay treatment
High index of suspicion
Testicular Torsion tx
Scrotal exploration, with untwisting of cord and orchidopexy; ?contralateral orchidopexy
High salvage rate if treated within 6 hours
Inflammation/infection ball mow hawk
Epididymitis
Epididymitis etiology
Ascending infection from urethra, prostate, bladder
<35 years - C. trachomatis, N. gonorrhoeae
>35years - E.coli
Surgery (vasectomy)
Other trauma
Epididymitis
Scrotal pain, scrotal enlargement, fever
Epididymitis
Good history and exam; UA C&S; ?penile swab/probe for STI, ?scrotal sonogram
Epididymitis
Antibiotics (empiric by age, i.e. doxycycline or ciprofloxacin)
Palliatives (scrotal support, NSAIDs, ice, narcotics)
- acute inflammatory reaction of testis secondary to infection
Orchitis
Orchitis etiology
Most common – viral mumps infection in children
Bacterial orchitis - most commonly associated with epididymitis in sexually active males and men >50 with BPH
C. trachomatis, N. gonorrhoeae, E. coli
Orchitis presentation
Scrotal pain (mild-severe) and swelling
Exam can reveal impressive induration and edema
Overlying skin frequently thickened
Testicle won’t move freely in the scrotum, seems “stuck”
Orchitis work up
Good history and exam; UA C&S; ?penile swab/probe for STI, ?scrotal sonogram
Orchitis tx
Viral (mumps orchitis) - no medications; may lead to infertility
Bacterial - treat suspected organism, exclude/address abscess
Highly curable cancer in young to middle-aged men
Testis Cancer
Testis Cancer histology
Germ cell (95%) Seminoma Non-seminoma (NSGCT) Mixed (managed as NSGCT) Non germ cell (5%) Rare secondary tumors (lymphoma, leukemia)
Testis Cancer epidemiology
8,500 new cases/year; 350 deaths/year
Trimodal: Up to 10 years (yolk sac); 20-40 years (seminoma); > 60 years (spermatocytic seminoma)
Testis Cancer presentation
painless testicular mass
Usually incidental by partner or after trauma
Cough or dyspnea secondary to lung metastases
GI symptoms secondary to retroperitoneal metastases
Gynecomastia
Testis Cancer work up
Scrotal sonogram
Tumor markers (AFP, beta-hCG, LDH);
CT to assess the lymph nodes of retroperitoneum
Radical inguinal orchiectomy
Testis Cancer tx
guided by histology (seminoma v. NSGCT) and staging (markers + imaging)
Surveillance
Adjuvant chemotherapy
Adjuvant radiotherapy
Retroperitoneal lymph node dissection (RPLND)
Testis Cancer prognosis
Cure rate 90% for seminoma (all stages combined)
Cure rate approaches 100% for low-grade NSGCT
