The Balls Flashcards
Hypogonadism:
-low T
Hypogonadism etiology:
Primary: Testicular failure (ex. mumps orchitis)
Secondary: Hypogonadotropic hypogonadism (age-related (ADAM), chronic opiates)
Hypogonadism etiology:
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
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.
ADAM questionnaire:
This basic questionnaire can be very useful for men to describe the kind
and severity of their low testosterone symptoms.
1. Do you have a decrease in libido (sex drive)? Yes No
2. Do you have a lack of energy? Yes No
3. Do you have a decrease in strength and/or endurance? Yes No
4. Have you lost height? Yes No
5. Have you noticed a decreased “enjoyment of life” Yes No
6. Are you sad and/or grumpy? Yes No
7. Are your erections less strong? Yes No
8. Have you noticed a recent deterioration in your ability to play sports? Yes No
9. Are you falling asleep after dinner? Yes No
10. Has there been a recent deterioration in your work performance? Yes No
If you Answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone.
Cryptorchidism:
testis (testes) not in scrotum
- Possibly absent; possibly non-palpable (20%); if palpable, won’t come down
- RARE
Cryptorchidism etiology:
not well understood
-Normal descent is androgen-independent, mediated by “descendin;” passage through inguinal canal begins 28 weeks
Cryptorchidism work-up:
- good physical exam (never forget the penis)
- possible scrotal US
- urologist may pursue more studies
tx of cryptorchidism:
hormonal manipulation (GnRH injection); orchidopexy
Places of cryptorchidism:
Inguinal canal - between internal and external rings
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
Descending of the testis:
Most descend spontaneously in first 3 months
If undescended at 6 months, descent is unlikely
3% of term infants, 30% of premature infants
10% bilateral
3% have one or both testes absent
risk factors of cryptorchidism:
Risk Factors:
Twins, low birth weight, pre-term delivery, family history, Prune Belly syndrome
risks from cryptorchidism:
- Ca
- -CA less likely if undescended testis was in inguinal canal vs. abdomen
- decreased fertility
- Torsion risk is 10% higher
Orchidopexy
putting the ball where it belongs
Hydrocele:
benign accumulation of serous fluid between layers of tunica vaginalis
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)
Varicocele:
congestion of veins around testis
varicocele epidemiology:
age 15-30, rarely over 40
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
Testicular torsion:
twisting of spermatic cord causing ischemia of testis
testicular torsion epi:
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
Epididymitis:
inflammation or infection of epididymis
epididymitis etiology:
-Ascending infection from urethra, prostate, bladder
<35 years - C. trachomatis, N. gonorrhoeae
>35years - E.coli
-Surgery (vasectomy)
-Other trauma
epididymitis presentation:
- scrotal pain
- scrotal enlargement
- fever
epididymitis work-up:
Good history and exam; UA C&S; ?penile swab/probe for STI, ?scrotal sonogram
epididymitis tx:
- Antibiotics (empiric by age, i.e. doxycycline or ciprofloxacin)
- Palliatives (scrotal support, NSAIDs, ice, narcotics)
orchitis:
acute inflammatory reaction of testis secondary to infection
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
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 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 ca work-up:
Scrotal sonogram
Tumor markers (AFP, beta-hCG, LDH);
CT to assess the lymph nodes of retroperitoneum
Radical inguinal orchiectomy
testis ca tx:
guided by histology (seminoma v. NSGCT) and staging (markers + imaging)
Surveillance
Adjuvant chemotherapy
Adjuvant radiotherapy
Retroperitoneal lymph node dissection (RPLND)
testis ca prognosis:
Cure rate 90% for seminoma (all stages combined)
Cure rate approaches 100% for low-grade NSGCT
