W2 Scrotal Pathology Acute (Joey)

Question 1

Testicular torsion
This is a ______
Most common in ______ and ______
Prehn’s sign is ______ !
Cremasteric sign is ______

Answer 1

Twisting (torsing) and of the spermatic cord that leads to obstruction of testicular artery and veins → decreased blood flow to the testicle, often causing acute, sharp scrotal pain related to ischemia

Testicular torsion is a urologic emergency

Sports is a big cause

MC in neonates and pubertal boys but can occur in any age

Prehn’s sign — negative, NO pain relief w/ scrotal elevation!

Cremasteric reflex — absent, diminished

Question 2

Testicular torsion
How does the patient present?
What is the position of the testicle?

Answer 2

Severe rapid onset of unilateral scrotal pain

+/- nausea, vomiting, low grade fever, scrotal swelling

PE:
—unilateral, firm, high riding testicle
—swelling, erythema
—bell clapper position
—scrotum should transluminate

DX:
scrotal ultrasound w/ arterial and venous doppler

Question 3

Testicular torsion — types 2

Answer 3

Extravaginal = neonates
3 structures rotate:
Testicle
Epididymis
Tunica vaginalis

Intravaginal = more common in puberty
Rotation of the testicle and epididymis WITHIN the tunica vaginalis

Question 4

Testicular torsion
Treatment — what do you try first
If that is unsuccessful?
What is the hour cutoff?

Answer 4

Attempt to untwist, medial to lateral, usually 2-3 twists (like opening a book)

if unsuccessful, immediate scrotal exploration

More successful if detorsion in <6h

Over this time, orchiectomy is likely

Question 5

Epididymo-Orchitis & Orchitis Key Points
What is it?
What is mumps orchitis ?

Answer 5

Inflammation of both epididymis and testicle

Isolated orchitis is WITHOUT epididymitis is very uncommon in adults

Acute orchitis from mumps is characterized by difuse testicular swelling and tenderness and may be difficult to distinguish from acute epididymo-orchitis.

Confirmed w/ serology

No abx. Rest. NSAIDs

Question 6

Fournier’s Gangrene
What is it?
What do you do?
How do you treat?

Answer 6

Definition: Fournier’s gangrene is a necrotizing fasciitis (mixed aerobic/anaerobic infection) of the perineum which often involves the scrotum in males

Clinical features: Variable, however may include tense edema outside the involved skin, blisters/bullae, crepitus, and subcutaneous gas,

Treatment: Management of necrotizing fasciitis consists of early (immediate?!) aggressive surgical debridement (until you reach pink, health, viable tissue

TX: broad spectrum antibiotic therapy (aggressive broad aerobic and anaerobic coverage to start - can always
narrow abx later down the line once more confident tx is working), and hemodynamic support as needed.

Question 7

Testicular Trauma: Hematocele vs Testicular Rupture

Answer 7

The spectrum of traumatic complications can range from a hematocele (blood within the tunica vaginalis) to a pyocele (pus within the tunica vaginalis) to testicular rupture.

Testicular Rupture: A rip or tear in the tunica albuginea resulting in extrusion of the testicular contents, including the seminiferous tubules. It is a rare complication of testicular trauma, and can result from blunt or penetrating trauma, although blunt trauma is more likely to cause rupture.

Question 8

Testicular mass

Answer 8

Testicular Mass is considered cancer until proven otherwise — TRUE mass on the testicle

true testicular mass warrants IMMEDIATE referral to a Urologist and Oncology (call, email, knock on doors, do all you can to make sure pt is seen w/in days)