W2 Scrotal Pathology Benign Non Acute (Joey) Flashcards
What is the purpose of the rete testes
What is the purpose of the epididymis?
A sperm mature they are introduced to the lumen of the
seminiferous tubules and make their way through the rete testes to the epididymis for storage and maturation
Rete Testis:
—Anastomotic (connection) point between the seminiferous tubules and the efferent ducts that lead to the epididymis
—Site of fluid resorption back into the testicle
—Should allow sperm cells to pass through & a little fluid, resorb fluid
Epididymis
responsible for storage of sperm after production in the sertoli cells of the testicles, site of the majority of sperm maturation
Epididymal Cysts
What is it?
What are the causes?
Prevalent in?
An epididymal cyst is an often benign fluid containing cystic
lesion in the tubules of the epididymis that creates an outpouching, often palpable, mass.
Causes
—spontaneous/physiologic
—iatrogenic: vasectomy, radical prostatectomy
—infectious/trauma
—medications
prevalent in males in puberty and advanced age
Epididymis cyst — workup and diagnosis
Gold standard to diagnose?
What should you see on transilumination
Which reflex is in tact
Where would you palpate a cyst
Treatment ?
Diagnosis can me made clinically or via imaging, but best confirm via imaging (scrotal ultrasound)
Always get an u/s with any complaint in that area
Transilumination:
—Pen light behind the scrotum
—It should illuminate if it’s a cyst
Cremasteric reflex should be intact
Cysts are usually palpated laterally
TREATMENT
—conservative is best, rest, scrotal elevation
—if voiding dysfunction, treat this too. Sometimes this can cause referred pain to the scrotum
—surgical: elective: transscroptal cyst lysis or excision if it’s really big
⭐️Prehn’s sign and cremasteric reflex
For Prehn’s — what does positive mean? What does negative mean?
What two conditions does it help to distinguish between?
Slide 7
PREHN’S SIGN
Prehn’s Sign is a diagnostic study that can be performed during physical exam
● How to perform: Place your hand below the scrotum, then move your hand up slowly to elevated the scrotum and testicles bilaterally
● Can be useful in helping determine weather scrotal / testicular pain is due to Epididymitis or Testicular Torsion (more on this later)
○ Positive Prehn’s Sign: Pain RELIEF with scrotal elevation — in epidimytis because you’re relieving some of the tugging pressure
○ Negative Prehn’s Sign: NO pain relief with scrotal elevation in acute things like torsion, pain will still be there
CREMASTERIC REFLEX
● Cremasteric Reflex Test is also a diagnostic study that can be performed during the PE
● How to perform: Using finger/swab, lightly poke / scrape / move finger along the superior and medial aspect of the the thigh
● Normal physiologic response is immediate contraction of the cremasteric muscle (from internal oblique) and elevation of the ipsilateral testicle and scrotal contents
● Details: Sensory fibers of the ilioinguinal nerves are stimulated → relayed to spinal cord → motor fibers of genitofemoral nerves (f/L1,L2) activate cremasteric muscle fibers
Epididymitis
Which infection/pathogen is the likely cause?
Which patient population?
How do you diagnose?
What will the Prehn sign reveal?
Epididymitis is inflammation of the epididymis, which usually leads to subsequent chronic pain/irritation (may be acute as well)
Often infectious
Chlamydia & gonorrhea
Most common is sexually active males with multiple partners and without protection (infectious), younger males 18-35
DX:
—SCROTAL ULTRASOUND
—normal cremasteric reflex
—tenderness laterally
— + Prehn’s sign (elevation helps)
—testicle shouldn’t be painful
—should transiluminate
Presentation
—Mass and pain, can be dull, can be sharp, constant
—Worse with ambulation
—Frequent UTs
Epididymitis treatment
2 medications
If one can’t be tolerated?
If Suspecting GC / CT as cause (age <35 years old, unprotected, polyamorous, other risk hx)
Standard Empiric Tx:
Ceftriaxone 250 mg IM 1x + Doxycycline 100 mg PO BID x10 days
■ If cannot take doxycycline (ex: allergy, DDI), may use azithromycin 1 g PO 1x instead, though azithro resistance is a growing issue (and poor efficacy in tx of CT alone)
■ The doxycycline course (or azithromycin) would also likely treat mycoplasma/ureaplasma as well
If Suspecting enteric pathogens as cause (age >35 years old, monogamy, insertive anal intercourse):
Standard Empiric Tx: Ceftriaxone 250 mg IM 1x + Levofloxacin 500 mg PO BID x10 days
Scrotal A&P review
What are the layers of the scrotum?
Mnemonic: “Some Dang Englishman Called It The Testes”
outside to inside
SKIN → DARTOS (fascia) → EXTERNAL SF (fascia) → CREMASTER (muscle) → INTERNAL SF (fascia) → TUNICA VAGINALIS (parietal layer) → TUNICA VAGINALIS (visceral layer)
Spermatic cord:
● Contains the Testicle, Epididymis, Vas Deferens, Testicular Artery, Pampiniform Plexus, Testicular Nerve Fibers, and Lymphatic Vessels
● Above Spermatic Cord contents are “ensheathed” in external SF, cremaster (from the internal oblique muscle), and internal SF
● Testicle and Epididymis are coated in the parietal layer of tunica vaginalis, testicle itself in visceral layer
● In utero, spermatic cord and contents make their way out of the peritoneum True Scrotum: through processus vaginalis and down
● Skin Layer, Dartos Fascia the inguinal canal (more to come)
Varicocele
What is it?
Which side is more common?
Which side if concerning?
How would a patient describe the texture?
How would you diagnose?
Dilated and Tortuous Veins of the Pampiniform Plexus (Mesh-like Vein Network of the Spermatic Cord)
Left varicocele is far more common
Solitary right varicocele is very uncommon and is usually indicative of another problem
—usually asymptomatic, coming in for something else
—fullness, heaviness, maybe dull constant pain
—unilateral
—no fever/chills
— 🐛PE: bag of worms 🐛
—varicocele may not transluminate
—normal cremasteric reflex
DX: scrotal ultrasound w/ venous Doppler
Why are left varicoceles more common?
What is the nutcracker theory?
—left testicular vein is one of the longest vessels in the body
—left testicular vein inserts into left renal vein
—creates a higher pressure system than on the right = retrograde blood flow and valve damage
—the right is long but inserts into the inferior vena cava and inserts at a 45º angle. It’s a lower pressure system
What is the nutcracker theory?
—states that SMA creates tourniquet effect on left renal vein.
—may not be true
Grading of varicoceles
Subclinical: _________
I : _________
II : _________
III : _________
Subclinical: seen on imaging, no varicocele on exam
I : small, palpable w/ valsalva
II : moderate, palpable when standing w/o valsalva
III : large, easily visible
Varicocele treatment
—conservative, rest, elevation, NSAIDs
—check semen analysis, T-levels etc
Surgical — elective
—venous ligation
—embolization
—repair indicated: low T, may or may not improve serum T in 6-12mo
—pain alone is not an indication for repair
Solitary Right-Sided Varicocele or Acute Onset Presentation or L or R Varicocele
What is the cause?
What do you order?
As the right gonadal vein drains directly into the IVC , the veins that drain the R scrotum should be a lower pressure system compared to the L.
Falling in line with this thought process, varicoceles on the right side alone are unlikely to present themselves without some sort of IVC / intra-abdominal venous obstruction, like a tumour invasion into the IVC
Findings of a solitary RIGHT varicocele on physical exam or imaging (scrotal US), warrants CT abdomen / pelvis to r/o ⭐️right renal mass, ⭐️ liver mass, other obstructive process (as R sided varicocele may be 1st presenting sign of abdominal mass)
CT A/P should also be ordered in the presence of an acute (new, rapidly progressing) presentation of a RIGHT or LEFT varicocele, especially if they did not have the varicocele since peri-pubertal times as this may also be indicative of a new intra abdominal mass compressing venous outflow from the scrotum
Layers of the scrotum
Visceral layer is right on top of tunica albuginea
Hydrocele
Which layers is it between?
A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the TUNICA VAGINALIS, which directly surrounds the testis and spermatic cord.
hydroceles often arise over a prolonged period of time (years) and are believed to be due to a change / imbalance in the secretion and reabsorption of peritoneal fluid from the tunica vaginalis layers (from peritoneum) - aka “Primary
Hydrocele vs hematocele
Hematocele could indicate rupture of what?
Hydrocele:
—collection of fluid
—translucent
—could be inflammation related to epididymis
—could be congenital
Hematocele:
—collection of blood
—not translucent
—could indicate rupture of testicular artery
Varicocele
—dilated veins
—common on the left
—feels like bundle of worms
Hydrocele and hematocele
—Normal cremasteric reflex
—Prehn’s Sign may or may not be POSITIVE (elevation helps sx)
Scrotal ultrasound
Hydrocele and hematocele
What do you do if conservative measures don’t work?
Aspirate, usually comes back, have to sclerose
Cryptorchidism
What is it?
Huge risk for what?
How do you diagnose?
Cryptorchidism is failure of descent of the testes into the scrotum during fetal development.
Huge risk for testicular cancer
a testis that is not within the scrotum and does not descend spontaneously into the scrotum by four months of age (or corrected age for premature infants). Cryptorchid testes may be absent or undescended:
Absent testis
Undescended tests: classic cryptorchidism
DX: scrotal ultrasound and lower belly ultrasound
Cryptorchidism treatment
Surgical treatment of undescended testes is recommended as soon as possible after four months of age for congenitally undescended testes and definitely should be completed before the child is two years old
Surgery: treatment is often surgical scrotal and/or abdominal exploration, followed by “orchidopexy” (fixation of the testicle into the scrotum)
Hormonal therapy not recommended
COMPLICATIONS
—hypogonadism
—⭐️increased risk of testicular cancer
—testicular torsion
