5/14 Scrotum, Penis, Testis

Question 1

What two tools can almost always help you diagnose scrotal masses??

Answer 1

ULTRASOUND *know this* 
Transilluminatio n(helps to see cystic structures)

Question 2

What is acute scrotum?

Answer 2

acute painful swelling of the scrotum; various etiologies (infectious, inflammatory, neoplastic, trauma, vascular problems etc etc - we’ll go through 1-2 examples of each)

Question 3

∆ btwn Epididymitis and Epididymo-orchitis?

Answer 3

Epididymitis - Infection of epididymis

Epididymo-orchitis - Infection of epididymis that extends to the testes

both are infectious causes of acute scrotum

Question 4

What are the common causes of Epididymitis and Epididymo-orchitis?

Answer 4

know this

Children – congenital GU abnormalities; E. coli or GNR

Young men – Chlamydia and gonorrhea (usually sudden onset of pain in the testicles (indicative of infection), burning with voiding)

Older men – associated with LUTS, E. Coli or Pseudomonas

Question 5

How can you tell if someone has chlamydia vs BPH as the cause of their Epididymitis and Epididymo-orchitis?

Answer 5

chlamydia - usually sudden onset of pain in the testicles (indicative of infection), burning with voiding

BPH - lower urinary tract symptoms (urgency/frequency)

Question 6

How would gonorrhea cause Epididymitis or Epididymo-orchitis?

Answer 6

urethra –> prostate –> seminal vesicles –> epididymis

inflammation may lead to abscess and destruction!

Question 7

How do you know if mumps is causing the orchitis?

Answer 7

acute orchitis occurs ~1 wk after the onset of swelling in the parotid glands

Question 8

How do you know if TB is causing the orchitis?

Answer 8

orchitis usually occurs after subsequent infection in upper GU tract (prostate, seminal vesicles, kidney)

Question 9

How do you know if syphillis (3˚) is causing the orchitis?

Answer 9

testes –> epididymis

presence of inflammation and endarteritis or gumma

Question 10

What is the gross hx of Epididymitis or Epididymo-orchitis?

Answer 10

suppurative inflammation and abscesses (may lead to chronic inflammation and scarring)

Question 11

What is the hx findings of Epididymitis or Epididymo-orchitis?

how do these things form?

Answer 11

sperm granulomas

integrity of BM of seminiferous tubules disrupted after inflammation/orchitis –> spillage of spermatozoa into the interstitium
Body mounts a strong immune response against acid-fast component in the lipid in spermatozoa –> formation of granuloma (contains histiocytes)

Question 12

US finding of Epididymitis or Epididymo-orchitis?

Answer 12

increased or “reactive” flow secondary to inflammation

Question 13

review: what causes fournier’s gangrene?
clinical presentation?
treatment?

Answer 13

polymicrobial (aerobic + anaerobic) infection

Necrotizing cellulitis and fasciitis, crepitus (air in skin)

emergency surgical debridement otherwise it can spread rapidly

Question 14

What type of reaction does Henoch-Scholein Purpura cause in acute scrotum?

Answer 14

inflammatory cause of acute scrotum

Question 15

review: what causes Henoch-Scholein Purpura?

When does it usually occur?

trmt?

Answer 15

Systemic vasculitis due to IgA immune complex deposition in post-capillary venules

often follows an acute respiratory illness (peak incidence is during the winter)

trmt: self-limiting

Question 16

review: what is the typical presentation of Henoch-Scholein Purpura? (obv related it to acute scrotum..)

Answer 16

Tetrad of sx usually affects gravity dependent areas: 
palpable purpura
joint pain
abdominal pain
glomerulonephritis

orchitis can result (pain/swelling of the testicles)

Question 17

how can tumors cause acute scrotum?

Answer 17

Tumor that causes the tunica albuginea surrounding the testicle to tear

Question 18

how can trauma to the testes cause acute scrotum?

Answer 18

Testicular rupture due to trauma, causes tears in the tunica albuginea surrounding the testicle, resulting in damage to the testicle. blood in the scrotum

Question 19

What is a hematocele and how does it cause an acute scrotum?

Answer 19

hematocele - occur when blood collects under the tunica albuginea

usually occurs due to trauma to the testes…ouch.

Question 20

How does testicular torsion cause an acute scrotum? What are the presenting sx?

Answer 20

Torsion (twisting of the spermatic cord and blood supply to the testicle), resulting in intense engorgement and hemorrhagic infarction if it is not rapidly corrected

Symptoms:

• sudden onset in testicular pain
• absent cremasteric reflet

Question 21

What are the 2 types of testicular torsion? Who does it usually affect?/

Answer 21

Intravaginal torsion - adults
Extravaginal torsion - neonates

know this

Question 22

What is intravaginal torsion of the testicles and how does it cause an acute scrotum?

who is most at risk?

Answer 22

testicle torsion occurs within the tunica vaginalis, usually bilateral

high risk with “bell clapper deformity”, where the tunica vaginalis testis completely encircles the testis, epididymis, and distal spermatic cord, thus predisposing the testes to torsion at a high point of attachment

Question 23

What does intravaginal torsion occur?

Answer 23

increased weight of the testicle after puberty + sudden contraction of the cremaster muscle (which inserts in a spiral fashion into the spermatic cord) causes torsion

Question 24

What is extravaginal torsion of the testicles and how does it cause an acute scrotum?

who is most at risk?

Answer 24

testicle torsion occurs outside of the tunica vaginalis, where the testes and gubernaculum are not fixed and can freely rotate.

The spermatic cord undergo torsion as a unit, twisting on its blood supply and causing infarction

NOTE that this is NOT associated with bell clapper deformity

Question 25

US findings testicular torsion?

Answer 25

absence of flow in testes (can be unilateral or bilateral)

Question 26

∆ in etiology btwn incarcerated hernia and strangulated hernia?

Answer 26

Incarcerated: bowel, omental, or abdominal content herniates but can be returned to its original compartment with manual manipulation strangulated: blood supply to the herniated tissue is compromised (herniated contents pass through a restrictive opening that reduces venous return -> swelling that compromises circulation to affected area)

Question 27

∆ in sx btwn incarcerated hernia and strangulated hernia?

Answer 27

incarcerated: severe pain + pulling in groin, nausea + vomiting strangulated: severe pain + tenderness

Question 28

Which one is a surgical emergency: incarcerated hernia and strangulated hernia

Answer 28

surgical emergency due to tissue necrosis risk

Question 29

Path of indirect hernia?

Answer 29

enters internal (deep) inguinal ring (lateral to inferior epigastric artery) exits the external (superficial) ring, and into the scrotum; usually follows the path of the descent of the testes. covered by all 3 layers of the spermatic fascia

Question 30

Why does indirect hernia occur? Who does it usually occur in?

Answer 30

testicles arises in the posterior abdominal wall and descends during gestation and exits the anterior abdominal wall into the testes and takes some of the peritoneum with it into the scrotum = tunica vaginalis is actually a piece of the peritoneum usually the extended piece fibroses off but if it doesn't then it is a potential space for hernia. children/infants are almost always indirect hernias bc the tunica vaginalis hasn’t properly obliterated

Question 31

path of direct hernia? who does it usually occur in?

Answer 31

protrudes through the inguinal triangle (medial to the inferior epigastric artery) - directly through abdominal wall - and out external (superficial) inguinal ring covered by external spermatic fascia; usually older men

Question 32

What is a spermatocele? Does it cause acute scrotum?

Answer 32

it is an epididymal cyst that is slowly enlarging and occurs OUTSIDE of the tunica vaginalis No it does not cause acute scrotum - this is actually painless cause it's slow growing

Question 33

If you were to aspirate a spermatocele, what would you find?

Answer 33

watery fluid that contains spermatozoa

Question 34

How would you diagnose spermatocele?

Answer 34

US - fluid filled cyst | Transillumination (+)

Question 35

How does a spermatocele compare to a hydrocele?

Answer 35

spermatocele = fluid OUTSIDE of the tunica vaginalis; + for spermatozoa Hydrocele = fluid within the tunica vaginalis, - for spermatozoa (it’s a cystic dilation of an extra-testicular structure; lined by tunica vaginalis)

Question 36

``` ∆ btwn spermatocele hydrocele chylocele hematocele ```

Answer 36

spermatocele = fluid OUTSIDE of the tunica vaginalis Hydrocele = fluid WITHIN the tunica vaginalis Chylocele - chyle or fatty lymph WITHIN the tunica vaginalis; due to lymphatic obstruction or lymphatic rupture Hematocele – blood WITHIN the tunical vaginalis

Question 37

risk factors for testes cancer?

Answer 37

Cryptorchidism (undescended testicle) Family hx/prior hx of testis cancer - greatest Infertility – reflection of problems in the testicle Iso-Chromosome 12p (+ in 70% of patients)

Question 38

clinical presentation of testes cancer?

Answer 38

Males age 15-35 Painless solid mass of body of the testis May have history of minor trauma U/S: hypoechoic solid mass = cancer until proven otherwise

Question 39

how does testicular cancer present on an US?

Answer 39

hypoechoic solid mass = cancer until proven otherwise

Question 40

tumor markers of testicular cancer? bonus points if you can say where they are produced from.

Answer 40

AFP – yolk sac elements; t1/2 = 5d ßhCG – produced by syncytiotrophoblasts; t1/2 = 24h LDH – measure of cellular turnover or tumor burden

Question 41

general treatment of testicular cancer? Why is it done this way?

Answer 41

inguinal orchiectomy - incision is in the abdomen prevents contamination of the scrotal lymphatics, which drain to the inguinal LN

Question 42

How is testicular cancer graded?

Answer 42

``` TNMS: Tumor Nodes Metastases Serum Markers ```

Question 43

How is testicular cancer staged?

Answer 43

Stage 1 – limited to testicle (T1-T4) Stage 2 – primary + nodal tumor, but no evidence of metz Stage 3 – evidence of metz

Question 44

Two types of germ cell tumors?

Answer 44

Seminomatous GCT | Non-Seminomatous GCT

Question 45

Types of Seminomatous GCT?

Answer 45

Seminoma | Spermatoctic seminoma

Question 46

seminoma ``` when does it usually occur? is it malignant? prognosis? clinical presentation? tumor markers? ```

Answer 46

peak incidence: 30s MALIGNANT - usually late metastasis, but excellent prognosis b/c it extremely sensitive to chemotherapy and radiation painless, homogenous testicular enlargement markers: isochromosome 12p, placental ALP

Question 47

seminoma gross hx: micro hx:

Answer 47

Gross: firm, tan, solid, bulging, bulky, no necrosis or hemorrhage microHx: sheets of lymphocytes + large polyhedral cells with “fried egg appearance”; divided by fibrous septa, may be associated w/ granulomatous reaction

Question 48

Spermatoctic seminoma when does it usually occur? is it malignant? prognosis? tumor markers?

Answer 48

peak incidence: mid 60s not malignant - does not metz outside of the testes; excellent prognosis b/c it extremely sensitive to chemotherapy and radiation tumor markers: NONE

Question 49

Spermatoctic seminoma gross hx: micro hx:

Answer 49

gross; mucoid, solid gray micro: 3 cell types (small medium large, with medium being the most common) in edematous stroma, ø lymphocytes, ø granulomas (unlike the classic seminoma)

Question 50

if the pathology shows a pure seminoma but there is an elevated AFP, what does this mean?

Answer 50

means that there is an undetected additional component of NSGCT and should be treated as a NSGCT (Non-Seminomatous GCT)

Question 51

Where does Non-Seminomatous GCT usually arise from? What are the different types of Non-Seminomatous GCT?

Answer 51

Arise from germinal (seminiferous) epithelium Tends to recapitulate normal embryogenesis - their pattern is usually differentiated toward >1 components of the embryo: - Embryonal carcinoma - Yolk sac tumor - Choriocarcinoma - Teratoma

Question 52

Embryonal carcinoma is also known as: is it malignant? presentation? tumor markers?

Answer 52

“angry tumor” MALIGNANT PAINFUL (worse prognosis than seminoma) markers: increased hCG + normal AFP when pure increased hCG + increased AFP if mixed

Question 53

Embryonal carcinoma gross hx: micro hx:

Answer 53

gross: variegated, hemorrhagic mass w/ necrosis micro: glandular and papillary structures or solid patterns; usually contain pleomorphic, primitive cells with ill-defined cell borders commonly mixed w/ other tumor types

Question 54

``` Yolk Sac Tumor: where does it arise from? is it malignant? presentation? tumor markers? ```

Answer 54

extra-embryonic mesoderm and endoderm aggressive malignancy usually in boys < 3yo tumor marker: AFP

Question 55

Yolk Sac Tumor: gross hx: micro hx:

Answer 55

gross: non-encapsulated; homogenous yellow-white mucinous appearance micro: Schiller-Duval body + hyaline globules

Question 56

What are Schiller-Duval bodies?

Answer 56

found in YOLK sac tumors; endodermal sinus – central blood vessels surrounded by multiple layers of tumor cells – it tries to recapitulate the placenta; sort of looks like primitive glomeruli

Question 57

``` Choriocarcinoma: where does it arise from? is it malignant? presentation? tumor markers? ```

Answer 57

extra-embryonic trophoblast of the placenta high metastatic potential via hematogenous spread to the lungs and brain (may present with hemorrhagic stroke due to bleeding into the metz) presentation: may produce gynecomastia or symptoms of hyperthyroidism (hCG is an LH and TSH analog) tumor marker: hCG

Question 58

Choriocarcinoma gross hx: micro hx:

Answer 58

gross: areas of hemorrhage “blood filled lakes” and necrosis micro: presence of disordered syncytio- (larger) and cyto- (smaller) trophoblastic elements, usually around a blood-filled space due to hematogenous metz

Question 59

``` Teratoma: where does it arise from? is it malignant? presentation? tumor markers? ```

Answer 59

somatic differentiation of ectoderm, endoderm, and mesoderm malignancy depends on age - usually the ADULT form is malignant 2 distinct age peaks: infancy and young adulthood tumor markers: usually hCG + AFP in 50% of cases

Question 60

Teratoma - ∆ btwn mature and immature forms?

Answer 60

mature: structures derived from all 3 germ layers immature: resembles embryonic tissue or fetal tissue w/ secondary malignant component

Question 61

Teratoma - ∆ btwn adult and childhood forms?

Answer 61

Childhood: usually completely MATURE, pure, and benign (regardless of any immature element) Adult, esp in M: almost always have some IMMATURE elements, are usually mixed, and have malignant potential due to their metastatic potential (maturity ≠ benignity)

Question 62

Teratoma gross hx: micro hx:

Answer 62

gross: variegated, nodular, solid & cystic micro: subtypes are defined by the maturity of the tissues; various structures (gut, brain, keratin)

Question 63

How do you treat a Non-Seminomatous GCT? What is critical to note in the treatment of these tumors?

Answer 63

NSGCT is sensitive to chemotherapy. Residual masses + draining LN may contain microscopic tumor cells or residual teratomatous elements even after chemo; must be SURGICALLY REMOVED or else it will grow into another tumor

Question 64

Sex-Cord Stromal Tumors?

Answer 64

Leydig Cell tumor | Sertoli cell tumor

Question 65

when and where does a leydig cell tumor present?

Answer 65

presents 20-60yo present outside of the seminiferous tubules

Question 66

sx of Leydig Cell tumor?

Answer 66

usually androgens producing | associated w/ precocious puberty in boys, gynecomastia in men,

Question 67

Leydig Cell tumor gross hx: micro hx:

Answer 67

Gross: well-circumscribed, small, solid, usually homogeneous (golden brown in color) histology: reinke crystals

Question 68

where does a Sertoli cell tumor usually present? how does it compare to a leydig cell tumor?

Answer 68

present inside of the seminiferous tubules | leydig = outside

Question 69

sx of sertoli cell tumor?

Answer 69

usually hormonally silent and benign

Question 70

Sertoli cell tumor gross presentation?

Answer 70

well-circumscribed, small, solid, usually homogeneous (same as leydig)

Question 71

Testicular lymphoma who does it usually affect? how does it arise? is it malignant?

Answer 71

common testicular cancer in older men not a primary cancer but actually arises from lymphoma metz to the testes aggressive

Question 72

Hypospadias - what is it?

Answer 72

Arrested penile development that results in: - urethra that doesn’t reach the tip of the penis - chordee (fibrotic areas that run along the ventral aspect of the penis and cause curvature of the penis

Question 73

Hypospadias trmt?

Answer 73

DO NOT CIRCUMCISE - b/c the hooded foreskin is used to reconstruct the uretrha to make the child look normal

Question 74

Epispadias/Extrophy - what is it? how does it occur?

Answer 74

Bladder is present on the anterior abdominal wall and the penis is split on the dorsal surface; due to failure of ingrowth of mesoderm into the cloacal membrane during embryogenesis

Question 75

what is a phimosis? paraphimosis?

Answer 75

phimosis - normal; occurs at birth where the foreskin cannot be fully retracted over the glans penis paraphimosis - foreskin becomes trapped behind the glans penis, and cannot be reduced (pulled back to its normal flaccid position covering the glans penis)

Question 76

what is Balinitis?

Answer 76

Inflammation under the foreskin, usually related to poor hygiene or fungal infection trmt: hygiene + antifungals +/- circumcision

Question 77

What is Lichen Sclerosis et atrophicus? What does it look like? trmt? complications?

Answer 77

Chronic infiltrating cicatrizing skin condition -> pathological phimosis and meatal stenosis Appears as a white patch or roughened scale on glans or prepuce treatment: Steroids + Circumcision complications: phimosis, carcinoma?

Question 78

what is Balanitis xerotica obliterans (BXO)

Answer 78

Lichen Sclerosis et atrophicus in MALES

Question 79

Peyronie’s disease - what is it? What is it caused by? when does it usually occur and in what patients?

Answer 79

CT d/o where a fibrotic band in the corpora albugenia of the penis that results in a bending of the penis (does not affect the erectile tissue of the corpora cavernosa) trauma (coital trauma or urethral instrumentation) causes an inflammatory fibrotic reaction peak incidences: 20-80 years (median, 53 years) associated with the use of β-blockers, HTN, diabetes, and immune reactions, etc

Question 80

What is Priapism? what is it usually associated with?

Answer 80

painful sustained erection not associated with sexual stimulation or desire associated with - trauma - sickle cell disease (sickled RBC are trapped in vascular channels) - medications (anticoagulants, PDE-5 inhibitors, SARI (trazaBONE), alpha blockers, cocaine)

Question 81

when does penile fractures occur? What is done when this occur?

Answer 81

Sudden bending of the penis during intercourse leading to rupture of the corpora cavernosa and rapid loss of erection; may injure urethra Treatment: repair

Question 82

What is Condyloma acuminata? What is it caused by? histological feature? trmt?

Answer 82

flat, warty, papillary growth on genital surfaces HPV, usually 6/11 strains papillomatosis, acanthosis, hyperkeratosis, and presence of KOILOCYTES chemical or physical destruction, immunotherapy, surgical treatment

Question 83

What is penile cancer? What is it caused by? histological feature? where does it usually metz to?

Answer 83

papillary or flat forms that begins on the glans or inner surface of the prepuce near the coronal sulcus HPV, usually 16/18 strains Invasive Squamous cell carcinomas with variable keratinizatio/ keratin pearl formation Inguinal and iliac lymph nodes, hematogenous spread is uncommon

Question 84

treatment of penile cancer?

Answer 84

control of primary tumor: local excision, laser, or partial penectomy (usually if the tumor is too large) +/- node dissection must assess and treat inguinal nodes to look for metz (usually cancers start off in the penis -> inguinal LN -> pelvic LN -> metz)