5/14 Scrotum, Penis, Testis Flashcards Preview

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Flashcards in 5/14 Scrotum, Penis, Testis Deck (84):

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

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


What is acute scrotum?

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)


∆ btwn Epididymitis and Epididymo-orchitis?

Epididymitis - Infection of epididymis

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

both are infectious causes of acute scrotum


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

*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


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

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

BPH - lower urinary tract symptoms (urgency/frequency)


How would gonorrhea cause Epididymitis or Epididymo-orchitis?

urethra --> prostate --> seminal vesicles --> epididymis

inflammation may lead to abscess and destruction!


How do you know if mumps is causing the orchitis?

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


How do you know if TB is causing the orchitis?

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


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

testes --> epididymis
presence of inflammation and endarteritis or gumma


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

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


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

how do these things form?

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)


US finding of Epididymitis or Epididymo-orchitis?

increased or “reactive” flow secondary to inflammation


review: what causes fournier's gangrene?
clinical presentation?

polymicrobial (aerobic + anaerobic) infection

Necrotizing cellulitis and fasciitis, crepitus (air in skin)

emergency surgical debridement otherwise it can spread rapidly


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

inflammatory cause of acute scrotum


review: what causes Henoch-Scholein Purpura?

When does it usually occur?


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


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

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

orchitis can result (pain/swelling of the testicles)


how can tumors cause acute scrotum?

Tumor that causes the tunica albuginea surrounding the testicle to tear


how can trauma to the testes cause acute scrotum?

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


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

hematocele - occur when blood collects under the tunica albuginea

usually occurs due to trauma to the testes...ouch.


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

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

- sudden onset in testicular pain
- absent cremasteric reflet


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

Intravaginal torsion - adults
Extravaginal torsion - neonates

*know this*


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

who is most at risk?

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


What does intravaginal torsion occur?

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


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

who is most at risk?

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


US findings testicular torsion?

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


∆ in etiology btwn incarcerated hernia and strangulated hernia?

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)


∆ in sx btwn incarcerated hernia and strangulated hernia?

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

strangulated: severe pain + tenderness


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

surgical emergency due to tissue necrosis risk


Path of indirect hernia?

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


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

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


path of direct hernia?

who does it usually occur in?

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


What is a spermatocele? Does it cause acute scrotum?

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


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

watery fluid that contains spermatozoa


How would you diagnose spermatocele?

US - fluid filled cyst
Transillumination (+)


How does a spermatocele compare to a hydrocele?

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)


∆ btwn

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


risk factors for testes cancer?

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)


clinical presentation of testes cancer?

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


how does testicular cancer present on an US?

hypoechoic solid mass = cancer until proven otherwise


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

AFP – yolk sac elements; t1/2 = 5d

ßhCG – produced by syncytiotrophoblasts; t1/2 = 24h

LDH – measure of cellular turnover or tumor burden


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

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


How is testicular cancer graded?

Serum Markers


How is testicular cancer staged?

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


Two types of germ cell tumors?

Seminomatous GCT
Non-Seminomatous GCT


Types of Seminomatous GCT?

Spermatoctic seminoma



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

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


gross hx:
micro hx:

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


Spermatoctic seminoma

when does it usually occur?
is it malignant?
tumor markers?

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


Spermatoctic seminoma
gross hx:
micro hx:

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)


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

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


Where does Non-Seminomatous GCT usually arise from?

What are the different types of Non-Seminomatous GCT?

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


Embryonal carcinoma is also known as:

is it malignant?
tumor markers?

“angry tumor”

PAINFUL (worse prognosis than seminoma)

increased hCG + normal AFP when pure
increased hCG + increased AFP if mixed


Embryonal carcinoma
gross hx:
micro hx:

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


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

extra-embryonic mesoderm and endoderm

aggressive malignancy

usually in boys < 3yo

tumor marker: AFP


Yolk Sac Tumor:

gross hx:
micro hx:

gross: non-encapsulated; homogenous yellow-white mucinous appearance

micro: Schiller-Duval body + hyaline globules


What are Schiller-Duval bodies?

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


where does it arise from?
is it malignant?
tumor markers?

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


gross hx:
micro hx:

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


where does it arise from?
is it malignant?
tumor markers?

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


Teratoma - ∆ btwn mature and immature forms?

mature: structures derived from all 3 germ layers

immature: resembles embryonic tissue or fetal tissue
w/ secondary malignant component


Teratoma - ∆ btwn adult and childhood forms?

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)



gross hx:
micro hx:

gross: variegated, nodular, solid & cystic

micro: subtypes are defined by the maturity of the tissues; various structures (gut, brain, keratin)


How do you treat a Non-Seminomatous GCT?

What is critical to note in the treatment of these tumors?

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


Sex-Cord Stromal Tumors?

Leydig Cell tumor
Sertoli cell tumor


when and where does a leydig cell tumor present?

presents 20-60yo

present outside of the seminiferous tubules


sx of Leydig Cell tumor?

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


Leydig Cell tumor
gross hx:
micro hx:

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

histology: reinke crystals


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

present inside of the seminiferous tubules

(leydig = outside)


sx of sertoli cell tumor?

usually hormonally silent and benign


Sertoli cell tumor gross presentation?

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


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

common testicular cancer in older men

not a primary cancer but actually arises from lymphoma metz to the testes



Hypospadias - what is it?

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


Hypospadias trmt?

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


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

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


what is a phimosis? paraphimosis?

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)


what is Balinitis?

Inflammation under the foreskin, usually related to poor hygiene or fungal infection

trmt: hygiene + antifungals +/- circumcision


What is Lichen Sclerosis et atrophicus?

What does it look like?



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?


what is Balanitis xerotica obliterans (BXO)

Lichen Sclerosis et atrophicus in MALES


Peyronie’s disease - what is it?

What is it caused by?

when does it usually occur and in what patients?

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


What is Priapism? what is it usually associated with?

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)


when does penile fractures occur?

What is done when this occur?

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

Treatment: repair


What is Condyloma acuminata?

What is it caused by?

histological feature?


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


What is penile cancer?

What is it caused by?

histological feature?

where does it usually metz to?

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


treatment of penile cancer?

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)