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DISORDERS OF THE SCROTUM & TESTES Flashcards

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1
Q

CRYPTORCHIDISM

  1. What is it?
  2. Incidence is directly related to what? 2
A
  1. Undescended testes or absent testes (agenesis)
    - Occurs when one or both of the testicles fail to move down into the scrotal sac.
  2. Incidence is directly related to -birth weight and
    - gestational age:
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2
Q

CRYPTORCHIDISM

  1. ___ of premature males
    - The cause in full term infants is poorly understood
  2. ____% of full term infants are born with undescended testicles:
    Most cases are idiopathic
    Some may be genetic or hormonal
A
  1. 1/3

2. 3-5

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3
Q

CRYPTORCHIDISM PATHOLOGY
1. Testes develop intra-abdominally in the fetus and usually descend into the scrotum through the___________ during the _________ month of gestation

  1. Undescended testicles remain where? 2
A
  1. inguinal canal, 7th to 9th
    • in the lower abdomen or
    • at a point of descent into the inguinal canal
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4
Q

CRYPTORCHIDISM PATHOLOGY

  1. The scrotal sac is what?
  2. The testis can be felt how? 2
  3. Spontaneous decent often occurs during when?
  4. By age what, the incidence decreases to 0.8%?
  5. Spontaneous decent rarely occurs after when?
A
  1. empty
  2. either is
    - not palpable or
    - can be felt external to the inguinal ring
  3. first 3 months of life
  4. 6 months
  5. 6 months of age!
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5
Q
  1. Pathological changes to the undescended testicle can be demonstrated when?
  2. What are these patholoic changes? 3
  3. When the disorder is unilateral, it also may produce morphologic changes in what?
A
  1. at 6-12 months
    • Delay in germ cell development
    • Changes in the spermatic tubules
    • Reduced number of Leydig cells
  3. contralateral descended testicle
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6
Q

CONSEQUENCES OF CRYPTORCHIDISM

4

A
  1. Infertility:
  2. Malignancy—risk is increased!!!
  3. Indirect inguinal hernias
  4. Increased incidence of testicular torsion
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7
Q

Why is infertility decreased in CRYPTORCHIDISM? 3

A
  1. Increases if disorder is bilateral
  2. Decreased sperm counts
  3. Poorer quality sperm
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8
Q

CRYPTORCHIDISM EXAM AND DIAGNOSIS

4

A
  1. Careful examination of genitalia in male infants
  2. Differentiate between undescended testes from retractable testes:
  3. Ultrasound occasionally
  4. Laparoscopy for diagnosis and treatment
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9
Q

Differentiate between undescended testes from retractable testes: How?
4

A
  1. Retract into the inguinal canal with cremasteric muscle reflex
  2. Are usually palpable at birth
  3. Careful palpation in warm room can bring them down
  4. Usually assume a scrotal position during puberty**
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10
Q

CRYPTORCHIDISM Treatment goals?

3

A
  1. Enhance future fertility potential
  2. Placement of the gonad in a favorable place for cancer detection
  3. Improved cosmetic appearance
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11
Q

CRYPTORCHIDISM
1. Orchiopexy should be considered after when, as the rate of descent diminishes considerably after this point?

2.What is it?

A
  1. 6 months of life
  2. Surgical placement and fixation of the testes in the scrotum
    - 95% of orchiopexy patients will be fertile
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12
Q

CRYPTORCHIDISM Lifelong follow-up:
2

What should we educate about?

A
  1. Infertility issues
  2. Testicular cancer issues

**Upon reaching puberty, instruct boys in the necessity of testicular self-examination
This should be done monthly

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13
Q

HYDROCELE
1. What is it?

  1. Unilateral or bilateral?
  2. Usually due to?
A
  1. Excess fluid collects between the layers of the tunica vaginalis usually peritoneal fluid due to a weakness in the patent processus vaginalis**
  2. Can be both
  3. Due to a primary congenital defect or secondary condition
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14
Q 
HYDROCELE
Primary congenital:
1. Found in who?
2. Associated with what?
3. Prognosis?
4. When is surgical treatment indicated?
A
  1. Male infants and children
  2. Associated with indirect inguinal hernia
  3. Infant hydroceles usually close spontaneously
  4. If persists beyond 2 years of age, surgical treatment is indicated
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15
Q

HYDROCELE: Secondary causes?

7

A
  1. Trauma
  2. Epididymitis
  3. Testicular torsion
  4. Orchitis
  5. Infection
  6. Testicular cancer
  7. Appendiceal torsion
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16
Q

HYDROCELE

  1. On palpation feels how?
  2. Can be mistaken for what?
A

1 .Palpated as cystic mass(es)
Can become quite large
2. Mass can be mistaken for a solid tumor

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17
Q

HYDROCELE

Dx? 2

A
  1. Transillumination

2. US

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18
Q

HYDROCELE
1. Hydrocele develops in a young man without apparent cause: How should we

  1. In an adult male, hydrocele is a relatively benign condition
    - Presents how?
    - Feeling of heaviness where?
    - Pain where?
A
  1. Hydrocele develops in a young man without apparent cause:
    - It should be considered cancer until proven otherwise
    - Careful evaluation is needed to exclude cancer or infection
  2. In an adult male, hydrocele is a relatively benign condition:
    - Is often asymptomatic
    - Feeling of heaviness in the scrotum
    - Pain in the lower back
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19
Q

HEMATOCELE
1. What is it?

  1. What can it cause?
  2. Etiologies? 4
A
  1. Accumulation of blood in the tunica vaginalis
    - Can compromise testicle
  2. Causes scrotal skin to become dark red or purple
  3. Etiologies:
    - abdominal surgical procedure
    - scrotal trauma
    - bleeding disorder
    - testicular tumor
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20
Q

SPERMATOCELE

  1. What is it?
  2. Located where?
  3. Attached where?
  4. Usually how big?
  5. Freely movable and should do what?
  6. How can they be problematic?
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A
  1. Painless, sperm-containing cyst that forms on the epididymis
  2. Located above and posterior to the testes
  3. Attached to the epididymis
    - Separate from the testes
    - May be solitary or multiple
  4. Usually greater than 2cm
  5. Freely movable and should transilluminate
  6. Rarely cause problems
    If large, may become painful and require excision
21
Q

VARICOCELE

  1. What is it?
  2. If condition is persistent, what happens? 2
  3. What is decreased in 65% to 74% of men? 2
  4. Rarely found when?
  5. Highest incidence is what ages?
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A
  1. Varicosities of the pampiniform plexus:
    - The network of veins that supplying the testes
  2. If condition is persistent,
    - damage to the elastic fibers and
    - hypertrophy of the vein wall occurs (like varicose veins in the legs)
    • Sperm concentration and
    • motility are decreased in 65% to 74% of men
  4. Rarely found before puberty
  5. Highest incidence is men between 15 and 35 years of age
22
Q

VARICOCELE
LEFT SIDE MORE COMMON
1. Left gonadal vein inserts where?

  1. Right gonadal vein enters where?
  2. Incompetent valves are more common in the left, causing what?
  3. The force of gravity resulting from the upright position also contributes to what?
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A
  1. in the left renal vein at a right angle.
  2. inferior vena cava.
  3. reflux of blood back into the veins of the pampiniform plexus.
  4. venous dilatation.
23
Q

VARICOCELE SYMPTOMS/EXAM
-Can present how? 5

  • Usually readily Dx how?
  • Exam should be done with the pt in what position?
  • The varicocele typically disappears how?
  • Scrotal palpation will feel how?
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A
  1. Can be asymptomatic.
  2. Dull aching,
  3. atrophy, and
  4. infertility
  5. An abnormal feeling of heaviness in the left when standing and relieved when recumbent
  6. Usually readily diagnosed on PE:
  7. Exam should be done with the patient in the standing and recumbent position.
  8. The varicocele typically disappears in the supine position
  9. Scrotal palpation will feel like “a bag of worms”
24
Q
  1. VARICOCELE TREATMENT
    3
  2. Who is this necessary in?
  3. Obliteration of the dilated veins. How? 3
  4. For those who are not needing increased fertility— how should we treat? 2
Study These Flashcards
A
    • Surgical ligation of the gonadal vein**
    • Interventional radiology
    • Embolization of veins
  2. Necessary in young males who are showing testicular atrophy**
    • Some improvement in infertility
    • Relief of the “heavy” feeling
    • Cosmetic improvement
  4. NSAIDS & scrotal support
25
TESTICULAR TORSION 1. What is it? 2. Two peak ages? 3. Acute urological emergency?
1. Twisting of the spermatic cord that suspends the testis 2. Two age peaks: - Perinatal and prepubertal - Presents between ages 10-25 3. Acute urological emergency—viability of the testes is at risk
26
What is pathogonomic for torsion of appendix testes?
Blue dot sign (of dangerous appendix testis)
27
``` TESTICULAR TORSION Congenital, neonates: 1. Prevalence? 2. How will it look? 3. Color? 4. Swelling? 5. Rule out? ```
1. Less common 2. Firm, smooth, painless scrotal mass 3. Scrotal skin appears red 4. Some edema 5. Physical exam and exclude the presence of a hernia WONT TRANSILLUMINATE
28
TESTICULAR TORSION Pediatrics and Adolescents: 1. Severity? 2. PP? 2 3. Rarely seen after age___? 4. What is essential?
1. This is a true surgical emergency 2. - Testes rotates on the long axis of the tunica vaginalis, rotates about the distal spermatic cord - Cuts off blood supply to the testis 3. 30 4. Early recognition and treatment are
29
Symptoms of testicular torsion? 7 Degree on swelling and redness depends on what?
1. Patients present in severe distress within hours of onset 2. Often accompanied with nausea and vomiting 3. Tachycardia 4. Large, firm and tender testes 5. Pain radiates to inguinal area 6. Testicle is often high in the scrotum and in abnormal orientation 7. Cremasteric reflex is frequently absent Degree of swelling and redness depends on the duration of the symptoms
30
1. IMAGING: testicular torsion? | 2. What is our referral window?
1. Color Doppler ultrasonography must be done right away 2. Referral to urology!!!! 4-6 hour window
31
TESTICULAR TORSION 1. Attempt _________, which can be attempted with pain relief as the guide for successful detorsion 2. The procedure is similar to the "what" when the provider is standing at the patient's feet? 3. Most torsions twist inward and toward the mid line; thus, manual detorsion of the testicle involves twisting how?
1. manual detorsion 2. opening of a book 3. outward and laterally.
32
If manual detorsion doesnt work: 1. First option? 2. Second?
1. Surgical detorsion and fixation of the testicle (orchiopexy) 2. Orchiectomy
33
1. When is a Orchiectomy done? 2. Salvage rates are directly related to what? 3. What prophylatic measure is performed?
1. Done when testis is deemed nonviable after surgical detorsion 2. Salvage rates are directly related to the duration of the torsion 3. Usually prophylactic fixation of the opposite testicle is performed!
34
What are the two major types of epididymitis?
1. Sexually transmitted infections: | 2. Primary non-sexually transmitted infections
35
Sexually transmitted infections: 1. Associated with what? 2 2. Bugs? 2 Primary non-sexually transmitted infections 1. Associated with what? 3 2. Bugs? 3 Other causes? 2
Sexually transmitted infections: 1. - Associated with urethritis - Associated with young men 2. - N. Neisseria gonorrhea - Chlamydia trachomatis Primary non-sexually transmitted infections: 1. - Associated with UTI’s and - Prostatitis - Associated with men over 35 2. - E-coli - Pseudomonas - Gram-positive cocci -Post vasectomy -Trauma *****Most cases of epididymitis are caused by bacterial pathogens.
36
EPIDIDYMITIS 1. What is it? 2. Can also experience reactive hydrocele. How will this present? 3. Symptoms? 4
1. Unilateral pain and swelling in the epididymis over a period of days 2. Erythema and edema of the overlying scrotal skin Can become extremely large (reactive hydrocoele) 3. - Tenderness over the groin or in the lower abdomen - Fever - Dysuria - Could have urethral discharge if gonococcal
37
EPIDIDYMITIS LABS | 4
1. CBC 2. Urinalysis and culture 3. Urethral culture (or urine NAAT) 4. Gram stain
38
EPIDIDYMITIS TREATMENT | 4
1. Scrotal elevation and support 2. Antibiotics appropriate to age, physical findings, urinalysis, cultures or gram’s stain, sexual history 3. Oral analgesics and antipyretics 4. Sexual activity or physical strain should be avoided until symptoms resolve
39
HYPOGONADISM Definition? Etiologies? 5
1. Definition: - Testosterone deficiency with associated symptoms or signs, deficiency of spermatozoa production, or both - Either primary or secondary Etiology 1. Primary hypogonadism 2. Failure of testes to respond to FSH and LH 3. Testosterone is low to inhibit production of FSH and LH 4. Most common cause is Klinefelters Syndrome Secondary hypogonadism 5. Failure of hypothalamus to produce gonadotropin-releasing hormone (GnRH) or pituitary gland to produce enough FSH and LH
40
``` Signs and Symptoms 3 categories 1. Congenital hypogonadism? 2 2. Childhood-onset? 1 3. Adult-onset? 3 ```
Congenital hypogonadism 1. 1st trimester- Results in inadequate male sexual differentiation 2. 2nd or 3rd trimester- Results in microphallus and undescended testes Childhood-onset -Impairs development of secondary sexual characteristics 3. Adult-onset - Decreased libido - ED - Depression and anger
41
How will childhood onset hypogonadism affect them as adults? 5
As adults have: 1. Poor muscle development 2. High-pitched voice 3. Small scrotum 4. Decreased penis and testicular growth 5. Sparse pubic and axillary hair
42
HYPOGONADISM Dx? 3 Treatment? 1 Adverse affects? 5
``` 1. Diagnosis Begin with; -FSH -LH -Free/Total testosterone levels ``` 2. Treatment -Testosterone replacement therapy (TRT) Gel 1% or 1.62% Transdermal axillary solution Transdermal patch Sub-Q implants IM injections (cheapest) 3. Adverse effects - Erythrocytosis - Venous thromboembolism - Acne - Gynecomastia - Low sperm counts
43
INFERTILITY 1. What is this? 2. Causes? 4 3. Male factors? 3
1. Inability to get pregnant after trying for at least 1 year - About one-third of cases are caused by male factor 2. Causes: - Blockage of the reproductive system - Medicines - Undescended testicles - Infections 3. Male factors - Pretesticular - Testicular - posttesticular
44
INFERTILITY 1. Ask about medical history Such as?4 2. Physical Exam? 6
1. - Previous semen analysis - ED or other sexual dysfunction - Trauma - Previous pregnancies 2. - Testicular size - Vas deferens - Spermatic cord - Penis - Rectum - Body habitus
45
INFERTILITY Dx? 5
1. Semen analysis 2. Antisperm antibody test 3. Hormonal analysis 4. Transrectal ultrasound 5. Scrotal ultrasound
46
Semen analysis looks at what? | 4
``` 1. Semen volume 2-5ml pH level 7.2-7.8 2. Sperm density >20 million 3. Motility 50% forward progessive 4. Morphology >60% normal ( ```
47
INFERTILITY | Tx?
1. Boxer shorts 2. Avoid hot tubs 3. Timing of intercourse 4. Avoid illegal drugs, chemicals, and spermicidals 5. Medications 6. Surgical
48
Infertility meds? 3 Surgica options? 4
1. Medications - Clomiphene citrate (Clomid) - Imipramine - Zoloft 2. Surgical - Varicocelectomy - Vasovasostomy - Testicular biopsy (TESE) - Transurethral resection of ejaculatory ducts

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