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Clin med A 2 > Penile and scrotal disorders > Flashcards

Penile and scrotal disorders Flashcards

1
Q

what is a hydrocele?

A

accumulation of fluid around the testis

MCC of painless scrotal swelling in peds; can also occur in adults

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2
Q

what are the three types of non-comunicating hydroceles

A
  • Testicular - around testicle only
  • Inguinoscrotal - testicle and inguinal region
  • Cord - adjacent to spermatic cord
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3
Q

what are communicating hydroceles? how common is it?

A
  • hydroceles that communicate with the peritoneal cavity.
  • may change during the day with activity
  • processus vaginalis is patent in:
  • > 80% of newborns
  • 40-50% of 2 year olds
  • 25% of adults
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4
Q

what are the s/s of hydroceles

A
  • fluid filled cystic scrotal mass, anterior to testis
  • usually little/no pain
  • +/- scrotal fullness/heaviness
  • usually gradually onset
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5
Q

what is the PE for hydroceles

A
  • no inflammation
  • nontender
  • transillumination presents with light shining through the fluid
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6
Q

when are UA and US indicated in Hydroceles?

A
  • UA - evaluates for signs of infection if suspicious
  • US - evaluates for masses, delineates extent of fluid (can get doppler for blood flow if suspected torsion)
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7
Q

what idicates whether you should treat a hydroceles?

A
  • No treatment - infantile, asymptomatic, noncommunicating is physiologic and will resolve in 18-24 months
  • treat - if persist >12-18 mo, is communicating or symptomatic
  • treat if acute onset
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8
Q

what is the treatment for hydroceles

A
  • needle aspiration of fluid +/- sclerotherapy to tunica vaginalis (less invasive but high rate of recurrence)
  • hydrocelectomy (excision of hydrocele sac. definitive)
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9
Q

when should you refer hydroceles?

A
  • sudden onset
  • symptomatic
  • if pt wants treatment
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10
Q

what is a varicocele

A

Dilated, engorged, tortuous veins within the pampiniform plexus of scrotal veins

“varicose veins in scrotum”

This is the most surgically correctable cause of male infertility!!

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11
Q

what side are vericoceles MC on? why?

A

The left side! due to testicular veins draining into the L renal vein instead of into the IVC!

Unilateral R varicocele can indicate possible IVC obstruction

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12
Q

what are the symptoms of varicoceles

A
  • scrotal enlargement or heaviness
  • +/- dull aching pain
  • may have infertility as initial complaint
  • may be asymptomatic
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13
Q

What will the PE show in varicoceles

A
  • dilated veins in scrotal sac “bag of worms” feeling (ew)
  • increased with standing and valsalva
  • may improve w supine position
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14
Q

what diagnostic studies are ordered for varicoceles

A
  • labs to rule out other disorders
  • US to confirm diagnosis
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15
Q

what is the treatment for varicoceles

A
  • asymptomatic = observation only
  • conservative = scrotal support, NSAIDS
  • severe s/s or fertility desired = surgical tx.
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16
Q

what are surgical tx options for varicoceles

A
  • Occlusion (balloon) or embolization of spermatic vein
  • Injected ablation (sclerotherapy) of spermatic vein
  • Surgical ligation of pampiniform plexus
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17
Q

what are complications of varicoceles? how do we prevent varcioceles?

A
  • complications - testicular atrophy, infertility
  • prevention - regular TSE for early diagnosis and treatment
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18
Q

what is testicular torsion

A

Twist in the spermatic cord causing compromised testicular blood supply

THIS IS AN EMERGENCY

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19
Q

when is testicular torsion most common?

A

peaks in neonatal period and early puberty

65% of cases are 12-18 y/o males

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20
Q

what are risk factors for testicular torsion

A
  • Trauma
  • Vigorous exercise or sexual intercourse
  • Cryptorchidism
  • Bell-clapper deformity
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21
Q

what are symptoms of testicular torsion

A
  • Sudden onset of severe unilateral scrotal pain and swelling
  • +/- lower abdominal pain, N/V
  • +/- hx of intermittent similar symptoms
  • Lack of voiding symptoms
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22
Q

what are PE findings in testicular torsion

A
  • Classic - high-riding testis, slightly larger than unaffected testis, transverse lie in scrotum
  • Often erythematous and tender
  • Pain does not relieve with scrotal support (negative Prehn’s sign)
  • Cremasteric reflex - stroke or pinch skin of upper thigh while observing ipsilateral testis - typically absent in torsion
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23
Q

what are the diagnostic studies used for testicular torsion

A
  • Doppler US (test of choice!! if inconclusive or unavailable must do surgical exploration)
  • UA - r/o infection
  • radionuclide scintigraphy - can also demonstrate low blood flow
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24
Q

what are complications of testicular torsion

A
  • infertility
  • testicular necrosis and loss
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25
Q

What is the treatment for testicular torsion?

A
  • manual (opening book method) - give anesthesia and turn affected testicle in the medial to lateral direction 180-720 degrees. success = pain relief. THIS STILL REQUIRES SURGICAL FIXATION
  • surgery - detorsion and fixation of involved testis and contralateral testes. pre-lab = CBC/renal function
  • pain relief with narcotics

note: 1/3 of patients require manual turning in the lateral to medial direction

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26
Q

what is the TWIST scoring system

A

Testicular W/U for Ischemia and Suspected Torsion

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27
Q

what is the prevention methods for testicular torsion

A

Avoidance of testicular trauma
Pre-emptive correction of diseases such as cryptorchidism and bell-clapper deformity

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28
Q

what is testicular appendage torsion?

A

torsion affecting one of the four testicular appendages which are:
appendix testis (90%), appendix epididymis (8%) , paradidymis, vas aberrans

MC in YOUNGER patients!!

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29
Q

what are the symptoms of testicular appendage torsion

A
  • Similar but less severe than testicular torsion
  • Scrotal pain, +/- swelling
  • Normal, minimally tender scrotum and testicle on exam
  • Might localize tenderness to upper pole of testis / epididymis
  • “Blue dot sign”
  • Later in course - scrotal edema +/- hydrocele
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30
Q

what would an ultrasound show in testicular appendage torsion

A
  • normal testicular blood flow
  • small hyperechoic region adjacent to testis
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31
Q

what is the treatment for testicular appendage torsion

A
  • Scrotal support, limitation of activity
  • Oral analgesics (NSAIDS)
  • If unable to r/o testicular torsion - surgery
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32
Q

what is Phimosis? what is the MCC?

A

contracted foreskin that cant retract over the glans penis

MCC - Chronic infection from poor local hygiene

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33
Q

what is the cause of phimosis in younger children? what about in older men who are diabetic?

A
  • Children < 2-3 yrs - often physiologic
  • Diabetic older men - often due to chronic balanoposthitis
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34
Q

what are the symptoms of phimosis

A
  • May have no s/s other than inability to retract foreskin
  • Edema, erythema and tenderness of prepuce or purulent discharge if infected
  • “Ballooning” of prepuce during urination
  • Only emergent if urinary retention
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35
Q

what is the treatment of phimosis caused by infection

A
  • fungal → topical clotrimazole or nystatin or oral fluconazole
  • Bacterial → topical bacitracin, oral metronidazole (Flagyl)
  • Cellulitis or extends to shaft → cephalexin (Keflex)
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36
Q

What is the treatment of temporary phimosis

A
  • hemostat dilation, catheter, topical steroids
  • Frenar stretch +/- steroids - gradually increase compliance
  • Surgical incision - dorsal slit
  • Catheter - if urinary retention present
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37
Q

what is the treatment for recurrent or persistent phimosis or balanitis/balanopsthitis?

A

circumcision

38
Q

what are the complications of phimosis

A
  • preputial calculi - dysuria, gross hematuria, foul smelling discharge, ballooning, calculi (tx is calculus removal, incision, circumcision)
  • squamous cell carcinoma (asymptomatic or similar s/s of calculi, may see BIL inguinal LAD)
  • urinary retention, UTI, dyspareunia, painful erections
39
Q

what is the preventive measures for phimosis

A
  • Proper hygiene of foreskin
  • Control of systemic conditions
  • Circumcision
40
Q

what is paraphimosis

A

Inability to reduce previously retracted foreskin causing fixed in retracted position proximal to corona and glans

this can lead to Lymphedema and venous congestion of prepuce → arterial occlusion → necrosis, gangrene, autoamputation

41
Q

what are causes of paraphimosis

A
  • Pre-existing phimosis
  • Failure to replace foreskin
  • Sexual activity, erotic dancing
  • Penile trauma
  • Plasmodium falciparum
  • Forceful retraction (infant foreskin)
42
Q

what are symptoms of paraphimosis

A
  • Swollen, erythematous, tender foreskin proximal to glans
  • “Donut sign”
  • Swollen, erythematous, tender glans; may be necrotic
  • Flaccid penis proximal to foreskin
43
Q

what is the treatment of paraphimosis

A
  • emergent urology consult for manual reduction!!!! (manual pressure on glans for 5 min to reduce edema then push glans proximally while pulling prepuce distally!)
  • refractory to manual reduction may need needle decompression, dorsal slit of foreskin, or osmotic agents.
  • consider abx
  • circumcision after inflammation subsides!
44
Q

what are complications of paraphimosis

A
  • penile ischemia, necrosis and gangrene
  • loss of penile tissue
45
Q

what are preventative measures for paraphimosis

A
  • Avoidance of precipitating activities
  • Proper education on care of foreskin and glans
  • Treatment of phimosis
  • Circumcision
46
Q

What is priapism

A

A prolonged and painful pathological erection
(engorgement of the corpora cavernosa with blood, often not associated with sexual stimulation)

47
Q

what are causes of priapism

A
  • 60% idiopathic
  • MC cause is intracavernous injection ED treatment
  • diseases such as sickle cell, leukemia, cancer (in children MC cause is sickle cell and other hematologic diseases)
  • trauma
  • medications (anti-HTN, psych meds, oral ED meds)
48
Q

What is the difference between high flow (nonischemic) priapism and low flow (ischemic) priapism

A
  • high flow is rare and often painless, resulting from trauma to the perineum which causes loss of penile arterial regulation
  • low flow is more common and painful, resulting from a physiologic obstruction of venous drainage.
49
Q

How do you diagnose and treat high flow priapism

A
  • Doppler US of penis - aneurysms of central arteries
  • Aspirated blood → high O2, low CO2
  • Treat with embolization of aneurysms
50
Q

how do you diagnose low flow priapism

A

Aspiration of dark acidic low CO2 intracavernosal blood from corpus cavernosum

51
Q

What are the symptoms of high and low flow priapism

A
  • High flow - painless prolonged erection
  • low flow - several hours of painful erection where the glans penis and corpus spongiosum are soft and uninvolved. The corpora cavernosa is tense and congested with blood and tender to palpation
  • Low flow is a urologic emergency!!!
52
Q

what is the treatment for priapism

A
  • Anesthesia - narcotics; epidural or spinal
  • Subcutaneous terbutaline can be used for early tx
  • Corporal aspiration of viscous blood with irrigation (plain saline or alpha adrenergic agonists)
53
Q

what is the treatment for refractory priapism

A
  • Winter procedure - needle through glans into corpora → fistula between corpora cavernosa and corpus spongiosum
  • Excision of tunica albuginea
  • Cavernosa-spongiosum shunt
  • Saphenous vein-cavernous shunt
54
Q

what are the complications of priapism

A
  • If Prolonged → interstitial edema and fibrosis of corpora cavernosa, causing impotence and permanent damage!
  • possible urinary retention
55
Q

What are the preventative measures for priapism

A
  • Avoidance of known causative factors and trauma
  • Optimal management of comorbid diseases
  • Early treatment to avoid impotence
56
Q

What is peyronie’s disease

A
  • Fibrosis of dorsal covering sheaths (tunica albuginea of corpora cavernosa)
  • this does not permit involved area to lengthen with erection and causes a curved penis when erect
  • mostly found in middle-aged and older men
57
Q

what are the causes of peyronie’s disease

A
  • cause is unclear BUT, this is what the slide said
  • Trauma to penis during intercourse
  • Vasculitis and connective tissue disease
  • DM and hypercholesterolemia
  • Associated with smoking, ETOH, Dupuytren contracture
  • Genetic predisposition
58
Q

what are the symptoms of peyronie’s disease? What will the PE show in these patients?

A
  • Painful erection, penile curvature
  • Poor erection distal to curved area
  • Usually no pain without an erection
  • PE will show raised; firm plaque to dorsal penis, often midline
59
Q

What is the treatment for peyronie’s disease

A
  • initially observed because 50% have spontaneous remission
  • oral - vitamin E, para-aminobenzoic, colchicine
  • intralesional injection - verapamil, steroids, dimethyl sulfoxide, or PTH
  • radiation therapy
  • surgical - excision of plaque with graft of skin, vein, or tunica vaginalis graft; excision of plaque with suturing (if impotent insert penil prosthesis)
60
Q

What are complications of peyronie’s disease

A
  • ED
  • impotence
  • physiological complications
61
Q

what are preventative measures for peyronie’s disease

A
  • avoidance of penile trauma
  • limit alcohol and tobacco use
  • control comorbidities
62
Q

what is the MC type of penile cancer

A

squamous cell carcinoomas

63
Q

how common is penile cancer?

A
  • rare in developed countries (<1% of cancers in men in US)
  • common in underdeveloped countries (10-20% of cancers in men)

Average age of dx is 60 years but it can be much younger.

64
Q

what are the risk factors for penile cancer

A
  • Chronic infection/inflammation, HPV - seen in 30-50% of all penile carcinomas, HIV - increases incidence by 4-8x
  • Hx of penile injury or urethral stricture
  • Hx of phimosis
  • Hx of tobacco use
65
Q

what are the symptoms of penile cancer

A
  • MC is skin abnormality or palpable lesions on the penis (25% painless lump, 13% ulcers, 6% rash)
  • inguinal LAD in 30-60% (50% are malignant infiltration related, 50% are inflammatory reactions to cancer)
  • metastatic symptoms (bone pain, cough, skin lesions)
66
Q

what are diagnostics for penile cancer

A
  • If s/s of infection (erythema, discharge) - may do 4-6 week trial of abx
  • No s/s of infection or if worsening/no improvement with abx - biopsy (May also do biopsies of inguinal lymphadenopathy)
  • Metastatic Symptoms - bone pain, cough, skin lesions indicate CT of chest/abd/pelvis, general lab work/up (CBC, BMP/CMP)
67
Q

what is the treatment for penile cancer?

A
  • if low risk of recurrence then do a limited excision. This is for minimally invasive tumors. Goal is to preserve as much anatomy/function as possible. Laser therapy, topical therapy and radiation may also be used
  • If higher risk recurrence do partial or total penile amputation +/- inguinal lymph node dissection and chemotherapy/radiation.
68
Q

what is epididymitis? what are the two types?

A

inflammation of the epididymis!

STD related (typically men<40) - associated with urethritis, chlamydia and gonorrhoeae

non-STD related (typically men 40+) - associated with UTI, Postatitis and G- rods (e. coli, proteus, klebsiella

Other causes include medications such as amiodarone as well as reflux of urine.

69
Q

what are signs and symptoms of epididymitis

A
  • May present after physical strain, trauma, or sex
  • +/- urethritis, prostatitis or cystitis symptoms
  • Fever
  • Pain and swelling in scrotum - may radiate
  • Early - testicle normal or minimally tender and epididymis is tender and palpable
  • Late - may be hard to distinguish from testis
  • +/- reactive hydrocele
  • +/- inguinal lymphadenopathy
  • May see positive Prehn’s sign
70
Q

what diagnostic studies would be used in the evaluation of epididymitis

A
  • UA - pyuria, bacteriuria, hematuria, culture
  • Urethral swab (Gonorrhea - G- intracellular diplococci. Chlamydia - WBC without visible organisms )
  • PCR for gonorrhea/chlamydia
  • CBC - leukocytosis and left shift
  • ESR/CRP - may be increased
71
Q

what are complications of epididymitis

A
  • Infectious - orchitis, chronic epididymitis, sepsis, abscess
  • Long-term - fibroplasia, decreased fertility
72
Q

what is the treatment for epididymitis

A
  • bed rest, scrotal elevation, ice packs
  • analgesics (NSAIDS)
  • Abx if likely STD - empiric tx is ceftriaxone + doxycycline
  • if its unlikely to be an STD you can give levo or bactrim
  • improvement should occur within 3 days and resolution within 2-4 weeks
73
Q

what are preventative measures for epididymitis

A
  • Prompt treatment of prostatitis, UTI, urethritis
  • Safe sex practices
  • Treatment of partners with STIs
  • Minimize use of foley catheters
74
Q

What is orchitis

A

Inflammation/Infection of testis (usually occurs with other illnesses)

75
Q

what are causes of orchitis

A
  • Bacterial - usually complication of epididymitis
  • Granulomatous - autoimmune response to sperm
  • Viral - M/C mumps; also EBV, coxsackie, VZV, echovirus
76
Q

what are signs and symptoms of orchitis

A
  • Swelling, tenderness and erythema of testis +/- urethritis, cystitis, prostatitis, epididymitis +/- reactive hydrocele
  • scrotal pain - more gradual onset and less severe than torsion. May have positive prehn’s sign
  • fever, +/- nausea and vomiting (may have malaise, resp symptoms, parotid swelling)
  • +/- inguinal LAD
77
Q

what are diagnostic studies for evaluation of orchitis

A
  • UA - pyuria, bacteriuria, hematuria, culture
  • Urethral swab (Gonorrhea - G- intracellular diplococci. Chlamydia - WBC without visible organisms)
  • PCR for gonorrhea/chlamydia
  • CBC - leukocytosis and left shift
  • ESR/CRP - may be increased
78
Q

what is the treatment for orchitis

A
  • Bed rest, scrotal elevation, ice packs
  • analgesics (NSAIDs)
  • Abx empiric - ceftriaxone + doxy
  • Abx if practicing anal sex - ceftriaxone + levo
  • abx if unlikely to be STD - levo only
  • if viral, supportive care only
79
Q

what are complications for orchitis

A
  • Infectious - sepsis, abscess formation
  • Long-term - fibroplasia, decreased fertility, testicular atrophy
80
Q

what are preventative measures for orchitis

A
  • Prompt treatment of UTIs - prostatitis, cystitis, urethritis, epididymitis
  • Safe sex practices
  • Tx of partners with STDs
  • Minimize use of foley catheters
  • Vaccination
81
Q

what are the types of scrotal masses

A
  • hydrocele
  • spermatocele
  • epididymal cyst
82
Q

what is an epididymal cyst and how does it present?

A
  • found on head of epididymus
  • Asymptomatic
  • Associated with DES use during pregnancy and Von Hippel-Lindau disease
  • Noted on exam - US can assist diagnosis
  • No specific tx needed
83
Q

what is a spermatocele? how does it present and how do you diagnose and treat it?

A
  • epididymal cyst >2 cm (2-5 cm) that is Superior to and distinct from testis
  • rarely symptomatic; may be painful
  • US - can assist diagnosis
  • treatment - observation, may need surgical excision
84
Q

what is the MCC of solid testicular tumors in men 18-40

A
  • cancer!
  • MC cancer males 20-35
  • 90-95% are germ cell tumors
85
Q

What are risk factors for testicular tumors

A
  • Cryptorchidism (10% cancer is pts with + hx)
  • Exogenous estrogen during pregnancy
  • Infertility
  • Family history, HIV, ethnicity
  • Questionable - trauma, infection-related atrophy, high fat diet
86
Q

What are signs and symptoms of testicular tumors

A
  • usually a 3-6 mo delay to tx
  • MC symptom is painless enlargement of testis (testicular or scrotal heaviness or painless nodules on
  • acute testicular pain (10%)
  • metastatic symptoms (10%)
  • asymptomatic (10%)
87
Q

what are the symptoms of metastasis for the different metastatic areas

A
  • MC site of metastasis - retroperitoneal abdominal lymph nodes
  • Back pain (retroperitoneal)
  • Cough/dyspnea (pulmonary)
  • Anorexia, N/V (retroduodenal)
  • Bone pain (skeletal)
  • LE swelling (IVC obstruction)
88
Q

What diagnostic studies can be done in evaluation of testicular tumors

A
  • Alpha-fetoprotein, hCG, LDH
  • advanced - anemia, LFTs, renal function
  • scrotal US - initial eval (after dx stage with CT abdomen/pelvis)
  • definitive dx - radical inguinal orchiectomy (Transscrotal biopsy is contraindicated)
89
Q

what is treatment for testicular tumors

A
  • Inguinal exploration with vascular control of spermatic cord (If CA not excluded by examination, orchiectomy)
  • Radical inguinal orchiectomy
  • Radiation/chemo depends on subtype
90
Q

What is the follow up protocol for testicular tumors

A
  • Monthly for 1st 2 years, bimonthly 3rd year
  • Tumor markers at each visit
  • CXR and CT every 3 months
  • 80% relapse in 1st 2 yrs after treatment
91
Q

what is the prognosis for testicular tumors

A
  • Most cancers - 90% + 5 year survival rates
  • Disseminated or bulky (> 10 cm) retroperitoneal disease - 55-80%
92
Q

that wasnt too bad

A

lil baby!

Clin med A 2 (30 decks)

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