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Gu Exam 3 > Scrotal and Penile Disorders > Flashcards

Scrotal and Penile Disorders Flashcards

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1
Q

Scrotal masses that are always painful

A

● Epididymitis
● Orchitis
● Testicular Torsion

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2
Q

Scrotal masses/pain categories - HIMBIN

A

● Hernias (inguinal, femoral)
● Infections (epididymitis, orchitis, prostatitis, cellulitis, scrotal abscess)
● Masses (hydrocele, epididymal cysts, testis cancer)
● Blood flow issues (testicular torsion, varicocele)
● Inflammation (Non-bacterial, idiopathic, chronic inflammatory pain)
● Nerve related (Chronic, normal u/s, history of back injury, referred pain)

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3
Q

Hydrocele

A

Fluid accumulation between tunica layers of the testis

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4
Q

Hydrocele etiology

A

● Fluid accumulation between tunica layers of the testis
○ In children, fluid develops from communication directly with the abdomen
○ In adults, usually fluid accumulates through diffusion with time
○ May be associated with testicular cancer (10%) or abdominal masses

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5
Q

Hydrocele Presentation - Adult vs. Children

A

● Adult: Gradually (generally
painless) enlarging testicle
● Children: Enlarged scrotum, typically painless, that goes away in when the child lays down (the fluid drains back into the abdomen)

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6
Q

Hydrocele Diagnosis

A

● Bilateral comparison
● Transillumination – Fluid accumulation of the
anterior superior aspect of the testicle
● Ultrasound

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7
Q

Hydrocele Diagnosis

A

● Bilateral comparison
● Transillumination – Fluid accumulation of the
anterior superior aspect of the testicle
● Ultrasound

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8
Q

Hydrocele Management

A

● Observation – scrotal support
● Refer
● Drainage – needle aspiration
○ Temporary solution
● Surgical excision – Hydrocelectomy

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9
Q

Spermatocele

A

Fluid accumulation in the epididymis
● “Hydrocele” or cysts of the epididymis
● Can be confused with hydrocele on exam (if large enough)

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10
Q

Spermatocele Presentation

A

● Similar to hydrocele
○ Painless, sometimes bothersome mass of the posterior aspect of the testicle
○ Usually will be found on ultrasound for scrotal mass

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11
Q

Spermatocele Treatment

A

● Observation
● Refer
● Surgical excision
○ Less bleeding and complications than
hydroceles

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12
Q

Varicocele

A

Dilated (varicose) veins of the spermatic cord (pampiniform plexus)

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13
Q

Varicocele Epidemiology

A

● 15-20% of healthy men
● 35-40% of men with primary infertility
● Most common in ages 15-25 years-old
● Left testicle 85-90% of the time

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14
Q

Varicocele Etiology

A

● Venous insufficiency
● Tumors
● Physical activities
● Unknown

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15
Q

Varicocele Presentation

A

● Unilateral scrotal swelling superior to the testicle and
epididymis
○ Pain +/- (may have referred abdominal pain)
● Can be present for years
● Enlarged, potentially visible, veins in the scrotum – “Bag of Worms”

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16
Q

Varicocele Grading

A

○ Grade 1 – Palpable only with Valsalva
○ Grade 2 – Palpable without Valsalva
○ Grade 3 – Visible externally with or without Valsalva

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17
Q

Varicocele Diagnosis

A

● Physical exam
● Ultrasound

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18
Q

Varicocele Management

A

● Observation
● Refer
● Percutaneous embolization of
the veins
● Surgical ligation

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19
Q

Epididymitis/Orchitis

A

Bacterial infection of the epididymis or testicle

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20
Q

Epididymitis/Orchitis Etiology

A

● Children – Enteroviruses, adenoviruses, and mycoplasma pneumoniae
○ Orchitis – Mumps
● <35 years old – Most likely STI (>50%) Gonorrhea or Chlamydia
● >35 years old – More likely uropathogens – E. Coli, Klebsiella, Enterococcus,
Enterobacter, pseudomonas

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21
Q

Epididymitis/Orchitis Presentation

A

● Gradual worsening of severe scrotal pain
○ Develops over hours or days
● Typically unilateral, but can be bilateral
● Pain may radiate up the cord into the groin,
or abdomen
● Fever and chills
● May have external erythema of the scrotum
● Swelling and tenderness of the epididymis

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22
Q

Epididymitis/Orchitis Diagnosis

A

● Prehn’s sign
○ Elevation of the scrotum takes the weight off of the inflamed inflamed epididymis, alleviating the pain of epididymitis, but worsens testicular torsion
● STI testing – men < 35 years old
● Scrotal Ultrasound: Preferred imaging if unable to make diagnosis on history and physical exam alone
● Epididymitis/orchitis will not transilluminate

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23
Q

Prehn’s sign

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A

Elevation of the scrotum takes the weight off of the inflamed inflamed epididymis, alleviating the pain of epididymitis, but worsens testicular torsion

24
Q

Epididymitis/Orchitis management

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A

● Suspecting STI (Gonorrhea/Chlamydia)
○ Empiric therapy with Doxycycline 100 mg PO BID x 10 days PLUS
Ceftriaxone 1 gram IM once
● Negative STI screen or unlikely Gonorrhea/Chlamydia
○ TMP/SMX or Ciprofloxacin x 10-14 days
● Supportive therapy
○ NSAIDs, scrotal elevation, rest

25
Epididymitis/Orchitis Referral guidelines
● If failing empiric therapy, consider repeat scrotal ultrasound to confirm or change diagnosis ● If no resolution on empiric therapy, then refer to Urology
26
Testicular Torsion
Twisting of the testicle/spermatic cord restricting blood to the testicle
27
Testicular Torsion Epidemiology
● Accounts for 15% of the cases of “acute scrotum” in the ER (1 in 4000 males) ● Emergent condition ● Most common ages 12-18, peak at age 14 ● Rare in men over 30
28
Testicular Torsion Etiology
● Lack of the gubernaculum allows the testicle to “lay” sideways, increasing the chance of torsion, resulting in ischemia ● Left > Right
29
Testicular Torsion Presentation
● Sudden onset of severe unilateral pain ● Significantly swollen and erythematous scrotum ● Affected testicle WILL BE higher ● Negative Prehn’s Sign ○ Elevation of the testicle offers no relief ● Refer ER
30
Testicular Torsion Diagnosis
● Emergent ultrasound ○ Quickly and carefully to evaluate blood flow
31
Testicular Torsion Management
● Surgical detorsion – restore blood flow ○ Detorsion within 6 hours of onset of symptoms
32
Phimosis
Contracted foreskin cannot be retracted over the glans
33
Physiologic Phimosis
○ Nearly all (96%) uncircumcised boys – resolves with time ■ Persists in 10% at age 3 and <5% at age 16 ○ This doesn’t interfere with urination, cause pain, or infections
34
Acquired (pathologic) Phimosis
Adults, caused by poor hygiene (most often in the elderly, people with economic situations, mental disabilities) or recurrent balanitis
35
Phimosis
● Tight foreskin ● Unable to retract over the corona of the glans ● Not usually painful at rest, but the cracking of the skin hurts a lot ○ Tearing of the skin where from trying to pull foreskin back (Acquired)
36
Phimosis management
● Physiologic Phimosis – Allow time for the phimosis to resolve ○ Can use steroids if too tight and causing complications ● Acquired Phimosis – Medium to high-potency steroid cream ○ Only effective if able to see the ring of phimosis
37
Phimosis Prevention
● Hygiene, daily washing of foreskin, retracting foreskin to completely clean will prevent this from occurring ● Watch for this issue in elderly, patients with mental issues, patient in low-income situations without access to good hygiene ● Caution against leaving the foreskin retracted over the glans to avoid paraphimosis
38
Phimosis complication
Balanitis – Nearly impossible to get if circumcised ● Inflammation of the glans penis ○ Fungal infection – candida ○ Inflammatory ● Desquamation of the foreskin Balanitis – Nearly impossible to get if circumcised ● Firm glans with inflammation causing narrowing of the urethral meatus ○ Balanitis Xerotica Obliterans → cancer
39
Balanitis Treatment
antifungal cream +/- steroid ● For recurrent cases – circumcision
40
Paraphimosis
The foreskin becomes trapped behind the corona
41
Paraphimosis Etiology
● 1% of uncircumcised males over 16 years old ● Always associated with phimosis ● Tight, inflammatory band of foreskin that can cause loss of blood flow to the distal penis ● Urological Emergency
42
Paraphimosis Presentation
● Edematous glans with trapped prepuce proximal to the glans ● Pain at the site of the phimotic ring and distally
43
Paraphimosis Management
● Urgent reduction ○ Someone with experience ● Refer to ER if you are unable to reduce in the clinic ● Urology consult eventually to address circumcision, to avoid future issues
44
Prevention of a Paraphimosis
● Caution against leaving the foreskin retracted over the glans to avoid paraphimosis
45
Priapism
Painful erection lasting >4 hours
46
Priapism etiology
● Pooling of blood in the corpora cavernosa causing oxygen-deprived blood to dominate the tissue, leading to ischemia, causing cell death of the penis over time ● Drugs ○ Trazodone, alcohol, cannabis, cocaine, nitroglycerine, injected vasodilators, and rarely oral ED drugs (PDE-5 meds like Viagra) ● Sickle cell disease ● Trauma ● Spinal cord injury
47
Priapism presentation
Painful erection
48
Priapism diagnosis
● If < 4 hours, but painful erection, can try ice packs and vigorous exercise to shunt blood away from the pelvis ● If > 4 hours, needs referral to ER with Urology consultation generally
49
Priapism management
● Initial therapy in the ER involves penile injection of phenylephrine ● Second line – bilateral, large-bore needles with forced fluid evacuation of blood ● Last resort – surgery for distal shunt procedure to drain the blood from the penis
50
Priapism prevention
● High risk of recurrence ● Avoidance of inciting medications or drugs is the principal management strategy ● Caution patients if prescribing trazodone, nitroglycerin
51
Peyronies
Fibrous scar tissue on the cavernosa that causes a curvature in the penis
52
Occurs in 0.5% of men and 3-15% of men with Dupuytren’s contractures
Peyronies
53
Peyronies etiology
● Often idiopathic ● Trauma when the penis is erect (accidental withdrawal) ● Micro-trauma (various causes)
54
Peyronies presentation
● Curvature of the penis, generally only present while erect ● Can be quite painful, but often doesn’t cause pain ● Can impair ability to have intercourse
55
Peyronies Progression
Progression is 20-40-40 ● 20% will resolve spontaneously ● 40% will remain stable over time ● 40% will worsen with time
56
Peyronies diagnosis
● Palpable plaque ● Patient reports curvature ● Hx of trauma
57
Peyronies Management
● Observation ● Urology referral ● Xiaflex (collagenase clostridium histolyticum) – Injection of collagenase enzyme to break up collagen bonds in the scarred plaque ● Surgery

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