SM_241b: Benign Male Genital Disorders

Question 1

Describe abdominal wall and corresponding scrotal wall layers

Answer 1

Abdominal wall and corresponding scrotal wall layers

Abdominal wall - scrotum

• Skin - skin
• Scarpa’s fascia - dartos and smooth muscle
• External oblique fascia - external spermatic fascia
• Internal oblique muscle and aponeurosis - cremasteric fascia and muscle
• Transversus abdominis muscle and aponeurosis - cremasteric fascia and muscle
• Transversalis fascia - internal spermatic fascia
• Peritoneum - tunica vaginalis

Question 3

Describe scrotal disorders

Answer 3

Scrotal disorders

• Hydrocele
• Testicular tumor
• Cyst of epididymis
• Spermatocele
• Cyst of hydatid of morgagni
• Epididymitis
• Varicocele

Question 4

___, ___, ___, and ___ are scrotal masses that exhibit (+) transillumination

Answer 4

Scrotal masses that exhibit (+) transillumination

• Hydrocele
• Spermatocele
• Epididymal cyst
• Indirect inguinal hernia (containing fluid)

Question 5

____ is a diagnostic procedure commonly used to diagnose scrotal pathology

Answer 5

Scrotal ultrasound is a diagnostic procedure commonly used to diagnose scrotal pathology

Question 6

____, ____, ____, ____, and ____ are scrotal masses that do NOT transilluminate

Answer 6

Scrotal masses that do NOT transilluminate

• Testicular tumor
• Epididymal tumor
• Spermatic cord tumor
• Varicocele
• Abscess

Question 7

Describe varicocele

Answer 7

Varicocele

• Examine patient supine and standing with concurrent Valsalva maneuver
• Grade 1: palpable only with concurrent venous malformation
• Grade 2: easily palpable w/o venous malformation
• Grade 3: visible through scrotal skin

Question 8

Solitary right varicocele should prompt consideration of imaging studies to rule out a ___

Answer 8

Solitary right varicocele should prompt consideration of imaging studies to rule out a retroperitoneal mass

Question 9

This is ___

Answer 9

This is orchitis and pyocele

Question 10

This is a ___

Answer 10

This is a large scrotal abscess

Question 11

Non-communicating hydrocele can be managed with ___, ___, or ___

Answer 11

Non-communicating hydrocele can be managed with observation, aspiration / sclerosis, and surgery

Question 12

____ is the site of a direct inguinal hernia

Answer 12

Inguinal (Hasselbach’s) triangle is the site of a direct inguinal hernia

Question 13

For inguinal hernia repair, ____ is the site of nerve block and ____ is the incision site

Answer 13

For inguinal hernia repair, anterior superior iliac spine is the site of nerve block and pubic tubercle area is the incision site

Question 14

Describe steps of inguinal hernia repair

Answer 14

Steps of inguinal hernia repair

1. Dissection of cord and indirect sac
2. Plug placement into internal ring
3. Suture placement into rectus sheath

Question 15

Describe predisposing factors for testicular torsion

Answer 15

Predisposing factors for testicular torsion

• Hypermobile testis
• High-riding testis
• Transverse orientation
• Bell clapper deformity
• Undescended testis
• Family history
• Sudden movement, trauma, cold temperature

Question 16

Testicular torsion can be ____, ____, or ____

Answer 16

Testicular torsion can be intravaginal, extravaginal, or long mesorchium

Question 17

Describe extravaginal torsion

Answer 17

Extravaginal torsion

• Neonatal or perinatal event
• Vanishing testis syndrome
• Purple, blue scrotum, firm testicle
• Often no distress
• 5-22% bilateral
• 33% synchronous presentation
• Risk factors: prolonged labor, large birth weight, breech presentation
• Almost never salvageable

Question 18

Describe intravaginal testicular torsion

Answer 18

Intravaginal testicular torsion

• All age groups at risk but most common in early puberty
• Spermatic cord twists inside tunica vaginalis due to its insertion on the cord -> allows testis to turn freely within the scrotum
• Prompt surgical exploration to detorse testis (if salvageable) with bilateral orchidopexy vs removal of necrotic testis and contralateral orchidopexy

Question 19

Describe differential diagnosis for testicular torsion

Answer 19

Differential diagnosis for testicular torsion

Question 20

The most likely differential diagnoses are ____, ____, and ____

Obtain ____

Answer 20

The most likely differential diagnoses are testicular torsion, epididymitis + orchitis, and testicular tumor

Obtain scrotal US with color doppler (not perfect)

Question 21

This is ___

Answer 21

This is epididymo-orchitis

Question 22

Male 12-16 years old presenting with sudden severe unilateral pain, nausea / vomiting, no cremasteric reflex, and no relief with lifting (Prehns’ sign) has ___

Answer 22

Male 12-16 years old presenting with sudden severe unilateral pain, nausea / vomiting, no cremasteric reflex, and no relief with lifting (Prehns’ sign) has intravaginal torsion

Question 23

Describe presentation of intravaginal torsion

Answer 23

Intravaginal torsion: presentation

• Peak in age 12-16 years
• Pain: sudden, severe, unilateral
• NOT active at the onset of pain
• Early presentation: nausea / vomiting, no cremasteric reflex, no relief with lifting (Prehn’s sign)
• Late presentation: swollen, redness can seem to cross midline
• Very late presentation: non-tender (nerves are dead), swollen, purple, eggplant

Question 24

Describe workup for intravaginal torsion

Answer 24

Intravaginal torsion workup

• Urinalysis
• Doppler US (not perfect)
• Clinical diagnosis: if there is suspicion, do emergent exploration (do NOT delay for US)

Question 25

Describe management of intravaginal torsion

Answer 25

Intravaginal torsion

1. Preoperative manual detorsion (will almost always salvage testis if performed in < 6 hours)
2. Surgery: bilateral orchidopexy

Question 26

Describe prognosis of intravaginal torsion

Answer 26

Intravaginal torsion prognosis

• Compartment syndrome theory
• Total ischemia time > 6 hours -> very poor prognosis
• Trick question: patient comes in and is now 8 hours from onset and looks bad -> still explore because have to try
• Paternity usually ok if contralateral testicle is normal

Question 27

Describe torsed appendages

Answer 27

Torsed appendages

• Mullerian duct remnants: appendix testis, prostatic utricle
• Wolffian duct remnant: appendix epididymis
• Physical exam: blue dot sign
• Duppler US: inflammatory blob above testicle
• Supportive care: rest, ice, NSAIDs