The Testis

Question 1

___ is the condition of having low testosterone

Answer 1

hypogonadism

Question 2

What is the range of low testosterone?

Answer 2

< 150-200 ng/dL

Question 3

What is the etiology of hypogonadism?

Answer 3

Primary: Testicular failure → Mumps orchitis

Secondary: Hypogonadotropic hypogonadism → Age-related (ADAM), chronic opiates

Question 4

What are some s/s of hypogonadism?

Answer 4

↓ energy/fatigue
ED
↓ force of ejaculation
↓ libido

Question 5

What do you use in the work-up of hypogonadism?

Answer 5

Exam

Free and total testosterone; If low→ DEXA scan (<100 ng/dL)

Question 6

What is the tx for hypogonadism?

Answer 6

Androgen (testosterone) supplementation

Question 7

What are 2 locations that you should not apply testosterone gel?

Answer 7

Nipples

Scrotum

Question 8

When do you need to f/u w/ a pt being treated for hypogonadism?

Answer 8

3, 6 and 12 months after initiating, then annually

Question 9

What labs will you order to monitor a pt w/ hypogonadism?

Answer 9

PSA
Hemogram (H&H)
Testosterone
Review of urinary sx
DRE

Question 10

What are important counseling points you should give to a pt being tx w/ hypogonadism?

Answer 10

Prostate CA monitoring
CV risks
Infertility

Question 11

___ is a testis (testes) not in scrotum; possibly absent or non-palpable (20%), if palpable→ will not come down

Answer 11

Cryptorchidism

Question 12

What is descent of a testis determined by?

At what age gestation should the testis pass through the inguinal canal?

Answer 12

Androgen-independent, mediated by “descendin”

28 wks

Question 13

What is the tx for Cryptorchidism?

Answer 13

GnRH injxn

Orchidopexy

Question 14

What are the 3 true types of cryptorchidism?

Answer 14

Abdominal
Inguinal
Suprascrotal

Question 15

What are the 5 ectopic types of cryptorchidism?

Answer 15

Prepenile
Superficial ectopic 
Transverse scrotal 
Femoral 
Perineal

Question 16

____ is cryptorchidism that is proximal to the inguinal ring

Answer 16

Intra-abdominal (10%)

Question 17

____ is cryptorchidism that is truly absent, probably due to a prior gestational vascular event

Answer 17

Absent testis (20%)

Question 18

___ is cryptorchidism that is below the internal ring but out of normal path

Answer 18

Ectopic testis

Question 19

____ is cryptorchidism that reflects an exuberant cremasteric reflex

How long should you follow this pt?

Answer 19

Retractile testis

until puberty

Question 20

Most cryptorchidism descend spontaneously in the 1st __ months

Answer 20

3

Question 21

Cryptorchidism occurs in __% of term infants and ___% of premature infants

Answer 21

3%

30%

Question 22

Cryptorchidism is bilateral __% of the time

Answer 22

10%

Question 23

What are some risk factors for cryptorchidism?

Answer 23

twins
low birth wt
prr-term delivery
FHx
Prune belly syndrome

Question 24

What are complications of cryptorchidism?

Answer 24

CA risk
Decreased fertility
Torsion is x10 higher

Question 25

___ is the benign accumulation of serous fluid between layers of tunica vaginalis

Answer 25

Hydrocele

Question 26

What is the presentation of of adult hydrocele?

Answer 26

Scrotal discomfort and enlargement | Possible h/o trauma or infxn

Question 27

What are some possible etiologies of adult hydroceles?

Answer 27

Idiopathic post-traumatic post-infectious

Question 28

What is included in the work up of an adult hydrocele

Answer 28

Careful exam Transillumination Possible scrotal sonogram

Question 29

What are the tx for adult hydrocele?

Answer 29

Expectant management if asymptomatic Aspiration/sclerosis assoc. w/ recurrence Scrotal excision (hydrocelectomy)

Question 30

What is the presentation of an infant hydrocele?

Answer 30

Hemi scrotal enlargement | Volume/size waxes and wanes during day

Question 31

What is the etiology for an infant hydrocele?

Answer 31

Patent processus vaginalis (communicating hydrocele)

Question 32

What is the tx for an infant hydrocele?

Answer 32

If persistent after one year, repair via inguinal incision

Question 33

___ is congestion of veins around the testis

Answer 33

Varicocele

Question 34

What age range is most likely to have a varicocele? Least likely?

Answer 34

15-30 y/o rarely >40 y/o

Question 35

What is the etiology for varicoceles? What could indicate malignancy?

Answer 35

Reflects valvular anomaly exacerbated (or caused) by gonadal venous anatomy Rare malignant etiology (consider if R-sided, or in man >40 y/o)

Question 36

What are the s/s of a varicocele? Majority on L or R side?

Answer 36

``` Asymptomatic Dull ache Infertility Scrotal enlargement Majority on left ```

Question 37

What does the work-up for a varicocele include?

Answer 37

Clinical “bag of worms” on palpation due to dilatation of veins in pampiniform plexus R-sided will need to r/o mass (more concerning side for varicocele occurrence)

Question 38

What is the tx for a varicocele?

Answer 38

Varicocelectomy, embolization | ⅔ surgically tx have fertility improvement

Question 39

___ is the twisting of the spermatic cord causing ischemia of testis

Answer 39

Testicular Torsion

Question 40

What is the epidemiology for testicular torsion? Unimodal, Bimodal, or Trimodal distribution?

Answer 40

Bimodal distribution Neonatal (extravaginal) vs. pubertal (intravaginal)

Question 41

What are some etiologies for testicular torsion?

Answer 41

Bell-clapper deformity Cryptorchidism Trauma Sex

Question 42

What are the s/s of testicular torsion?

Answer 42

Sudden severe onset Unilateral scrotal pain N/V Abd pain Sx may be intermittent (intermittent torsion)

Question 43

What is included in the work-up of testicular torsion?

Answer 43

``` High riding testes (-) cremasteric reflex scrotal edema TTP Prehn's sign: pain unrelieved by scrotal elevation ``` Need a high index os suspicion, US are often misleading

Question 44

What is the tx for testicular torsion? Within what timeframe do you prefer to catch/tx?

Answer 44

Scrotal exploration (untwisting of cord and orchidopexy, contralateral orchidopexy) High salvage rate if tx w/in 6 hrs

Question 45

____ is inflammation/infxn of epididymis

Answer 45

Epididymitis

Question 46

What are some etiologies of epididymitis? What age ranges correlate with what infectious organisms?

Answer 46

Ascending infxn from urethra, prostate, bladder (<35 y/o C. trachomatis, N. gonorrhoeae >35 y/o→ E.coli) Surgery (vasectomy) Other trauma

Question 47

What are s/s of epididymitis?

Answer 47

Scrotal pain Scrotal enlargement Fever

Question 48

What is included in the w/u of epididymitis?

Answer 48

UA , Cx, penile swab/probe for STI

Question 49

What is the tx for epididymitis ?

Answer 49

Abx (empiric by age→ i.e. doxycycline or cipro) Palliative (scrotal support, NSAID, ice, narcotics)

Question 50

What are the two types of testicular CA? Which is more common?

Answer 50

Germ cells (95%) Non Germ cells (5%)

Question 51

What are the types of germ cell testicular CA?

Answer 51

Seminoma (90% cure rate) Non-seminoma (near 100% cure rate) Mixed

Question 52

What is the epidemiology for testicular CA?

Answer 52

Trimodal: Up to 10 yrs (yolk sac) 20-40 yrs (seminoma) >60 yrs (spermatocytic seminoma)

Question 53

How does a pt w/ testicular CA usually present?

Answer 53

Painless testicular mass Usually incidental by partner or after trauma Cough or dyspnea secondary to lung metastases GI sx secondary to retroperitoneal metastases Gynecomastia

Question 54

What is included in the tx for testicular CA?

Answer 54

Scrotal sonogram Tumor markers (AFP, beta-hCG, LDH) CT to assess the lymph nodes of retroperitoneum Radical inguinal orchiectomy

Question 55

____ is an acute inflammatory rxn of the testis 2° to infxn

Answer 55

Orchitis

Question 56

What are the most common causes/organisms of orchitis?

Answer 56

Most common→ viral mumps infxn in children Bacterial orchitis→ C. trachomatis, N. gonorrhoeae, E. coli (most commonly assoc. w/ epididymitis in sexually active males and men >50 w/ BPH)

Question 57

What are the s/s of orchitis?

Answer 57

Scrotal pain (mild-severe) Swelling Overlying skin frequently thickened Testicle will not move freely in the scrotum, “stuck”

Question 58

What is the tx for orchitis?

Answer 58

Viral (mumps orchitis)→ no meds; may lead to infertility Bacterial→ tx suspected organism, exclude/address abscess