Uro- Scrotal Masses & Testicular conditions

What special test can help distinguish if something is fluid filled vs solid?

trans-illumination

What is a hydrocele?

accumulation of fluid in the scrotum

What are pts w/ a communicating hydrocele at risk of developing?

inguinal hernias

When are communicating hydroceles self-limiting?

w/in 1st year of life

What forms a communicating hydrocele?

patent processus vaginalis which allows peritoneal fluid to fill the scrotum; congenital defect

What forms a non-communicating hydrocele?

fluid comes from the mesothelial lining of the tunica vaginalis; acquired defect

What differentiates a communicating and non-communicating hydrocele?

non has no connection to peritoneum & is mostly seen in adolescents and adults

What are features of communicating hydroceles?

may change in size throughout the day, smaller in AM than PM; can be reduced

What is the Silk Glove Sign seen in communicating hydroceles?

layers of processes vaginalis can be felt around the spermatic cord feeling like “silk rubbing on silk” w/o a lump

What are features of non-communicating hydroceles?

remains constant size, fluid cannot be reduced; may be d/t trauma, surgery, epididymitis, appendiceal torsion

What is the diagnostic study for a hydrocele?

*can also be used to r/o epididymitis, masses, torsion, etc

scrotal US

What is the tx for an asx hydrocele?

observation, scrotal support

What is the tx for a symptomatic hydrocele?

hydrocelectomy OR aspiration (inc risk of hematocele/infxn, high rate of recurrence)

What activity is restricted after a hydrocelectomy?

no straddling activities for 2 weeks

What is a varicocele?

dilation of the pampiniform venous plexus and internal spermatic vein

Which side are varicoceles typically seen on (90%)?

left

What is the MCC of poor sperm production and dec semen quality?

varicocele

What are features of a varicocele?

typically asx, but can be palpated; some report dull, aching, or throbbing sensation

When should you be suspicious of a retroperitoneal or renal mass causing obstruction as the cause of a varicocele?

present on the right, does not decompress when supine, occurs abruptly, enlarges rapidly

What does a varicocele feel like upon palpation?

“bag of worms”

What is a Grade 1 varicocele?

palpable only w/ valsalva

What is a Grade 2 varicocele?

palpable w/o any valsalva

What is a Grade 3 varicocele?

visible to the examiners eye

What test is diagnostic of a varicocele?

scrotal US w/ doppler

When is a referral for a hydrocele needed?

persistent discomfort, abn appearance, presence of a mass, non-palpable testicle, progressively enlarging

What test is needed for a right sided varicocele or sudden onset, non-reducible varicocele?

CT abd or renal US

When is a referral needed for a varicocele?

difference in testicular size, painful, > Grade 2

What is a spermatocele?

benign cystic accumulation of sperm that arises from the head of the epididymis

What are features of a spermatocele?

smooth, soft, well-circumscribed cyst located at the epididymal head; usually asx

What is the diagnostic test for a spermatocele?

scrotal US

What is the tx for a spermatocele?

asx: reassurance and observation

sx: uro referral → spermatocelectomy

What is an inguinal hernia?

defect w/in the muscular layers of the abd causing a protrusion, bulge, or projection of an organ or part of an organ

Which type of inguinal hernia is a surgical emergency?

non-reducible (incarcerated)

Where does a direct inguinal hernia protrude?

directly through Hesselbach’s triangle

Where does an indirect inguinal hernia protrude?

through the internal inguinal ring, lateral to the inferior epigastric vessels

What makes up Hesselbach’s triangle?

inf epigastric artery/vein, rectus abd muscle, inguinal ligament

What are features of an indirect hernia?

enlarges w/ valsalva

M: bulge/mass in scrotum, follows spermatic cord

W: bulging in labia, follows round ligament

What causes a direct hernia?

result of weakness in the floor of the inguinal canal

What is the tx for an inguinal hernia?

herniorrhaphy

What are ssx of an inguinal hernia incarceration/strangulation?

pain, hernia that is stuck or irreducible, overlying skin discoloration (blue/purple), constipation or vomiting

What are clinical features of testicular masses?

painless swelling or nodule, occasional dull ache or heavy sensation; usually malignant

What is one of the MC malignancies in men 15-45 yo?

testicular CA

*has a high cure rate (>90%) if caught early

What testing is done for a testicular mass?

UA, scrotal US, labs

What labs need to be drawn when a pt presents w/ a testicular mass?

AFP, LDH, beta-HCG

What is the tx for testicular masses?

uro referral; surgical → orchiectomy

What is testicular torsion?

twisting of the spermatic cord structures, followed by venous congestion, loss of arterial inflow, and subsequent ischemia of I/L testis; UROLOGIC EMERGENCY

What deformity is associated with testicular torsion?

“bell clapper”

What is an extravaginal testicular torsion?

entire cord becomes twisted

What is an intravaginal testicular torsion?

results from inadequate fixation of the testis to tunica vaginalis through the gubernaculum

What are features of testicular torsion?

acute onset of scrotal/testicular pain, scrotal swelling, N/V; mostly occurs in adolescents

How would testicular torsion present on PE?

scrotal edema, erythema, tenderness; firm/hard testis, high riding testicle (sometimes lays horizontal), absence of cremasteric reflex

What test should be done for testicular torsion?

scrotal US w/ doppler

What is the tx for testicular torsion?

manual detorsion

STAT uro consult

surgery → detorsion and B/L orchiodopexy (no straddling activity for 2 weeks postop)

How soon does testicular torsion need to be treated to save the testicle?

4-6 hrs→ 90% saved

12 hrs→ 50%

24+ hrs→ <10%

What is appendiceal torsion?

torsion of the testicular appendages

Where is the appendix testes?

superior pole between the testis and epididymis (majority of appendiceal torsion cases)

Where is the appendix epididymis located?

head of the epididymis (20-30%) of appendiceal torsion cases

What are features of appendiceal torsion?

“blue dot” sign, gradual onset of testicular pain, pain worsens w/ movement, scrotal swelling/tenderness, cremasteric reflex present, NO N/V

What imaging is done in appendiceal torsion?

*helps r/o testicular torsion

scrotal US

What is the tx for appendiceal torsion?

self-limiting, rest, NSAIDs, scrotal elevation, ice

What is epididymitis?

inflammation of the epididymis typically d/t bacterial infection

What are the MCC of epididymitis in males < 39 yo?

Chlamydia trachomatis & Neisseria gonorrhea

*less common = Ureaplasma or Mycoplasma

What are the MCC of epididymitis in males > 39 yo?

E. coli, Coliform bacteria, Pseudomonas

What are non-infectious causes of epididymitis?

trauma, AI, amiodarone use

What are the clinical features of epididymitis?

acute/subacute U/L scrotal or testicular pain, pain w/ movement, sx of urethritis or prostatitis; swelling

sexually active: urethral discharge (thin/watery = chlamydia; thick/purulent = gonorrhea)

non-SA: chemical -exercise or retrograde flow of urine

What testing is done for epididymitis?

scrotal US, UA + culture

What is the tx for epididymitis?

NSAIDs, scrotal elevation/rest, Abx

• enteric coverage: Ceftriaxone + FQ

• chlamydia & gonorrhea: Ceftriaxone + Azithro or Doxy

• non-SA: Levo OR bactrim

What is orchitis?

inflammation of one or both testes d/t bacteria or viruses (typically accompanied by epididymitis)

What are viral causes of orchitis?

mumps, rubella, coxsackievirus, varicella, echovirus, CMV

What are bacterial causes of orchitis?

E. coli, Klebsiella pneumo, Pseudomonas aeruginosa, Staph, Strep

What causes orchitis in sexually active pts?

Neisseria gonorrhea, Chlamydia trachomatis, Treponema palldium

When does orchitis appear in mumps?

4-8 days after parotitis

What are features of orchitis?

fever, blood in semen, penile discharge, pain w/ intercourse or ejaculation, scrotal edema/erythema, pain is worse w/ BM or straining, negative cremasteric reflex

What testing is done for orchitis?

CBC w/ diff, UA + culture, urethral swab + culture, scrotal US w/ doppler

What is the tx for orchitis?

empiric abx based on most likely pathogen (if STD, tx partner)

NSAIDs, bed rest, scrotal elevation, ice packs

What is testicular trauma?

rare condition characterized by extrusion of the seminiferous tubules through the ruptured tunica albuginea; associated w/ blunt trauma to the testicle

What are features of testicular trauma?

immediate swelling/pain that does not improve, scrotal hematocele or hydrocele, ± urethral injury, hematoma, or ecchymosis

What is the tx for testicular trauma?

STAT uro consult, surgery for scrotal exploration

What is Fournier’s gangrene?

form of necrotizing fasciitis of the superficial/deep fascial plans affecting the perineum and scrotum d/t infection

What are features of Fournier’s gangrene?

prodrome of fever, lethargy 2-7 days prior to skin changes, intense genital pain/tenderness (pain out of proportion), skin edema, dusky appearance to skin, gangrenous discoloration

What is the study of choice in Fournier’s gangrene?

CT

What is the tx for Fournier’s gangrene?

broad spectrum abx, STAT uro consult, surgical debridement