Epididymitis, Orchitis, Testicular Torsion, Varicocele, Spermatoceles, Hydrocele, ED, Balanitis

What are clinical manifestations of varicoceles?

*"Bag of worms"* superior to the testicle. Usually painless but may cause a dull ache or heavy sensation. *Dilation usually decreases when patient is supine or with testicular elevation and worsens when patient is upright and with Valsalva.*

What are clinical features of erectile dysfunction?

1) *HISTORY*: medications (antihypertensives like BBs), sexual history (timing/frequency of sexual relations, partners, presence of morning erections, ejaculation, and ability to masturbate.) 2) May use IIEF questionnaire to evaluate. 3) PMH: HTN, DM, endocrine disease, past surgeries or trauma. 4) Physical exam: look for penile deformities (i.e. Peyronie disease--fibrous plaque causing penile curvature), testicular atrophy, HTN, peripheral neuropathy, and other signs of endocrine, vascular, or neuro abnormalities

How is epididymitis treated?

1) <35: ceftriaxone 250 mg IM plus doxy 100 mg BID OR azithro 1 g x 7 days. *Test for cure should be done 1 week after conclusion of therapy.* 2) >35: Cipro 500 mg BID x 10-14 days 3) Supportive cares: bed rest, scrotal elevation, analgesics.

What diagnostic studies are indicated for erectile dysfunction?

1) CBC, UA, lipid profile, TSH, serum testosterone, glucose, and prolactin screening should be done depending on suspected case. 2) FSH and LH may be necessary if there are abnormalities in testosterone or prolactin levels. 3) Nocturnal penile tumescence testing will differentiate organic from psychogenic impotence. 4) Direct injection of vasoactive substances into the penis should induce erections in men with intact vascular systems. 5) If they fail injections, may need studies to evaluate arterial and venous vasculature such as US of the cavernous arteries, pelvic arteriography, or cavernosonography.

How is testicular torsion diagnosed?

1) Clinical diagnosis 2) If dx equivocal, do not wait for lab studies--time is of the essence 3) Doppler U/S will show decreased blood flow to the affected spermatic cord/testis. 4) Radioisotope scan demonstrates decreased uptake in the affected testes.

How is balanitis treated?

1) First line: proper hygiene with normal saline and non-allergenic soaps 2) If source not identified: Topical clotrimazole or miconazole BID for 7 days. If dermatitis suspected, may trial 1% hydrocortisone cream. 3) If severe candidal infection, may treat with once dose of oral fluconazole 150 mg. 4) If bacterial source, oral or topical Flagyl, cephalexin, mupirocin, dicloxacillin.

What are s/sx of epididymitis?

1) Heaviness and dull, aching discomfort in the affected hemiscrotum which can radiate to the ipsilateral flank. 2) Hx may reveal heavy lifting, trauma, or sexual activity. 3) Markedly swollen epididymis and *exquisitely tender to the touch*, eventually becoming a warm, erythematous, enlarged scrotal mass. May be difficult to distinguish testes from epididymis as it progresses. 4) +/- fevers, chills 5) *Phren sign* (relief of pain with scrotal elevation) is classic but not reliable

What is treatment for orchitis?

1) If mumps is cause, supportive cares with icing and analgesia. 2) If bacteria is cause, treatment is same as epididymitis. 3) Carefully evaluate any scrotal masses.

How is testicular torsion treated?

1) Mild analgesics once dx made. 2) *Surgical emergency.* Manual detorsion may be attempted by experienced clinicians, but whether that is successful or not, surgery is necessary. 3) *Greater chance of salvage is it has been 6 hours or less.* Surgical detorsion and orchiopexy are definitive. 4) Emergent surgical intervention on the affected testis must be followed by elective surgery on the other testis to anchor it and prevent torsion.

What are clinical manifestations of hydroceles?

1) Painless scrotal swelling that may increase throughout the day. +/- dull ache or heavy sensation. *Communicating worsens with valsalva.* 2) +Transillumination on phys exam. Must r/o a testicular tumor.

What are clinical features of testicular torsion?

1) Sudden onset of severe unilateral pain and scrotal swelling. 2) Testis is painful to palpation, testicle and scrotum are edematous, there is no relief with elevation (negative Phregn sign), no cremasteric reflex, horizontal testis

How is erectile dysfunction treated?

1) True psychogenic causes can be treated with behaviorally oriented sex therapy. Patients with organic causes may also benefit from counseling. 2) Hypogonadism may benefit from testosterone replacement therapy, but evidence is limited. 3) Wt loss 4) PDE-5 inhibitors are the mainstay--Sildenafil, vardenafil, tadalafil 5) Other: vacuum constriction devices, injected or inserted vasoactive substances, penile prostheses. If there is a disorder of the arterial system, may need arterial reconstruction.

What are diagnostic studies for epididymitis?

1) UA: pyuria and bacteriuria 2) Cultures show positive results for suspected organisms. 3) Scrotal ultrasound: *enlarged epididymis, increased testicular blood flow* +/- reactive hydrocele 4) CBC: leukocytosis 5) Others: STD testing (RPR, HIV, G/C)

What are diagnostic studies for males with orchitis?

1) UA: pyuria and bacteruria 2) Cultures positive for suspected organisms 3) Scrotal U/S: used to detect abscess or tumor or to rule out torsion

How are hydroceles treated?

1) Usually no treatment needed 2) Surgical repair may be needed if it persists beyond 1 year of age, older patients with communicating hydroceles or hydroceles associated with complications.

What is a spermatocele?

A painless cystic mass containing sperm

Most cases of male erectile disorders are due to what?

A primary organic cause rather than a psychogenic cause, though nearly all cases have a secondary psychogenic component.

What is orchitis commonly caused by?

Ascending bacterial infection from the urinary tract

What diagnostics are indicated in patients with balanitis?

Can be diagnosed clinically, but may consider KOH prep and STI testing

How are spermatoceles diagnosed?

Clinically but scrotal ultrasonography provides a very accurate diagnosis. *Avoid FNA.*

What are causes of hydroceles in infants?

Congenital: due to incomplete obliteration of the processus vaginalis. Usually close within 1st year of life and may not require treatment.

What is a hydrocele?

Cystic testicular fluid collection resulting in a testicular mass. *MC cause of painless scrotal swelling.*

What is a varicocele?

Cystic testicular mass of *varicose veins*: pampiniform venous plexus and internal spermatic vein. Asx varicoceles may be seen in p to 10% of the population.

What is a non-communicating hydrocele?

Derived from fluid from the mesothelial lining of the tunica vaginalis (no connection to peritoneum)

What are some major predictors of male ED?

HTN, DM, hyperlipidemia, and CVD

What are SE of PDE-5 inhibitors?

Headache, flushing, dyspepsia, rhinitis, visual disturbances, and possible priapism. *Avoid in patients taking nitrates.*

When is epididymitis considered to be chronic?

If it has been refractory to treatment for >6 weeks and may be caused by Mycobacterium tuberculosis (consider testing for this)

What is erectile dysfunction?

Inability to maintain an erect penis with sufficient rigidity to allow sexual intercourse.

What is epididymitis?

Infection of the epididymis acquired by retrograde spread of organisms though the vas deferens.

What is balanitis?

Inflammation of the glans penis

Varicoceles are the most common surgically correctable cause of what?

Male infertility (seen in ~30% of infertile men because the increased temperature from increased venous blood flow inhibits spermatogenesis.)

Orchitis occurs in 25% of postpubertal males with which infection?

Mumps

How are spermatoceles treated?

No medical treatment necessary unless very large, then can be removed surgically.

What is management for varicoceles?

Observation in most. Surgery in some cases (spermatic vein ligation, varicocelectomy).

Where do varicoceles most commonly occur?

On the *left side* because the left spermatic vein enters the left renal vein at a 90 degree angle.

What are symptoms of balanitis?

Over 3-7 days, pain, tenderness, or pruritus of the glans and/or foreskin develops. Physical examination shows erythema, which may be associated with a curd-like or purulent exudate, ulcerations, or other findings depending upon the etiology.

What are clinical features of spermatoceles?

Palpable, round, firm cystic mass with distinct borders, free floating above the testicle that *transilluminates* and may be tender.

What are communicating hydroceles?

Peritoneal/abdominal fluid enters scrotum via a patent processus vaginalis that failed to close.

Complications of balanitis include:

Phimosis and Paraphimosis

What are risk factors for balanitis?

Poor hygiene in uncircumcised individuals leads to build up of debris, bacteria, fungi etc. Type 2 DM, trauma, obesity, and edematous conditions (i.e. CHF, nephrotic syndrome, cirrhosis)

Right-sided varicoceles in children under 10 may indicate what?

Possible retroperitoneal malignancy

Who is at greatest risk for testicular torsion?

Prepubertal and postpubertal young males (12-18) esp with a history of cryptorchidism and often occurs during athletic activity (running, jumping)

Sudden onset of a *left-sided varicocele in an older man* may indicate what?

Renal cell carcinoma

What needs to happen physiologically to maintain an erection?

Requires intact parasympathetic and somatic nerve supply, unobstructed arterial inflow, adequate venous constriction, hormonal stimulation, and psychological desire. Disorders of any of these systems may lead to impotence.

Where are spermatoceles located?

Superior and posterior and are *separate* from the testes.

What are s/sx of orchitis?

Testicular swelling and tenderness, usually unilateral. May also have associated fever and tachycardia.

What occurs during testicular torsion?

The testis is abnormally twisted on its spermatic cord, thus compromising arterial supply and venous drainage of the testis, leading to ischemia.

What are causes of hydroceles in adults?

Usually acquired from injury, infection, or inflammation.

What organisms are most commonly involved in: a. Men over 35 b. Men under 35

a. E. coli b. Gonorrhea and Chlamydia