GU
Workup of Testicular Torsion
(1) *Color Doppler Ultrasound* - Blood flow and soft tissue abnormalities - help differentiate benign and pathologic causes - 82-100% sensitivity for torsion - 97-100% specificity - Usually adequate to rule out testicular torsion
Significance of Unilateral R Varicoceles
Possible underlying pathology causing IVC obstruction since R gonadal vein directly empties into IVC (A) Renal cell carcinoma with IVC thrombus (B) Right renal vein thrombosis with clot propagation down IVC => CT unilateral R Varicoele OR any varicocele that doesn't decompress in recumbent position (nondiminishing)
Treatment of Orchitis
Except mumps orchitis - isolated orchitis without epididymitis very uncommon in adults => epididymo-orchitis should be primary diagnosis - In non-immune adults, viruses similar to children can rarely cause orchitis
Risk factors for Chronic Epididymitis
Post-pubertal boys and men (1) Sexual activity (2) Heavy physical exertion (3) Bicycle / Motorcycle riding => recurrent epididymitis should evaluate for structural abnormality of urinary tract
Treatment of Testicular Torsion
(1) *Immediate surgical exploration with intraoperative detorsion and fixation of both testes* - Delay in detorsion of few hours progressively higher rates of nonviability of testis - Detorsion and fixation of BOTH testes bc inadequate gubernacular fixation usually bilateral defect. - Longer periods of ischemia (>12 hours) may cause infarction with liquefaction requiring orchiectomy - Outcome of surgery better in children than adults (2) *Manual detorsion* - If surgery not immediately available (2 hours) - But shouldn't delay surgery - Classically rotates medially during torsion and detorsed by rotating outward toward thigh, but lateral in 1/3 cases - 180-720 degrees => multiple rounds of detorsion Successful detorsion if: - Relief of pain - Resolution of transverse lie - Lower position of testis in scrotum - Return of normal arterial pulsations on color Doppler => still need surgical exploration for orchiopexy to prevent recurrence and relieve residual torsion
Workup of Acute Scrotum
(1) *UA + Urine culture* - Pyuria / Bacteriuria suggest bacterial epididymitis or other infection . (2) *Color Doppler Ultrasound* - Blood flow and soft tissue abnormalities - help differentiate benign and pathologic causes - 82-100% sensitivity for torsion - 97-100% specificity
Presentation of *Torsion of Appendix Testis*
(1) 7-14 y/o (2) Leading cause of acute ped scrotal pathology - Rarely occurs in adults (3) Testicular pain more gradual than testicular torsion - Can have for several days before present (4) Pain ranges widely from mild to severe. (5) Reactive hydrocele (6) Tenderness can often be localized to exact location of appendix testis - Anterosuperior testis (7) Classic "blue dot" sign (21% sensitive) - Infarction and necrosis of appendix testis (8) Usually possible to discriminate tender appendix testis from normal, non-swollen testis and epididymis that aren't appreciably tender
Physical for Acute Scrotum
(1) Abdomen (2) Inguinal region (3) Spermatic cord (4) Scrotal skin (5) Testes (6) Tunica vaginalis (which may have fluid) (7) Epididymis (8) *Cremasteric reflex* - Stroking or gently pinching skin of upper thigh - Expect cremasteric contraction with elevation of ipsilateral testis - Absent reflex suggests testicular torsion (9) Testicular lie
History for Acute Scrotum
(1) Abrupt / Insidious onset (2) Location of pain (3) Trauma / Surgery (4) Urinary complaints (frequency, urgency, dysuria (5) Systemic symptoms (fever, rigors) (6) Prior episodes - Intermittent testicular torsion
Presentation of *Sperm Granuloma*
(1) After vasectomy - Most have asymptomatic firmness in entire epididymis from ductal obstruction (2) Some have painful nodule at site of division of vas deferens on testicular side - From leakage of sperm from lumen of vas deferens => immunologic response to "foreign" protein (previously sequestered by blood-testis barrier)
Diagnosis of Fournier's Gangrene
(1) CT / MRI - Helpful in showing air along fascial planes or deeper tissue involvement. (2) Imaging studies SHOULDN'T delay surgical therapy if progressive soft tissue infection
Treatment of Fournier's Gangrene
(1) Early / Aggressive Surgical exploration + debridement of necrotic tissue - May need cystostomy, colostomy, or orchiectomy (2) Antibiotic - Antibiotic alone = 100% mortality rate (3) Hemodynamic support
Pathophysiology of Varicoceles being more common in L hemiscrotum
(1) Left spermatic (gonadal) vein enters Left renal vein at perpendicular angle (2) Intravascular pressure L renal vein > R bc compressed between aorta and SMA - "nutcracker effect" (3) Increased pressure in L gonadal vein => dilate + cause incompetence of valve leaflets => retrograde flow of blood toward the testis when standing (4) Venous complex in scrotum dilates => anything from minimal fullness on Valsalva maneuver to large soft scrotal mass ("bag of worms") that decompresses and disappears in recumbent position
Presentation of *Epididymitis*
(1) Most common adult scrotal pain in outpatient setting (2) *Testicular Swelling / Pain* - Later (3) *Induration + Exquisite tenderness* of involved epididymis (4) *Epididymitis most commonly infectious* - Can be due to noninfectious causes (eg, trauma, autoimmune disease) - Acute (<6 weeks) or chronic (≥6 weeks) - Chlamydia / Gonorrhea / STIs < 35 y/o - E coli, Pseudomonas for older - Anal insertive intercourse - coliform bacteria (5) *High Fever / Rigors* (6) *Irritative voiding symptoms* - Frequency, Urgency, Dysuria - UTI - Esp conjunction with acute prostatitis (epididymo-prostatitis), esp prostatic obstruction or recent urologic instrumentation
Presentation of *Testicular Cancer*
(1) Most common solid tumor in 18-40 y/o M (2) Painless mass - Usually found on exam (3) Scrotal pain - from rapidly growing germ cell tumor - From hemorrhage / infarction (4) Firm, nontender mass (5) DON'T transilluminate - But can have reactive hydrocele (6) Gynecomastia
Treatment of Sperm Granuloma
(1) NSAIDs (2) Scrotal elevation (3) Rarely Surgical excision of granuloma - For intractable pain
Presentation of *Epididymal Cysts*
(1) Palpated in head of the epididymis (2) generally Asymptomatic (3) Increased frequency in male offspring of mothers who used diethylstilbestrol during pregnancy (4) Epididymal cystadenomas more than 50% of Von Hippel-Lindau disease - often Bilateral => U/S if equivocal => no treatment needed
Treatment of Torsion of Appendix Testis
(1) Rest, ice, NSAIDs - Slow recovery - Pain may last for several weeks to months (2) Surgical excision of the appendix testis - Reserved for persistent pain
Treatment of Noninfectious Epididymitis
(1) Scrotal elevation (2) Rest from athletic activity (3) Warm baths (4) NSAIDs
Diagnosis of Testicular Ultrasound
(1) Scrotal ultrasound - Good initial test and usually sufficient - Mimicked by inflammation, hematoma, infarct, fibrosis, and tubular ectasia (2) MRI can help differentiate benign from malignant - If inconclusive ultrasound or microcalcification without obvious mass - NPV 100% - PPV 71% => small, benign calcifications on surface of testis relatively commonly detected on exam and U/S but don't need further evaluation. => if suspicious - serum alpha fetoprotein (AFP) and beta-hCG
Treatment of Epididymitis
(1) Severe epididymitis + testicular pain => Urology consult for possible exploration (2) Acutely febrile + Sepsis => hospitalization for IV hydration + parenteral antibiotics (3) Ice, scrotal elevation, NSAIDs helpful adjuncts (4) Less severe cases => outpatient antibiotics, ice, scrotal elevation => should improve with antibiotics in 2-3 days => otherwise need further eval => epididymitis from culture-proven Chlamydia or Gonorrhea should refer sex partners for evaluation and treatment
Diagnosis of Torsion of Appendix Testis
(1) Testicular ultrasound - If unclear from physical - Torsed appendage as lesion of low echogenicity with central hypoechogenic area - Color Doppler shows normal blood flow to testis occasional increase on affected side, possibly due to inflammation
Scrotal / Testicular Anatomy
(1) Testis / Testicle - Make sperm and androgens, primarily testosterone. (2) Tunica vaginalis - Potential space encompassing anterior 2/3 of testicle - Fluid may accumulate within - water in hydrocele, blood in hematocele, pus in pyocele (3) Epididymis - Tightly coiled tubular structure - Posterior testis running from superior to inferior poles - Sperm travels from tubules of rete testis into epididymis - Joins vas deferens - Storage and transport of sperm cells, facilitate sperm maturation (4) Spermatic cord - Testicular blood vessels + Vas deferens - Connected to base of epididymis - Runs into abdomen (5) Appendix testis - Small vestigial structure on anterosuperior testis - Embryologic remnant of Müllerian duct system) - 0.3 cm - Pedunculated shape predispose to torsion, esp during childhood
How to distinguish partial testicular torsion?
(1) Triangular / well defined (2) Blood flow peripherally (3) will Shrink within 2 weeks
Workup for Epididymitis
(1) UA + urine culture (2) Urethral swab for urethral discharge - Culture + Nucleic acid amplification testing for chlamydia and gonorrhea (3) Ultrasound - Acute onset of testicular pain for testicular torsion. Surgical exploration should be performed to rule out testicular torsion in equivocal cases.
Differentiate: (A) Cryptorchidism (B) Retractile testes
(A) *Cryptorchidism* - Failure of descent of testes into scrotum during fetal development - Testes in abdomen, inguinal canal, or other ectopic location (B) *Retractile testes* - Can manipulate testes into scrotum manually => examine adults both supine and standing with adequate cremasteric relaxation to differentiate true undescended / ectopic testes from retractile testes
Differential for *Non-acute Scrotum*
(A) Cryptorchidism (B) Varicocele (C) Epididymal Cysts (D) Spermatocele (E) Hydrocele (F) Testicular Cancer
Differentiate: (A) Idiopathic hydrocele (B) Other causes of Hydrocele
(A) Idiopathic hydrocele - Usually asymptomatic => surgical excision of hydrocele sack - Simple aspiration usually just has reaccumulation - Percutaneous aspiration + sclerosing agent better with low incidence of reactive orchitis / epididymitis, higher rate of recurrence, and makes surgery more difficult bc inflammatory adhesions (B) Other causes of Hydrocele - Epididymitis - Testicular torsion - Appendiceal torsion
Differential for Painful Testis
(A) Testicular torsion (B) Epididymo-orchitis (C) Hematocele (D) Testicular Fracture (E) Testicular Partial torsion
Grades of Varioceles
(Grade 1) Small size - Palpable only with valsalva maneuver (Grade 2) Moderate size - Nonvisible on inspection, but palpable upon standing (Grade 3) Large size - Visible on gross inspection
Presentation of *Mumps*
Acute, self-limited, viral syndrome (1) Malaise (2) Headache (3) Myalgia (4) Anorexia (5) Parotid swelling (6) Epididymo-orchitis - Most common complication of mumps infection in adult male - Most have fever and parotitis before orchitis - Severe testicular pain - Swelling / Erythema of the scrotum - Bilateral in 30% => ice packs, scrotal elevation, NSAIDs
Presentation of *Noninfectious Epididymitis*
Chronic condition (1) Precipitated by trauma, autoimmune disease, or vasculitis (2) Idiopathic in most cases - Reflux of urine thru ejaculatory ducts and vas deferens into epididymis => "chemical" inflammation with resultant swelling => ductal obstruction - Can still occur in previous vasectomy (3) Prolonged periods of sitting or vigorous exercise (4) Less epididymal inflammation (pain, swelling) => exclude other etiologies, esp infectious epididymitis. No further evaluation is necessary for noninfectious epididymitis
Presentation of *Hydrocele*
Collection of peritoneal fluid between parietal and visceral layers of tunica vaginalis (investing layer that directly surrounds testis and spermatic cord) - Same layer forming peritoneal lining of abdomen - Arise from imbalance of secretion and reabsorption of fluid from tunica vaginalis (1) Small, soft collections to massive, tense collections of several liters (2) Pain / Disability generally increase with size (3) Hydrocele fluid transilluminates well - Differentiates process from hematocele, hernia, or solid mass (4) Hydroceles in infancy usually "communicating," - Associated with patent processus vaginalis - allows flow of peritoneal fluid into scrotal sac - Usually disappear in recumbent position - Indirect hernia thru processus vaginalis => surgical repair => scrotal ultrasound if equivocal bc reactive hydrocele can occur with testicular neoplasm or acute inflammatory scrotal conditions
Presentation of *Varicocele
Dilatation of pampiniform plexus of spermatic veins (1) 15-20% post-pubertal males (2) Usually first appear at puberty - May get larger with time (3) Usually L hemiscrotum (4) Bilateral in 33% => need to investigate unilateral R varicoele (5) Asymptomatic (6) Dull, aching, usually left scrotal pain (7) Typically noticeable when standing and relieved by recumbency (8) Testicular atrophy - Believed to be secondary to loss of germ cell mass by induction of apoptosis initiated by associated increased scrotal temperature (9) Decreased fertility - May have normal semen parameters / fertility
Presentation of *Cryptorchidism*
Failure of descent of testes into scrotum during fetal development - Testes in abdomen, inguinal canal, or other ectopic location (1) Impaired spermatogenesis (2) Increased risk of testicular tumors (3) 30% preterm and 5% full-term undescended testicle during 0-1 y/o => most descend, 1% cryptorchidism at 1 y/o => less surgical removal (malignancy concern) bc CT can locate / eval => baseline CT scan at diagnosis and then every five years EXCEPT palpable testis in inguinal canal (risk for blunt traumatic injury from compression against pubic bone)
What is the location of transit for epididymo-orchitis?
From tail of epididymis to head and testicle - Usually have epididymitis before orchitis
Causes of *Referred Pain to Scrotum*
Genitofemoral, ilioinguinal, and Posterior scrotal nerves (A) AAA (B) Urolithiasis (C) Lower lumbar / Sacral nerve root impingement (D) Retrocecal appendicitis (E) Retroperitoneal tumor (F) Post-herniorrhaphy pain
Presentation of *Inguinal Hernia*
Herniation of bowel or omentum thru spermatic cord into scrotum (1) Pain - Severe if strangulated (2) Scrotal mass. (3) Usually localized in groin / abdomen vs scrotum (4) Bowel sounds may be audible in scrotum with herniated bowel
Diagnosis of Inguinal Hernia
Herniography, ultrasound, or MRI can help differentiate intrascrotal masses
Presentation of *Testicular Torsion*
Inadequate fixation of testis to tunica vaginalis => testis may torse (twist) on the spermatic cord => potentially producing ischemia from reduced arterial inflow and venous outflow obstruction (1) More common in neonates and post-pubertal boys (2) May occur after inciting event (eg trauma) or spontaneously (3) Sudden onset - Often several hours after vigorous physical activity or minor trauma to testicles - Awakening with scrotal pain in middle of night or morning - cremasteric contraction with nocturnal sexual stimulation during REM (4) N/V (5) Asymmetrically high-riding testis with long axis oriented transversely - Instead of longitudinally bc shortening of spermatic cord - *"Bell clapper deformity"* (6) Profound testicular swelling early - Early can distinguish swollen, exquisitely tender testis from softer, less tender epididymis posteriorly (7) Reactive hydrocele and overlying erythema of scrotal wall may be a later sign (12 to 24 hours) (8) Cremasteric reflex absent (9) Usually possible to detorse testis during exam - Gentle rotation away from the midline - Relief of pain with detorsion indicates likely testicular torsion => Urologic emergency => irreversible damage after 12 hours of ischemia, infertility (even with normal contralateral testis) bc disruption of "blood-testis" barrier may expose antigens from germ cells and sperm to develop anti-sperm antibodies
Presentation of *Fournier's Gangrene*
Necrotizing fasciitis of perineum by mixed infection with aerobic/anaerobic bacteria - Often involves scrotum (1) Severe pain starting on anterior abdominal wall, migrates into the gluteal muscles and onto scrotum and penis (2) Tense edema outside involved skin, blisters/bullae, crepitus, and subcutaneous gas (3) Systemic findings - Fever, tachycardia, hypotension
Treatment of Varicoceles
No clear guidelines or solid evidence established for treatment - surgical ligation or venous embolization (A) Surgical treatment - Ligating gonadal vein so retrograde blood flow can't reach plexus of veins in scrotum - Inguinal, Subinguinal, Lumbar, Laparoscopic, Microsurgical approach (B) Embolization - Some reports of embolization coils migrating to lungs / other organs - Surgical ligation generally preferred first-line (1) Boys with retarded growth of affected testis (2) Young men with testicular atrophy - Catch-up growth of atrophic testis possible and return of testicular size postoperatively directly correlates with normal fertility potential (3) Older man with completed family + only minor scrotal discomfort => scrotal support and NSAIDs (4) Younger infertile men or reduced semen parameters - Less clear - Uncontrolled studies of improvement with varicocele ligation - Recommend surgical ligation despite lack of clear data (5) Subclinical varicoceles - Part of infertility evaluation - Retrograde flow to scrotum by Color Doppler - Surgical ligation for subclinical varicoceles associated with subfertility is unclear (6) Young men with varicoceles and normal semen parameters => no evidenced-based guidelines (7) Older men with normal semen parameters => semen analysis every two years as long as desire continued fertility => follow-up is no longer necessary after family is complete
Antibiotics for Epididymitis
No optimal studies for antibiotic choice => CDC guidelines (1) Acute epididymitis from *Chlamydia / Gonorrhea* - *IM Ceftriaxone 250 mg x1 + PO Doxycycline 100 mg BID x10 days* - Azithromycin alternative if unable to tolerate doxycycline - Quinolones alone NOT recommended if gonorrhea suspected (eg, in patients with acute urethritis or proctitis, high risk for sexually transmitted disease) bc resistance (2) Acute epididymitis from *chlamydia / gonorrhea and enteric organisms* - Men who practiced insertive anal sex - *IM Ceftriaxone 250 mg x1 + Fluoroquinolone that covers enteric organisms* - PO Ofloxacin 300 mg BID x10 days - PO Levofloxacin 500 mg qDay x10 days (3) Acute epididymitis from *enteric organisms* - Men with negative gram stain or nucleic acid amplification test for Gonorrhea - Men with epididymitis after urinary-tract instrumentation - *Fluoroquinolones alone* - PO Ofloxacin 300 mg BID x10 days - PO Levofloxacin 500 mg qDay x10 days
Complications of *Scrotal Trauma*
Rarely severe testicular injury - Usually due to compression of testis against the pubic bones from direct blow or straddle injury (1) Hematocele - Blood within tunica vaginalis (2) Pyocele - Pus within tunica vaginalis (3) Testicular rupture => Color Doppler accurately diagnose extent of injury => Testicular rupture requires surgical repair
Differentiate: (A) Epididymal cyst (B) Spermatocele
Size difference *Spermatocele:* epididymal cystic masses > 2 cm - Always located superior to testis - Palpated as distinct from testis (differentiates from hydroceles) - Rarely symptomatic => surgical excision if chronic pain
Presentation of *Henoch-Schönlein purpura (IgA vasculitis)*
Systemic vasculitis (1) Non-thrombocytopenic purpura (2) Arthralgia (3) Renal disease (4) Abdominal pain (5) GI bleeding (6) Occasionally scrotal pain. => clinical diagnosis but ultrasound can help distinguish from testicular torsion
On scrotal ultrasound, what should be intact?
Tunica Albigunea
Differential for *Acute Scrotum*
Urologic emergencies (A) Testicular torsion (B) Severe infectious Epididymitis, (C) Fournier's gangrene - Necrotizing fasciitis of the perineum NON-Emergencies (D) Noninfectious Epididymitis (E) Orchitis (F) Appendix Testis Torsion (G) Trauma (H) Post-Vasectomy (I) Testicular cancer (J) Inguinal Hernia (K) Henoch-Schönlein purpura (IgA vasculitis) (L) Mumps (M) Referred Pain (N) Acute idiopathic scrotal edema
Treatment of Inguinal Hernia
Watchful waiting vs Surgical correction