testicular disorders

8/17/2019 Testicular Disorders

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Evaluation of TesticularDisorders

Richard E. Freeman MD MPH2013

Lock Haven University


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TESTICULAR EVALUATION

Section 1


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Testicular Anatomy


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History Age of Patient helpful in limiting differential and determining responsible

organisms : Nature of Pain:

Severity

uality !adiation Alleviating"Aggravating factors

Se#ual History Associated constitutional symptoms Associated urinary symptoms

Dysuria$ fre%uency$ hesitancy Discharge& etc 'ther

Activities involved (ith: Sports&lifting$ trauma


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Physical E#am Al(ays complete )*: & be systematic

+nspection& entire perineum& over$ under$ and beside S,in& cysts$ ulcers$ erythema"rash$ parasites

-asses&

Palpation

+nguinal& hernias$ masses$ nodes

Scrotum& .ord$ Epididymis$ Testes

Penile shaft / palpate from bulbous to tip& masses tenderness ulcers

-il, the shaft / discharge& E#amine urethral meatus

!ectal

Hemorrhoids Prostate

-asses

'ccult blood

Abdominal E#am & .omplete 00 Parotids


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Diagnostic Studies *rinalysis

*rethral Discharge

)ram Stain .ulture

P.! .hlamydia").2

*ltrasound Doppler *ltrasound

Testicular Scan


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Diagnosis Appearance on U/S

Normal testis Normal blood flo(Testicular Torsion Absent or decreased blood flo(

Epididymitis"'rchitis +ncreased blood flo(

Appendiceal Torsion Normal blood flo(

Dopper Utraso!ndDopper Utraso!nd


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THE PAINFUL TESTICAL

Section 3


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.ase 1 A ten year old male presents to your clinic

complaining of acute testicular pain (hile

playing outside this afternoon4 There is nohistory of trauma4 He is afebrile and denies

any recent symptoms of viral illness4 'n

physical e#am you note a tender right testicle

that has a transverse lie in the scrotal sac4

Elevating the testicle e#acerbates symptoms4


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TEST+.*5A! PA+N:

Differential Diagnosis Epididymitis"Epididymo&'rchitis

'rchitis

Testicular Torsion

Torsion

Torsion of Testicular appendi#


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Torsion Testicle Severe pain & abrupt onset

Possibly previous history ofsimilar episode that resolved

Absence of cremastericrefle# on affected sidesuggestive of torsion

High riding testicle (ithtransverse lie of testicle&suggests torsion

Prehn6s sign& lac, of painrelief (ith testicleelevation

http://home.mdconsult.com/das/book/body/115918401/604/I1281.fig


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Torsion Testicle 'ccurs due to anatomic defect in scrotal

development& Tunica 7aginalis compltely surrounds

the testes and possibly the cord4

No attachment of the Tunica vaginalis to the (all

of the scrotum4

Allo(s Testes to 8s(ing freely

89ell&.lapper deformity T(o variations

+ntravaginal Torsion

E#travaginal Torsion&E#clusively in neonates


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Torsion Testicle +ncidence& 1:;


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TEST+.*5A! T'!S+'N D+A)N'S+S: High degree of suspicion

CLINICAL DIAGNOSIS

9lood >lo(: *5T!AS'*ND & color doppler

!adionucleotide


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Torsion Testicle

REPRESENTS SURGICAL EMERGENCY

!e%uires immediate orchidope#y

.ontralateral side should be repaired at the

same time


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Testicular Salvage rates ? @ hours /


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Torsion Testicle

Differential includes

Appendiceal torsion

'rchitis

Epididymitis


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Appendiceal Torsion 'nset of Symptoms:

Subacute

Age Prepubertal

Tenderness 5ocalied to upper pole

*A Negative

.remasteric refle# Positive

Treatment 9ed rest"scrotal evalvation Surgical


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Torsion of Testicular appendi#

Appendi# Testes !emnant of -ullerian duct 3B2

89lue dot sign -ore common in children than testicular torsion

Appendi# Epididymis

!emnant of olffian duct 3FB2 Present as Subacute pain

Absence of systemic"*rinary tract symptoms


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9lue Dot sign


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Epididymitis

DE>+N+T+'N: +nflammation$ Pain$ S(elling of epididymis

Acute: Symptoms usually lasting ? @ (ee,s .hronic: Symptoms usually lasting C @ (ee,s

-ay be acute sub&acute chronic

EP+DE-+'5')G:

-ost common cause of acute scrotal pain Age: 1@&F< y"o =1&I< y"o

+ncidence parallels incidence of .hlamydia ).


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Epididymitis ET+'5')G:

!etrograde infection from the urinary tract4

Se#ually active / .hlamydia$ )onorrhea$ E4coli

'lder men and children& E4coli

Non&infectious / post surgery$ drugs

S+)NS"SG-PT'-S:

Scrotal pain& slo( onsetJ& Dysuria$ fre%uency$ Discharge$ >ever

Tenderness and s(elling epididymis


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Epididymitis

Natural History".omplications

Abscess

Epididymis and testicular infarction .hronic inflammation"disability


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EP+DGD+-+T+S

Diagnostic Studies *rinalysis

-ay reveal pyuria

*rine .ulture !esponsible organisms

*rethral S(ab )ram Stain

.ulture

P.!&)onorrhea".hlamydia


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Epididymitis

Treatment

? F= y"o

.eftria#one 3=< mg +- Do#ycy#line 1


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'rchitis

DE>+N+T+'N: +nflammation or infection of the testicles

may be related to epididymitis

E#tension to testes

Etiology: bacterial E4 coli$ L4 pneumoniae$ P4 aeruginosa$

Staph4 or Strep2 viral E97$ co#sac,ievirus$ arbovirus$

enterovirus$ -*-PS 7+!*S2


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'!.H+T+S -*-PS -ost common cause of orchitis

Appro#imately 3


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'!.H+T+S

S+)NS SG-PT'-S:

similar to epididymitis$

hematuria$ eMaculation of blood Pain$

entire testes s(ollen& e#%uisitely tender

Systemic& fever chills$ malaise


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'rchitis & Treatment

)ENE!A5:

9ED !EST$

S.!'TA5 S*PP'!T ANA5)ES+.S$ANT+E-ET+.s

7+!A5 etiology& Supportive care


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'rchitis& Treatment

9A.TE!+A5 etiology:

?F= y"o and se#ually active$

antibiotic coverage for se#ually transmitted pathogens

particularly gonorrhea and chlamydia2 .eftria#one and either do#ycycline or aithromycin is

appropriate4

CF= y"o

(ith bacterial etiology re%uire additional coverage for othergram&negative bacteria fluoro%uinolone not for gonorrhea2

T-P&S-


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PAINLESS SCROTAL MASSES

Section F


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PA+N 5ESS S.!'TA5 -ASSES

7aricocele

Hydrocele

Hernia Testicular Tumors

Spermatocele

Scrotal Edema


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7aricocele

"Patient presents #ith mass o$ scrot!m

that $ees ike %&a' o$ #orms(

"Most commony e$t sided d!e to

draina'e o$ L 'onada vein into the e$t

rena vein at an ac!te an'e and anatomicvariants #hich ca!se &ack press!re

")inicay &eni'n Except in the settin' o$

in$ertiity

"*0+ o$ men #ith in$ertiity have

varicocee.

",!r'ica remova may &e necessary

" -hy mi'ht this ca!se in$ertiity


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Varicocele


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Hydrocele

DE>+N+T+'N: >luid filled mass bet(een tunica

vaginalis testicle

ET+'5')Gfailure of patent processus vaginalis to

close failure of peritoneal fluid to be re&absorbed

EPIDEMIOLOGY

Common in ne(borns 1&@"1


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HGD!'.E5E

!+SL >A.T'!S Premature and lo(&birth&(eight infants +ndirect inguinal hernia

Primary testicular"intrascrotal pathology

Trauma Surgery

+ncreased intra&abdominal pressure

5ymphatic obstruction

7entriculoperitoneal shunt

Peritoneal dialysis

Ehlers&Danlos syndrome

Non communicating forms may result from trauma$ infection or neoplasm


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Hydrocele

Physical E#am

Transilluminating mass-waxes and wanes

May associated with a indirect hernia .onsider ultrasound due to possibility of neoplasm

causing Hydrocele

-anagement E#pectant& (atch and (ait

Surgical resection


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Hydrocele

.

N'!-A5.'--*N+.AT+N)

N'N&.'--*N+.AT+N)


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HE!N+A:

DE>+N+T+'N:

ET+'5')G:

EP+DE-+'5')G:


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HE!N+A:!+SL >A.T'!S'eing $a"e(

Fa$i") *is#or)(

Cer#ain $eica" coni#ions+ cystic fibrosis

C*ronic co!g*(4

C*ronic cons#ipa#ion( Straining during bo(el movementsE,cess -eig*#+ moderately to severely over(eight puts e#tra pressure on

abdomen4

Pregnanc)+ This can both (ea,en the abdominal muscles and cause increased

pressure inside your abdomen4

Cer#ain occ!pa#ions+ Having a Mob that re%uires standing for long periods or

doing heavy physical labor increases ris, of developing an inguinal hernia4

Pre$a#!re .ir#*+ +nfants (ho are born early are more li,ely to have inguinal

hernias4

His#or) o *ernias+ one inguinal hernia$ itOs much more li,ely developanother usually on the opposite side4


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Hernias: EXAM


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Hernias


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Hernias


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Hernias


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Hernias

.5+N+.A5 .'*!SE:

N'!-A5: !ED*.+95E

.omplications: INCARCERATION

Not easily manually reduced

STRANGULATION Surgical Emergency& *erniorr*ap*)

9lood supply to hernial contents omentum"intestines2 is

compromised tissue death


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Spermatocele

DE>+N+T+'N: *sually asymptomatic$ small mass of

the epididymis E%uivalent of a 9erry aneurysm of the

epididymis

9enign D+A)N'S+S:

normally confirmed (ith ultrasoundho(ever only definitive diagnosis ismade through biopsy or aspirationreturning spermatooa& not necessary2

T!EAT-ENT: Surgical e#cision reserved for chronic

pain or e#tensive enlargement


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CRYT!RCH"#"$M DE>+N+T+'N:

*ndescended or8Hidden

testis

EP+DE-+'5')G:

+ncidence&


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TE$T"C%&AR T%M!R$

EP+DE-+'5')G:

+ncidence lo(: ;"1


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0*o ge#s #es#ic!"ar cancer1

-en (ho are more li,ely to get testicular cancer: Are (hite

Have a father or brother (ho had testicular cancer

Have a testicle that did not come do(n into the scrotum

even if surgery (as done to remove the testicle or bring it

do(n

Have small testicles or testicles that arenOt shaped right

most testicles are round$ smooth and firm2

Have LlinefelterOs syndrome


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0*a# are #*e signs o #es#ic!"ar cancer1

A hard$ painless lump in the testicle this is the

most common sign2

Pain or a dull ache in the scrotum A scrotum that feels heavy or s(ollen

9igger or more tender breasts

9ac, Pain

Dyspnea


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Testicular .ancer

Histology: 3 groups

Nongerminal =B2 5eydig or sertoli cells

GERMINAL 23452 Seminoma$ Embryonal$

tertatoma$

choriocarcinoma$ yol,

sac tumors


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Testicular .ancer

)erminal tumors usually metastasie thru lymph

system e#cept for choricocarcinoma (hich

metastasie thru the vascular system4

T!EAT-ENT AND P!')N'S+S varies (ith type of tumor4

The earlier its found the better the outcomeQ

7irtually 1


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Testicular Self E#amination

.hec, your testicles

one at a time4 *se

one or both hands4

.up your scrotum

(ith one hand to see

if there is any

change4


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Testicular Self E#amination Place your inde# and

middle fingers under atesticle (ith your thumb

on top4 )ently roll the testicle

bet(een your thumb andfingers4

>eel for any lumps in oron the side of thetesticle4 !epeat (ith theother testicle4


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Testicular Self E#amination

>eel along the

epididymis for s(elling

testicular disorders

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