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Evaluation of Testicular Disorders

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Evaluation of Testicular Disorders Richard E. Freeman MD MPH 2013 Lock Haven University * * * * * * Mechanism. In cases of testicular torsion, an anatomic deformity ... – PowerPoint PPT presentation

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Title: Evaluation of Testicular Disorders


1
Evaluation of Testicular Disorders
  • Richard E. Freeman MD MPH
  • 2013
  • Lock Haven University

2
TESTICULAR EVALUATION
  • Section 1

3
Testicular Anatomy
4
History
  • Age of Patient helpful in limiting differential
    and determining responsible organisms
  • Nature of Pain
  • Severity
  • Quality
  • Radiation
  • Alleviating/Aggravating factors
  • Sexual History
  • Associated constitutional symptoms
  • Associated urinary symptoms
  • Dysuria, frequency, hesitancy
  • Discharge- etc
  • Other
  • Activities involved with
  • Sports-lifting, trauma

5
Physical Exam
  • Always complete GU - be systematic
  • Inspection- entire perineum- over, under, and
    beside
  • Skin- cysts, ulcers, erythema/rash, parasites
  • Masses-
  • Palpation
  • Inguinal- hernias, masses, nodes
  • Scrotum- Cord, Epididymis, Testes
  • Penile shaft palpate from bulbous to tip-
    masses tenderness ulcers
  • Milk the shaft discharge- Examine urethral
    meatus
  • Rectal
  • Hemorrhoids
  • Prostate
  • Masses
  • Occult blood
  • Abdominal Exam - Complete
  • ?? Parotids

6
Diagnostic Studies
  • Urinalysis
  • Urethral Discharge
  • Gram Stain
  • Culture
  • PCR (Chlamydia/GC)
  • Ultrasound
  • Doppler Ultrasound
  • Testicular Scan

7
Doppler Ultrasound
Diagnosis Appearance on U/S
Normal testis Normal blood flow
Testicular Torsion Absent or decreased blood flow
Epididymitis/Orchitis Increased blood flow
Appendiceal Torsion Normal blood flow
8
THE PAINFUL TESTICAL
  • Section 2

9
Case 1
  • A ten year old male presents to your clinic
    complaining of acute testicular pain while
    playing outside this afternoon. There is no
    history of trauma. He is afebrile and denies any
    recent symptoms of viral illness. On physical
    exam you note a tender right testicle that has a
    transverse lie in the scrotal sac. Elevating the
    testicle exacerbates symptoms.

10
TESTICULAR PAIN Differential Diagnosis
  • Epididymitis/Epididymo-Orchitis
  • Orchitis
  • Testicular Torsion
  • Torsion
  • Torsion of Testicular appendix

11
Torsion Testicle
  • Severe pain - abrupt onset
  • Possibly previous history of similar episode that
    resolved
  • Absence of cremasteric reflex on affected side
    suggestive of torsion
  • High riding testicle with transverse lie of
    testicle- suggests torsion
  • Prehns sign- lack of pain relief with testicle
    elevation

12
(No Transcript)
13
Torsion Testicle
  • Occurs due to anatomic defect in scrotal
    development- Tunica Vaginalis compltely surrounds
    the testes and possibly the cord.
  • No attachment of the Tunica vaginalis to the
    wall of the scrotum.
  • Allows Testes to swing freely
  • Bell-Clapper deformity
  • Two variations
  • Intravaginal Torsion
  • Extravaginal Torsion-Exclusively in neonates

14
Torsion Testicle
  • Incidence- 14000 males before age 25

15
TESTICULAR TORSION
  • DIAGNOSIS High degree of suspicion
  • CLINICAL DIAGNOSIS
  • Blood Flow
  • ULTRASOUND - color doppler
  • Radionucleotide

16
Torsion Testicle
  • REPRESENTS SURGICAL EMERGENCY
  • Requires immediate orchidopexy
  • Contralateral side should be repaired at the same
    time

17
Testicular Salvage rates
  • lt 6 hours 90-100 salvage rate
  • 12-24 hours 20-50
  • gt 24 hours 0-10

18
Torsion Testicle
  • Differential includes
  • Appendiceal torsion
  • Orchitis
  • Epididymitis

19
Appendiceal Torsion
  • Onset of Symptoms
  • Subacute
  • Age
  • Prepubertal
  • Tenderness
  • Localized to upper pole
  • UA Negative
  • Cremasteric reflex
  • Positive
  • Treatment
  • Bed rest/scrotal evalvation
  • Surgical

20
Torsion of Testicular appendix
  • Appendix Testes
  • Remnant of Mullerian duct (92)
  • Blue dot sign
  • More common in children than testicular torsion
  • Appendix Epididymis
  • Remnant of Wolffian duct (23)
  • Present as Subacute pain
  • Absence of systemic/Urinary tract symptoms

21
Blue Dot sign
22
Epididymitis
  • DEFINITION
  • Inflammation, Pain, Swelling of epididymis
  • Acute Symptoms usually lasting lt 6 weeks
  • Chronic Symptoms usually lasting gt 6 weeks
  • May be acute sub-acute chronic
  • EPIDEMIOLOGY
  • Most common cause of acute scrotal pain
  • Age 16-30 y/o 51-70 y/o
  • Incidence parallels incidence of Chlamydia GC

23
Epididymitis
  • ETIOLOGY
  • Retrograde infection from the urinary tract.
  • Sexually active Chlamydia, Gonorrhea, E.coli
  • Older men and children- E.coli
  • Non-infectious post surgery, drugs
  • SIGNS/SYMPTOMS
  • Scrotal pain- slow onset
  • - Dysuria, frequency, Discharge, Fever
  • Tenderness and swelling epididymis

24
Epididymitis
  • Natural History/Complications
  • Abscess
  • Epididymis and testicular infarction
  • Chronic inflammation/disability

25
EPIDYDIMITISDiagnostic Studies
  • Urinalysis
  • May reveal pyuria
  • Urine Culture
  • Responsible organisms
  • Urethral Swab
  • Gram Stain
  • Culture
  • PCR-Gonorrhea/Chlamydia

26
Epididymitis
  • Treatment
  • lt 35 y/o
  • Ceftriaxone 250 mg IM
  • Doxycyxline 100 BID x 14 days
  • gt 50 y/o
  • Treat responsible organism
  • Ciprofloxin/Quinilones
  • TMP/SMZ

27
Orchitis
  • DEFINITION
  • Inflammation or infection of the testicles
  • may be related to epididymitis
  • Extension to testes
  • Etiology
  • bacterial (E. coli, K. pneumoniae, P. aeruginosa,
    Staph. or Strep)
  • viral (EBV, coxsackievirus, arbovirus,
    enterovirus, MUMPS VIRUS)

28
ORCHITIS MUMPS
  • Most common cause of orchitis
  • Approximately 20 of prepubertal patients with
    mumps develop orchitis.
  • 4 out of 5 cases occur in prepubertal
    males(younger than 10 years).
  • Mumps orchitis follows the development of
    parotitis by 4-7 days.
  • Mumps orchitis presents unilaterally in 70 of
    cases (fertility usually maintained)
  • In 30 of cases, contralateral testicular
    involvement follows by 1-9 days.

29
ORCHITIS
  • SIGNS SYMPTOMS
  • similar to epididymitis,
  • hematuria, ejaculation of blood
  • Pain,
  • entire testes swollen- exquisitely tender
  • Systemic- fever chills, malaise

30
Orchitis - Treatment
  • GENERAL
  • BED REST,
  • SCROTAL SUPPORT ANALGESICS, ANTIEMETICs
  • VIRAL etiology- Supportive care

31
Orchitis- Treatment
  • BACTERIAL etiology
  • lt35 y/o and sexually active,
  • antibiotic coverage for sexually transmitted
    pathogens (particularly gonorrhea and chlamydia)
  • Ceftriaxone and either doxycycline or
    azithromycin is appropriate.
  • gt35 y/o
  • with bacterial etiology require additional
    coverage for other gram-negative bacteria
  • fluoroquinolone ( not for gonorrhea)
  • TMP-SMX

32
Painless scrotal masses
  • Section 3

33
PAIN LESS SCROTAL MASSES
  • Varicocele
  • Hydrocele
  • Hernia
  • Testicular Tumors
  • Spermatocele
  • Scrotal Edema

34
Varicocele
  • Patient presents with mass of scrotum that feels
    like bag of worms
  • Most commonly left sided due to drainage of L
    gonadal vein into the left renal vein at an acute
    angle and anatomic variants which cause back
    pressure
  • Clinically benign Except in the setting of
    infertility
  • 40 of men with infertility have varicocele.
  • Surgical removal may be necessary
  • Why might this cause infertility?

35
Varicocele
36
Hydrocele
  • DEFINITION
  • Fluid filled mass between tunica vaginalis
    testicle
  • ETIOLOGY
  • failure of patent processus vaginalis to close
    failure of peritoneal fluid to be re-absorbed
  • EPIDEMIOLOGY
  • Common in newborns 1-6/100 boys
  • Rarer in Adult males 1/100
  • When persistent or fluctuating Hydrocele seen
    after age of 1 a communication is present- (known
    as communicating Hydrocele)

37
HYDROCELE RISK FACTORS
  • Premature and low-birth-weight infants
  • Indirect inguinal hernia
  • Primary testicular/intrascrotal pathology
  • Trauma
  • Surgery
  • Increased intra-abdominal pressure
  • Lymphatic obstruction
  • Ventriculoperitoneal shunt
  • Peritoneal dialysis
  • Ehlers-Danlos syndrome
  • Non communicating forms may result from trauma,
    infection or neoplasm

38
Hydrocele
  • Physical Exam
  • Transilluminating mass-waxes and wanes
  • May associated with a indirect hernia
  • Consider ultrasound due to possibility of
    neoplasm causing Hydrocele
  • Management
  • Expectant- watch and wait
  • Surgical resection

39
Hydrocele
  • C

NON-COMMUNICATING
COMMUNICATING
NORMAL
40
HERNIA
  • DEFINITION
  • ETIOLOGY
  • EPIDEMIOLOGY

41
HERNIARISK FACTORS
  • Being male.
  • Family history.
  • Certain medical conditions cystic fibrosis
  • Chronic cough..
  • Chronic constipation. Straining during bowel
    movements
  • Excess weight moderately to severely overweight
    puts extra pressure on abdomen.
  • Pregnancy This can both weaken the abdominal
    muscles and cause increased pressure inside your
    abdomen.
  • Certain occupations Having a job that requires
    standing for long periods or doing heavy physical
    labor increases risk of developing an inguinal
    hernia.
  • Premature birth Infants who are born early are
    more likely to have inguinal hernias.
  • History of hernias one inguinal hernia, it's
    much more likely develop another usually on the
    opposite side.

42
Hernias EXAM
43
Hernias
44
Hernias
45
Hernias
46
Hernias
  • CLINICAL COURSE
  • NORMAL REDUCIBLE
  • Complications
  • INCARCERATION
  • Not easily manually reduced
  • STRANGULATION
  • Surgical Emergency- herniorrhaphy
  • Blood supply to hernial contents
    (omentum/intestines) is compromised ? tissue death

47
Spermatocele
  • DEFINITION
  • Usually asymptomatic, small mass of the
    epididymis
  • Equivalent of a Berry aneurysm of the epididymis
  • Benign
  • DIAGNOSIS
  • normally confirmed with ultrasound however only
    (definitive diagnosis is made through biopsy or
    aspiration returning spermatozoa- not necessary)
  • TREATMENT
  • Surgical excision reserved for chronic pain or
    extensive enlargement

48
CRYPTORCHIDISM
  • DEFINITION
  • Undescended orHidden testis
  • EPIDEMIOLOGY
  • Incidence-
  • 0.7-1 at age 1.
  • ETIOLOGY
  • Uncertain
  • COMPLICATIONS
  • Can lead to infertility and has a higher
    incidence of malignancy .
  • Tx- Orchiopexy

49
TESTICULAR TUMORS
  • EPIDEMIOLOGY
  • Incidence low 4/100,000
  • Prevalence 3.7/100,000
  • Most common cancer in men between ages of 15-35
  • Excellent prognosis with early detection

50
Who gets testicular cancer?
  • Men who are more likely to get testicular cancer
  • Are white
  • Have a father or brother who had testicular
    cancer
  • Have a testicle that did not come down into the
    scrotum even if surgery was done to remove the
    testicle or bring it down
  • Have small testicles or testicles that aren't
    shaped right (most testicles are round, smooth
    and firm)
  • Have Klinefelter's syndrome

51
What are the signs of testicular cancer?
  • A hard, painless lump in the testicle (this is
    the most common sign)
  • Pain or a dull ache in the scrotum
  • A scrotum that feels heavy or swollen
  • Bigger or more tender breasts
  • Back Pain
  • Dyspnea

52
Testicular Cancer
  • Histology
  • 2 groups
  • Nongerminal (5)
  • Leydig or sertoli cells
  • GERMINAL (95)
  • Seminoma, Embryonal, tertatoma, choriocarcinoma,
    yolk sac tumors

53
Testicular Cancer
  • Germinal tumors usually metastasize thru lymph
    system except for choricocarcinoma which
    metastasize thru the vascular system.
  • TREATMENT AND PROGNOSIS
  • varies with type of tumor.
  • The earlier its found the better the outcome!
  • Virtually 100 CURE if found before metastasis
  • gt80 if metastasized
  • chemotherapy

54
Testicular Self Examination
  • Check your testicles one at a time. Use one or
    both hands.
  • Cup your scrotum with one hand to see if there is
    any change.

55
Testicular Self Examination
  • Place your index and middle fingers under a
    testicle with your thumb on top.
  • Gently roll the testicle between your thumb and
    fingers.
  • Feel for any lumps in or on the side of the
    testicle. Repeat with the other testicle.

56
Testicular Self Examination
  • Feel along the epididymis for swelling
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