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Evaluation of Testicular Disorders. Richard E. Freeman MD MPH 2013 Lock Haven University. Section 1. TESTICULAR EVALUATION. Testicular Anatomy. History . Age of Patient helpful in limiting differential and determining responsible organisms : Nature of Pain: Severity Quality Radiation

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Evaluation of testicular disorders

Evaluation of Testicular Disorders

Richard E. Freeman MD MPH

2013

Lock Haven University


Testicular evaluation

Section 1

TESTICULAR EVALUATION



History
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


Physical exam
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


Diagnostic studies
Diagnostic Studies

  • Urinalysis

  • Urethral Discharge

    • Gram Stain

    • Culture

    • PCR (Chlamydia/GC)

  • Ultrasound

  • Doppler Ultrasound

  • Testicular Scan



The painful testical

Section 2

THE PAINFUL TESTICAL


Case 1
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.


Testicular pain differential diagnosis
TESTICULAR PAIN: Differential Diagnosis

  • Epididymitis/Epididymo-Orchitis

  • Orchitis

  • Testicular Torsion

  • Torsion

  • Torsion of Testicular appendix


Torsion testicle
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

  • Prehn’s sign- lack of pain relief with testicle elevation


Torsion testicle1
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


Torsion testicle2
Torsion Testicle

  • Incidence- 1:4000 males before age 25


Testicular torsion
TESTICULAR TORSION

  • DIAGNOSIS: High degree of suspicion

  • CLINICAL DIAGNOSIS

  • Blood Flow:

    • ULTRASOUND - color doppler

    • Radionucleotide


Torsion testicle3
Torsion Testicle

  • REPRESENTS SURGICAL EMERGENCY

  • Requires immediate orchidopexy

  • Contralateral side should be repaired at the same time


Testicular salvage rates
Testicular Salvage rates

  • < 6 hours – 90-100% salvage rate

  • 12-24 hours – 20-50%

  • > 24 hours – 0-10%


Torsion testicle4
Torsion Testicle

  • Differential includes

    • Appendiceal torsion

    • Orchitis

    • Epididymitis


Appendiceal torsion
Appendiceal Torsion

  • Onset of Symptoms:

    • Subacute

  • Age

    • Prepubertal

  • Tenderness

    • Localized to upper pole

  • UA Negative

  • Cremasteric reflex

    • Positive

  • Treatment

    • Bed rest/scrotal evalvation

    • Surgical


Torsion of testicular appendix
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



Epididymitis
Epididymitis

  • DEFINITION:

    • Inflammation, Pain, Swelling of epididymis

    • Acute: Symptoms usually lasting < 6 weeks

    • Chronic: Symptoms usually lasting > 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


Epididymitis1
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


Epididymitis2
Epididymitis

  • Natural History/Complications

    • Abscess

    • Epididymis and testicular infarction

    • Chronic inflammation/disability


Epidydimitis diagnostic studies
EPIDYDIMITISDiagnostic Studies

  • Urinalysis

    • May reveal pyuria

  • Urine Culture

    • Responsible organisms

  • Urethral Swab

    • Gram Stain

    • Culture

    • PCR-Gonorrhea/Chlamydia


Epididymitis3
Epididymitis

  • Treatment

    • < 35 y/o

      • Ceftriaxone 250 mg IM

      • Doxycyxline 100 BID x 14 days

    • > 50 y/o

      • Treat responsible organism

      • Ciprofloxin/Quinilones

      • TMP/SMZ


Orchitis
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)


Orchitis mumps
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.


Orchitis1
ORCHITIS

  • SIGNS & SYMPTOMS:

    • similar to epididymitis,

    • hematuria, ejaculation of blood

    • Pain,

    • entire testes swollen- exquisitely tender

    • Systemic- fever chills, malaise


Orchitis treatment
Orchitis - Treatment

  • GENERAL:

  • BED REST,

  • SCROTAL SUPPORT ANALGESICS, ANTIEMETICs

  • VIRAL etiology- Supportive care


Orchitis treatment1
Orchitis- Treatment

  • BACTERIAL etiology:

  • <35 y/o and sexually active,

    • antibiotic coverage for sexually transmitted pathogens (particularly gonorrhea and chlamydia)

    • Ceftriaxone and either doxycycline or azithromycin is appropriate.

  • >35 y/o

    • with bacterial etiology require additional coverage for other gram-negative bacteria

    • fluoroquinolone ( not for gonorrhea)

    • TMP-SMX


Painless scrotal masses

Section 3

Painless scrotal masses


Pain less scrotal masses
PAIN LESS SCROTAL MASSES

  • Varicocele

  • Hydrocele

  • Hernia

  • Testicular Tumors

  • Spermatocele

  • Scrotal Edema


Varicocele
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?



Hydrocele
Hydrocele

  • DEFINITION:

    • Fluid filled mass between tunica vaginalis & testicle

      ETIOLOGY

      failure of patent processusvaginalis 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)


Hydrocele risk factors
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


Hydrocele1
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


Hydrocele2
Hydrocele

  • C

NON-COMMUNICATING

COMMUNICATING

NORMAL


Hernia
HERNIA:

  • DEFINITION:

  • ETIOLOGY:

  • EPIDEMIOLOGY:


Hernia risk factors
HERNIA:RISK 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.






Hernias3
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


Spermatocele
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


Cryptorchidism
CRYPTORCHIDISM

  • DEFINITION:

    • Undescended or“Hidden 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


Testicular tumors
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


Who gets testicular cancer
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


What are the signs of testicular cancer
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


Testicular cancer
Testicular Cancer

  • Histology:

    • 2 groups

      • Nongerminal (5%)

        • Leydig or sertoli cells

      • GERMINAL (95%)

        • Seminoma, Embryonal, tertatoma, choriocarcinoma, yolk sac tumors


Testicular cancer1
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

    • >80% if metastasized

      • chemotherapy


Testicular self examination
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.


Testicular self examination1
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.


Testicular self examination2
Testicular Self Examination

  • Feel along the epididymis for swelling


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