Evaluation of Testicular Disorders

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

2. Section 1 TESTICULAR EVALUATION

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

8. Section 2 THE PAINFUL TESTICAL

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

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- 1:4000 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 • < 6 hours – 90-100% salvage rate • 12-24 hours – 20-50% • > 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 < 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

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 • < 35 y/o • Ceftriaxone 250 mg IM • Doxycyxline 100 BID x 14 days • > 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: • <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

32. Section 3 Painless scrotal masses

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 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)

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. 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.

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 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

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