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

Evaluation of Testicular Disorders

Richard E. Freeman MD MPH

2013

Lock Haven University

TESTICULAR EVALUATIONSection 1

Testicular Anatomy

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 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 Urinalysis Urethral Discharge

Gram Stain Culture PCR (Chlamydia/GC)

Ultrasound Doppler Ultrasound Testicular Scan

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

Doppler UltrasoundDoppler Ultrasound

THE PAINFUL TESTICALSection 2

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 Epididymitis/Epididymo-Orchitis Orchitis Testicular Torsion Torsion Torsion of Testicular appendix

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 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 Testicle Incidence- 1:4000 males before age 25

TESTICULAR TORSION DIAGNOSIS: High degree of suspicion CLINICAL DIAGNOSIS Blood Flow:

ULTRASOUND - color doppler Radionucleotide

Torsion Testicle

REPRESENTS SURGICAL EMERGENCY

Requires immediate orchidopexy Contralateral side should be repaired at the

same time

Testicular Salvage rates < 6 hours – 90-100% salvage rate 12-24 hours – 20-50% > 24 hours – 0-10%

Torsion Testicle

Differential includes Appendiceal torsion Orchitis Epididymitis

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 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

Blue Dot sign

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

Epididymitis ETIOLOGY:

Retrograde infection from the urinary tract.Sexually active – Chlamydia, Gonorrhea, E.coliOlder men and children- E.coliNon-infectious – post surgery, drugs

SIGNS/SYMPTOMS:Scrotal pain- slow onset+- Dysuria, frequency, Discharge, FeverTenderness and swelling epididymis

Epididymitis Natural History/Complications

Abscess Epididymis and testicular infarction Chronic inflammation/disability

EPIDYDIMITISDiagnostic Studies

Urinalysis May reveal pyuria

Urine Culture Responsible organisms

Urethral Swab Gram Stain Culture PCR-Gonorrhea/Chlamydia

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 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 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.

ORCHITIS SIGNS & SYMPTOMS:

similar to epididymitis, hematuria, ejaculation of blood Pain, entire testes swollen- exquisitely tender Systemic- fever chills, malaise

Orchitis - Treatment GENERAL: BED REST, SCROTAL SUPPORT ANALGESICS,

ANTIEMETICs

VIRAL etiology- Supportive care

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 massesSection 3

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

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?

Varicocele

Hydrocele

DEFINITION: Fluid filled mass between tunica

vaginalis & testicle

ETIOLOGYfailure of patent processus vaginalis to

close & failure of peritoneal fluid to be re-absorbed

EPIDEMIOLOGYCommon in newborns 1-6/100 boysRarer 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 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

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

Hydrocele C

NORMALCOMMUNICATING

NON-COMMUNICATING

HERNIA: DEFINITION: ETIOLOGY: EPIDEMIOLOGY:

HERNIA:RISK FACTORSBeing 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.

Hernias: EXAM

Hernias

Hernias

Hernias

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

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 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

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? 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?

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

Histology: 2 groups

Nongerminal (5%) Leydig or sertoli cells

GERMINAL (95%) Seminoma, Embryonal,

tertatoma, choriocarcinoma, yolk sac tumors

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 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 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 Examination Feel along the

epididymis for swelling