Scrotum Pathology PDF

Pathology of Scrotum Causes of Scrotal Pain Common o Testicular Torsion o Epididymitis Less Common o Appendix testis torsion o Testicular cancer o Fournier’s gangrene Evaluation of Acute Scrotal Pain History: location Dysuria Frequency Urgency Urinalysis Testicular Torsion Epididymitis Fournier’s Ga...

Pathology of Scrotum Causes of Scrotal Pain Common o Testicular Torsion o Epididymitis Less Common o Appendix testis torsion o Testicular cancer o Fournier’s gangrene Evaluation of Acute Scrotal Pain History: location Dysuria Frequency Urgency Urinalysis Testicular Torsion Epididymitis Fournier’s Gangrene Acute Scrotal Pain features in Adults Symptom Onset Pain Location Cremasteric Reflex Acute Testis Neg Acute/Chronic Epididymis Pos Acute Diffuse Pos Testicular Torsion Inadequate fixation of testis to tunica vaginalis Torsion of testis = twisting within the scrotum o Decreased arterial flow o Increased venous congestion o Ischemia Complications: o Infertility o Cosmetic deformity Physical Exam: Absent cremasteric reflex Ultrasound: 100% specific in diagnosing testicular torsion Epididymitis Inflammation of the epididymis Obstruction of urethra from any cause can increase risk o Congenital abnormalities o Prostate enlargement Root cause is often infectious, but culture is negative Complications if untreated o Testicular abscess o Infertility Causes of Epididymitis: o Men under 35 § Chlamydia trachomatis § Neisseria gonorrhea o Men older than 40 § E. Coli § Coliform bacteria § Pseudomonas Diagnosis o Urine sample o Ultrasound to rule out testicular torsion § Epididymitis = increased signal due to inflammation § Testicular torsion = no signal Epididymitis Acute Presentation o Severe pain and swelling of affected testicle o High fever/rigors o Irritative/obstructive urinary tract symptoms o Less common scrotal pain Chronic Presentation o Scrotal pain > 6 weeks in healthy male o Usually no urinary symptoms o More common – 80% of scrotal pain Torsion of Appendix Testis Most common cause of acute scrotal pathology in childhood (age 7-14) Physical exam: Blue dot sign o Caused by infarction and necrosis of appendix testis o Torsion most commonly Fournier’s Gangrene Necrotizing fasciitis of the perineum Physical exam o Tense edema of involved skin o Crepitus o Subcutaneous gas o Hypotension o Tachycardia o Fever CT or MRI show gas in perineum Do not delay treatment Treatment o Broad spectrum antibiotic therapy o Hemodynamic support as needed o Antibiotic therapy alone causes 100% mortality Non-tender Scrotal Issues Testicular Cancer Malignancy Rare o Unilateral Most common solid tumor in men ages 18-40 o Nontender mass in the scrotum MRI if USG inconclusive (100% NPV) o Appears age 20-40 Other tests: Alpha fetoprotein (germ cell tumors) Varicocele o Uncomfortable mass in superior pole of scrotum (usually left) o Nontender o Feels like a “bag of worms” o infertility by causing apoptosis of germ cells o Treatment in cases of significant discomfort or testicular atrophy/low sperm count § Surgical ligation Erectile Dysfunction Epidemiology of ED Inability to achieve or maintain erection Affects 50% of men older than 40 years Complex problem involving multiple pathways o Vascular o CNS/PNS o Hormonal Physiology of Erectile Function Response to tactile, olfactory, and visual stimuli Ability to achieve and maintain erection dependent on multiple pathways o Peripheral nerve function o Vascular supply is adequate Parasympathetic: maintains an erection (S2-4 roots) Sympathetic: orgasm Nitric Oxide Pathway o Produced by NO synthase – 3 subtypes, 2 are calcium dependent o Turns L-arginine into NO and L-citrulline o Activates guanalyl cyclase o Produces cGMP to relaxes smooth muscle – causes vasodilation Testosterone Levels decrease with age o Association of low testosterone and ED unclear o Treating low testosterone DOES NOT cure ED (erections improved only) Sexual stimulation causes: Release of NO, cGMP, cAMP Relaxation of smooth muscle in arteries/arterioles Dramatic increase in penile blood flow Obstructing venous outflow Organic Causes of ED SMOKING – 1.5x risk Vascular – 50% of all ED o HTN o CAD Respiratory o COPD o Sleep apnea Meds o Antihypertensives o Antidepressants (SSRI) o Antipsychotics (risperidone, etc) o Statins Risks of ED 62% increased risk of MI 44% increased risk of CardioV 39% increased risk of stroke Diagnosing ED Physical Exam o BP o BMI/weight o CV – central and peripheral Workup o A1C o Lipids o Metabolic profile – look for risk factors o If low libido/low T symptoms – check testosterone o Urinalysis o Urologic testing § PGE-1 (alprostadil) cavernosal injection § Doppler ultrasound: pre/post PGE-1 Treatment of ED Pharmacologic o PDE-5 Inhibitors (most commonly tx) o PGE-1 Injections + PDE-5 Inhibitors o MUSE – Medical urethral System for Erections o Testosterone Supplementation if