Testicular Disorders PDF

Chapter 133 TESTICULAR DISORDERS  Definition (1 of 2)  Scrotal pain may be a symptom of an underlying pathologic condition of the scrotum or testis. Can be sharp, dull, aching, uncomfortable or tender  May be an incidental finding or an acute presentation.  It is necessary to de...

Chapter 133 TESTICULAR DISORDERS  Definition (1 of 2)  Scrotal pain may be a symptom of an underlying pathologic condition of the scrotum or testis. Can be sharp, dull, aching, uncomfortable or tender  May be an incidental finding or an acute presentation.  It is necessary to determine the cause of the pain to evaluate the need for emergent referral and to exclude potentially life threatening or fertility threatening conditions.  Associated with/without pain, benign, malignant, life-threatening  Mass, cysts, edema  Specific disorders may occur more often in certain age groups.  Immediate referral to ED is warranted for sudden onset of severe pain in or swelling of the scrotum, elevation or abnormally positioning of a testicular, scrotal, or testicular erythema, tender scrotal masses. Evidence of increasing hematoma, absent cremasteric reflex, and testicular or scrotal edema.  Associated but non specific symptoms of testicular torsion: dysuria, abdominal pain, nausea, fever  Definition (2 of 2)  Structural—vascular  Varicocele- abnormal dilation of the plexus and spermatic veins in the spermatic cord, leading to testicular damage and male infertility. Found in men with primary infertility. Testicular pain and enlargement is improved when lying down, but mass may not be seen in this position. Have blue color through scrotal skin. Can complain of dullness, achiness, heaviness in scrotum that worsens with activity or straining. Typically a gradual onset of unilateral swelling, often painless. Will see an abnormally large spermatic cord (pampiniform) venous plexus (referred to as bag of worms). Diagnostic test: Testosterone levels, semen analysis to reveal oligospermia or azoospermia, US will reveal dilated pampiniform plexus vessel larger than 2-3 mm, Treatment: surgical intervention (varicocelectomy) is semen analysis reveals a volume discrepancy of more than 20%..  Testicular torsion- obstruction of blood flow to the testes due to a twisting of the arteries and veins in the spermatic cord. Trauma can be caused by burns, blunt force, or penetrating injury but half occur from sporting activities. Typically a sudden and severe onset of pain, more likely associated with nausea/vomiting. Classic findings include an elevated testis with a transverse lie, testicle that rides high In scrotum, and absent cremasteric reflex. No matter what the mechanism is for testicular torsion, it should be included within the differential diagnosis for any scrotal trauma. Diagnostic tests: Emergent surgical consultation, US will show enlarged testicle with diffuse hypoechogenicity, usually associated with a reactive hydrocele and epididymis/scrotal edema. Color flow doppler US will show absent blood flow. Treatment: Prompt surgical consultation with surgical exploration with the intent to prevent ischemia and restore blood flow.  Scrotal-inguinal hernia- results when a segment of the bowel slips through the internal inguinal ring, where it may remain in the inguinal canal or pas into the scrotal sac. May occur as a result of a defect in the anterior abdominal wall or a patent process vaginalis. Can be spontaneously reduced by digital manipulation. Unilateral inguinal or scrotal swelling and pain that decreases when recumbent and increases when standing in erect position. Diagnostic tests: When a hernia becomes strangulated or unreducible, this compromises blood supply and requires emergent surgical reduction. Strangulation should be suspected when a tender mass is palpated in the scrotum in addition to redness, nausea and vomiting. Auscultate bowel sounds over the mass for diagnosis of bowel in scrotal sac. Does not transilluminate and US will easily show the bowel mass within the scrotum. Treatment: Herniated bowel is reducible, surgical referral for future repair is indicated. Difficulty in reducing a hernia is cause for urgent surgical intervention. Pain may indicate incarceration of the bowel or complete inability to reduce, which is cause for immediate ER referral and surgical exploration.  Tumor  Testicular cancer- most common form of cancer in men ages 15-35 years. Associated with scrotal trauma, atrophy, undescended testicles (cryptorchidism), exogenous estrogen exposure, and family history of testicular cancer. Found on self examination, and typically a gradually progressive palpable testicular mass, may be painless or painful. May be able to palpate testicular mass, firmness, or induration. Most common form of testicular cancer is germ cell tumors. Serum tumor marker products for GCTs: AFP, hCG (gynecomastia in elevated hCG), LDH, transillumination, direct surgical exploration of testes, chest, abdominal and pelvic imaging. US can evaluate testicular masses and confirm the size and location of palpable tumors. Treatment: surgery, chemo, radiation.  Parasitic  Elephantiasis- caused by a filariasis (parasitic roundworm disease transmitted by flies/mosquitos) that affects the scrotum, causing massive scrotal lymphedema. Although rare it should be considered in the differential diagnosis of people who recently traveled to Africa or Asia, and health care workers involved in humanitarian missions in those areas. Diagnostic testing: Only definitive way to make the diagnosis is by detecting the parasite itself (either microfilariae or adult worms). Obtain blood samples during night when microfilariae are most active. A CBC and US can also be used. Treatment for W. bancrofti: diethylcarbamazine, which is not approved by the FDA and must be obtained from the CDC with positive lab confirmation.  Infectious  Epididymitis- acute/chronic inflammation of the epididymis (most common cause of acute scrotal pain in men). Chlamydia and gonorrhea are two most common causes in men under 35 years, and E.coli is common in men older than 35. In men > 35, it’s most often associated with urinary tract pathogens, structural abnormalities, and urologic procedures such as a TURP and urethral catheterization. May have fever, chills, and heavy sensation. Have a sudden onset of sharp, severe pain that can be partially relived by elevating the scrotum (Prehn sign). Have dysuria, urgency, frequency, lower back pain, scrotal edema. Have enlarged, tender epididymis, positive Prehn sign and urethral discharge, tender nodule at head of testicle or epididymis, has blue dot sign. Typically a more indolent onset compared to testicular torsion, less likely to have nausea/vomiting. Diagnostic testing: STD screening, scrotal US to demonstrate infarcted appendage. Urine culture and CBC to detect WBC and bacteriuria, NAAT to diagnosis chlamydia/gonorrhea. Consult urologist is septicemia is a concern. For both epididymitis and orchitis, If < 35 years, ceftriaxone IM 250-500 mg or azithromycin + doxycycline 100 mg BID for 10 days. If > 35 years, Bactrim or ciprofloxacin 500 mg. Elevate scrotum, ice and NSAIDs.  Orchitis- viral or bacterial systemic, blood borne infection that results in acute inflammation of one or both testicles. Can be a consequence of mumps (viral infection), coexist with prostate infections/epididymitis, or be a complication from syphilis, mycobacterial, or fungal infections. Usually caused by trachomatis and gonorrhea in adolescents and in men older than 35, it is E.coli. Typically gradual onset of testicular swelling/pain, swelling and tenderness is isolated to testes without epididymal involvement. Diagnostic tests: US that shows Ftnous hypoechoicity.  Cystic  Spermatocele- benign, painless sperm filled cyst of the epididymis. Form from the obstruction of efferent duct and contain a proteinaceous, milky fluid of lymphocytes and spermatozoa. Commonly occur after vasectomies. Typically a painless, well defined nodule. It is present on the head of the epididymis, and epididymal cysts arise throughout the epididymis. Epididymal cysts will contain clear serous fluid. Diagnostic tests: US shows mass located at the proximal aspect of the spermatic cord. Spermatoceles and epididymal cysts are indistinguishable visible on transillumination. No treatment if asymptomatic, but if discomfort persists, excision is recommended.  Fluid Accumulation  Hydrocele- accumulation of fluid within the tunica vaginalis surrounding the testicle, can result at birth and close at age 1-2 years. This is the most common cause of painless scrotal swelling. In adults they are the result of a trauma, hernia, testicular tumor, torsion, or complication of epididymitis. Typically a gradual progression of swelling. Diagnostic testing: Scrotal transillumination may be helpful, and US will be anechoic and reveal fluid filled tunica vaginalis. Treatment: Congenital hydrocele resolve on their own, asymptomatic hydrocele includes watchful waiting, and symptomatic hydrocele can be treated with surgical aspiration, resection, or sclerotherapy.  Hematocele- collection of fluid in the tunica vaginalis of the testes and identifies as a mass. This is a collection of blood rather than serous fluid and usually precipitated from trauma. Can be painful and tender on palpation. Large, painful scrotal mass with an antecedent history of trauma. Will see ecchymosis of scrotal skin, testicular tenderness or firmness. Diagnostic testing: US will show echogenic debris and reveal fluid filled tunica vaginalis, not visible on transillumination. Surgical exploration may be necessary to rule out cancer. Treatment: ice, elevation, scrotal support, bed rest. IF concerned testicle ruptured, immediate surgical exploration is undertaken. Clinical Presentation  Correlate history and symptoms to underlying pathologic condition.  On exams ask all male patients about changes in testicular size or the presence of nodules/masses, pain, or penile discharge.  Use OLDCARTS when they exhibit discomfort or pain  O- Onset  L- Location  D- Duration  C- Characteristics  A- Aggravating/Alleviating factors  R- Radiation/Relieving factors  T-Timing  S- Severity Example: Patient states his symptoms are relived by rest, that can be an indication of what is presenting. Physical Exam and Diagnostics  Inspect and palpate skin of the scrotum, epididymis, and spermatic cord for smoothness and lack of tenderness, edema, discoloration.  Office transillumination or US for masses, vascular findings  Abdominal, inguinal rectal exam as indicated  Diagnostics  Many testicular disorders are clinically apparent and diagnosed per clinical presentation or physical exam  Urinalysis/Urine culture  US  CT  Tumor markers  Differential Diagnosis  The differential diagnosis for any testicular disorder or acute scrotal mass/pain should first exclude the possibility of a testicular tumor.  The presence of a testicular mass is suggestive of a tumor and indicates the need for immediate referral.  Other differential diagnoses include  Cysts, testicular torsion, epididymitis, and epididymal-orchitis, hydrocele, hernia, hematoma, spermatocele, varicocele  Medications such as Amiodarone has been associated with non-infectious epididymitis  Varicocele is more distinguishable because it resembles a bag of worms on palpation.  Testicular cancer in men over 30 years old may have hydrocele development as a symptom.  A detailed history, physical exam, and key diagnostics (urinalysis, urine culture, ultrasound, CT, tumor markers) all aid in clarity for determining the precise diagnosis.  Management  Develop a direct plan of care based on underlying etiology of testicular condition  Testicular torsion is a medical emergency and should be surgically explored and relieved as quickly as possible to prevent the development of gangrene.  Specialist/surgical/emergency consultation  For any traumatic condition, sudden-onset unilateral scrotal pain, testicular torsion, herniation, or potential risk to fertility