FCP III: disorders of scrotum/testes (exam 6)

Term
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hydrocele
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Terms in this set (50)
hydrocele
collection of fluid between layers of tunica vaginalis
hydrocele etiology
- idiopathic (majority)
- can be associated w/ epididymitis or torsed appendix testis
most likely diagnosis
- unilateral scrotal swelling that transilluminates
hydrocele
Pt presents with painless, unilateral scrotal swelling. Other than appearance it is not bothersome to him. Left scrotum transilluminates on physical exam. How is this treated?
reassurance and monitoring

(asymptomatic/mildly symptomatic hydrocele)
hydrocele treatment options
needle aspiration or hydrocelectomy
which hydrocele treatment is less likely to recur?
hydrocelectomy
Pt has bothersome hydrocele. He does not want to undergo anesthesia for treatment. How do you proceed?
recommend needle aspiration with sclerosing agent but warn pt it has higher chance of recurrence (as compared to hydrocelectomy)
varicocele
dilated veins of pampiniform plexus
buzz word!
"bag of worms"
varicocele
What long term effects can a varicocele cause
testis damage and atrophy→ fibrosis and decreased spermatogenesis → prolonged stress leading to infertility
varicocele grade I, II, or III small size not grossly visible and only palpable during valsalvagrade Ivaricocele grade I, II, or III moderate size but not grossly visible, palpable while standinggrade IIA grade I/II/III varicocele is grossly visibleIIIWhich grade varicocele is only palpable while standing?grade IIWhich grade varicocele is only palpable with valsalva?grade IPt presents with a new right sided testicular mass. States he noticed it 1 mo ago and it has been progressively getting larger. Mass is palpable on exam. What are your next steps?concerning for renal cell carcinoma so consider imaging of right kidney (Right testicular mass, Rapid onset, Renal malignancy)How do you treat a palpable varicocele with normal semen analysismonitor semen analysis 1-2 x yrHow do you manage an asymptomatic varicocele in kids and pre-sexual adolescentsmonitor, and measure testicular size annually to detect size decreasesurgical indications for varicocele- symptomatic - palpable varicocele with abnl semen analysis - varicocele with smol testesWhy do we repair varicoceles in pts who have small testesrepair can reverse atrophysurgical options for the most likely diagnosis - "bag of worms"- open or laparoscopic surgery → ligation of vein to redirect venous outflow - percutaneous embolizationtesticular torsion risk factorsUndescended testis (cryptorchidism) "Bell clapper" deformityHow do you manage this pt? 16 yr old presents to ED with rapid onset of severe left testicular pain. Pain began 3 hrs ago. On exam, there is no swelling and pain is not relieved with elevation. Testes are high riding and cremasteric reflex is absent.manually detorse testis then emergent orchiopexy of both testesAfter ____ hrs, if testicular torsion is not treated, most testes are non-viable24 hrswhen should testicular torsion be treated in order to preserve viability<6 hrs (treat ASAP rocky)How do you manage this pt? 16 yr old presents to ED with rapid onset of severe left testicular pain. Pain began yesterday. On exam, testes are high riding and cremasteric reflex is absent. You attempt to manually detorse testes and then take pt to operating room where it is found that the testis is not longer viable.orchiectomy of affected testicle and orchiopexy of contralateral testicleWhat causes epididymitis other than infection?behcet dz, amiodarone accumulation (usually iatrogenic), or testis/epididymal tumorMC cause of epididymitis in men >35E. coliMC cause of epididymitis in men <35neisseria gonorrhoeae and chlamydiadiagnose and treat this pt 19 yr old male presents with c/o painful left testicle x 3 days. Onset was gradual and he has associated urethral discharge. Temp is 100.3F. PEx shows edematous, tender left testicle.epididymitis (secondary to n. gonorrhoeae or chlamydia) → ceftriaxone and doxy, plus recommend scrotal support, analgesia, and cold compressesepididymitis abx when you don't suspect an STDdoxycycline 100mg BID x 10 days or levofloxacin (500mg BID x 10 days)abx for epididymitis when STD is suspectedceftriaxone 250mg IM injection (just one) doxy 100mg BID x 10 dayschronic epididymitis conservative tx (not including medications)scrotal support activity modifications moist heatwhat is the treatment for chronic epididymitis with obstruction?vasovasostomy or epididymectomyRisk factors for testicular tumors include all of the following except: a) cryptorchidism b) FHx c) testicular atrophy d) HIV infectionc) testicular atrophytesticular tumor risk factorscryptorchidism FHx personal Hx HIV infectionWhat are NOT risk risk factors for testicular tumors?diethylstilbestrol exposure in utero testicular atrophy traumatesticular tumors clinical presentation- painless mass or swelling in testicle - right side > left side - back pain or abd masstumor markers for testicular cancerB-HCG, AFP LDHtesticular tumor diagnostic work up includes...US AFP, beta Hcg, and LDH LFTs CBC creatinine baseline CXRtesticular cancer treatmentradical inguinal orchiectomy chemo radiationradical orchiectomy for testicular cancer utilizes the scrotal/inguinal approachinguinal (I really don't know what this means but Howie specified inguinal so here we are)In general, when should you repeat tumor markers s/p orchiectomy for testicular tumorfive half lives of each specific tumor markerWhen do you initially repeat AFP, beta-hcg, and LDH levels s/p orchiectomy for testicular tumor? (asking about the 5 half lives, NOT post-orchiectomy surveillance in general)AFP → 5 wks beta hcg → 1-2 wks LDH → 3 wksstage I testicular cancerlocal tumorstage 2 testicular cancerperiaortic lymph node involvementstage 3 testicular cancermetastases to other areas (commonly the lungs)H&P and tumor marker surveillance s/p orchiectomy for testicular cancerevery 3-4 mo for 2 yrs → then 6-12 mo for 2 yrs → then annually thereafterimaging surveillance s/p orchiectomy for testicular cancerCT abd/pelvis every 6 mo for 2 yrs → then 6-12 mo for 1 yr → then annually for 2 yrs CXR as indicatedDespite a good prognosis, what makes managing testicular cancer difficult?compliancy during post-orchiectomy surveillance