Contents. Testicular torsion. H ydrocele. Epididym itis. Varicocele. Orch itis. Testicular cancer. Testicular traum a

Transcription

1 Male GU System There are 3 m ajor goals Attem pt to distinguish the testis from its associated structures - epididym is, vas deferens and blood supply. Com bining the structures as "epididym o-orchitis" although com m on is not helpful because m ost testicular problem s are vascular, or transm itted through the blood, while the other structures are best considered as extensions of the urinary system. Further, m alignancy is alm ost com pletely lim ited to the testis itself Understand the need to m aintain a high index of suspicion for testicular torsion, an em ergency with a less than 12 hour window of opportunity for successful intervention Understand also that testicular cancer, although uncom m on, occurs in the athletic age group and is the prototypical curable cancer

2 Contents Testicular torsion H ydrocele Epididym itis Varicocele Orch itis Testicular cancer Testicular traum a

3 Torsion Torsion and acute epididym itis are the m ost com m on causes of acute scrotal pain. This twisting of the sperm atic cord that results in obstruction of the blood vessels is m ore com m on in children, but accounts for 20% of acute pathology in post-pubertal m ales. Prom pt diagnosis is essential. Surgery perform ed within 12 hours results in about 70% salvage - m uch lower with delay Differentiating between these entities is often difficult on physical exam ination and pulsed and color Doppler ultrasonography is helpful Presentation Sudden onset - unilateral testicular pain possibly followed by scrotal swelling and erythem a, less com m only, lower abdom inal or inguinal pain Nausea and vom iting - 50% Previous rem itting episode - 40% Testis positioned horizontally rather than vertically Peak incidence - infancy and adolescence, rare after 30 Diagnosis and Managem ent H igh index of suspicion Urgent referral on suspicion Tim eliness is essence

4 Epididym itis Inflam m ation or infection of the epididym is, lying on posterior surface of testicle Most com m on cause of intrascrotal inflam m ation Usually due to retrograde extension of organism s from vas deferens Bacteriology prepubetal - E. coli less than 35, Chlam ydia trachom atis - 50% Neisseria gonorrhea - second Older than 35 - E. coli It has been postulated that chem ical epididym itis due to reflux of sterile urine is an unusual entity (lifting, weight room, etc.)

5 H ydrocele Definition A collection of serous fluid from defect or irritation in tunica vaginalis of scrotum. Most are asym ptom atic or sub-clinical and the usual presentation is a painless, enlarged, scrotum and a sensation of heaviness or dragging m ay be reported. The size m ay decrease with recum bency and increase in the upright position. They are bilateral in 7-10% of cases and are often associated with a hernia, especially on right

6 Exam Located superior and anterior to testis Abdom inal/testicular tenderness absent Light source shines through brightly (transillum ination) Differential diagnosis Torsion Orchitis H ernia Treatm ent Surgery in infant/congenital hydrocele None if adult and asym ptom atic

7 Varicocele Definition Dilation of pam piniform venous plexus and internal sperm atic vein, Occurs in approxim ately 15-20% of all m ales and 40% of infertile m ales and is m uch m ore com m on (80-90%) on left than right because of anatom ic factors. It is traditionally described as a "bag or worm s" when palpated through the scrotum. Diagnosis is usually self evident after palpation, particularly in the upright position but differential diagnosis includes: Torsion Orchitis H ernia Treatm ent Although varicocele is recognized as a cause of decreased testicular function, recent studies suggest that the fertility rate is not im proved by treatm ent

8 Orch itis Definition Acute inflam m atory reaction of testis secondary to infection. The m ajority are associated with viral m um ps but other viruses/bacteria can be involved. Approxim ately 20% of prepubertal patients with m um ps develop orchitis which rarely occurs postpubertaly. Bacterial orchitis is even rarer. Although unilateral testicular atrophy is said to occur in 60%, sterility is rarely a consequence. Presentation Testicular pain and swelling which varies from m ild discom fort to severe pain Fatigue, m alaise, fever and chills Follows m um ps parotitis by 4-7 days

9 Differential Diagnosis Testicular tum or H ydrocele Torsion Managem ent Urgent consultation for surgery if torsion is considered possible. Use color Doppler ultrasound if diagnosis rem ains unclear Supportive treatm ent for viral orchitis but appropriate antibiotics for suspected bacterial infection

10 Testicular cancer Although relatively rare - about 7,000 cases yearly in US, com pared with 180,000 cases of lung cancer and 210,000 cases of prostate cancer, it is the m ost com m on neoplasm in m en between ages 15 and 35. Germ cell tum ors, which have becom e a m odel for curable neoplasm, constitute the m ajority of those cancers. Other types m ake up less than 5%. Germ cell tum ors are seen principally in young white patients and the occurrence in African-Am erican and Asian patients is rare. Presentation Painless unilateral testicular m ass often m istaken for epididym itis or orchitis in early stages Som e degree of pain and discom fort later but acute pain is rare May present with back pain from m etastasis to retroperitoneal lym ph nodes or respiratory sym ptom s from pulm onary m etastasis Diagnosis Diagnosis is suspected when a white m ale between presents with above. Another peak in incidence occurs after age 50, when the m ost com m on tum or is lym phom a, followed by sem inom a Managem ent Prom otion of self-exam ination, sonography for testicular enlargem ent and urgent referral on further suspicion

11 Testicular traum a This is a relatively uncom m on injury and blunt traum a, alm ost always unilateral, accounts for 85%, the m ost com m on being sports injury Presentation May m anifest as hem atocele or ruptured testis in which tunica albuginea is violated Absence of scrotal swelling and hem atom a m ay indicate relatively benign injury but 80% of hem atoceles are associated with testicular rupture Com plete absence of pain with scrotal swelling and hem atom a raises possibility of infarction or torsion