Unit II: Reproduction Scrotal Pathology Ravin Bastiampillai, PGY-3 Division of Urology Original...

Unit II: Reproduction

Scrotal PathologyRavin Bastiampillai, PGY-3

Division of Urology

Original slides made by Laura Nguyen (PGY-5)

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Unit II: Reproduction | Scrotal Pathology | R. Bastiampillai

4232 List the differential diagnosis of scrotal pain

4221 Define the terms: varicocoele, hydrocele, spermatocoele,

epidymal cyst, acute orchitis, acute epididymitis and testicular

torsion and compare and contrast their clinical presentations

4223 Diagnostic tools and treatment options for varicocoele, hydrocele,

spermatocoele, epidymal cyst, acute orchitis, acute epididymitis

testicular torsion

Objectives

4225 Pathogenesis of testicular torsion and complications

4226 Recognize the need for urgent management of testicular torsion

4303 Describe pathogenesis of orchitis and epididymitis

4304 Describe the causes and diagnosis, treatment and complications

of orchitis and epididymitis

Objectives

4227 Prevalence and risk factors of testicular cancer

4228 Pathophysiology of testicular cancer

4229 Treatment options for testicular cancer

4230 Outline post-cancer care and support

4231 Impact of testicular cancer on biopsychosocial factors

Objectives

Anatomy

Clinical approach to scrotal masses

Scrotal masses

Acute scrotal pain

Testicular cancer

Outline

Anatomy

• Painful vs. Painless

• Benign vs. Malignant

• Etiology varies with age• Differential diagnosis differs between adults and children

Clinical Approach to Scrotal Masses

Clinical Approach to Scrotal Masses – HISTORY

• Age of patient

• History of Present Illness• OPQRST• Painful v. Painless• Lower urinary tract symptoms

• Past medical history, Family history, past surgical history

• Risk factors: infections, instrumentation of the urinary tract, congenital anomalies, prior history of neoplasm, trauma (recent and past)

Clinical Approach to Scrotal Masses – PHYSICAL EXAM

Vital signs: Temperature Abdominal and inguinal exam:

Hernias, lymph nodes, masses

Penis: Skin changes, masses, circumcised

Scrotum (supine and standing)• Skin

• Testes:

• Normal = 3.5cm long, 12-20cc volume

Hydrocele, varicocele, rashes, masses

Digital rectal exam

Differential Diagnosis

PAINFUL– Trauma

• Contusion, rupture

– Epididymo-orchitis

– Hernia

• Incarcerated, strangulated

– Torsion

• Testes

• Appendages

PAINLESS – Tumour

• Intratesticular

• Paratesticular

– Scrotal wall pathology

• SCC, sarcoma

– Varicocele

– Hydrocele

– Spermatocele

– Epididymal cyst

– Hernia

Differential Diagnosis

PAINFUL– Trauma

• Contusion, rupture

– Epididymo-orchitis

– Hernia

• Incarcerated, strangulated

– Torsion

• Testes

• Appendages

PAINLESS – Tumour

• Intratesticular

• Paratesticular

– Scrotal wall pathology

• SCC, sarcoma

– Varicocele

– Hydrocele

– Spermatocele

– Hernia

MALIGNANT

VARICOCELES

• Dilation of the veins of the pampiniform plexus of the spermatic cord due to absent competent venous valves in the spermatic vein

• 15% of males 30% of subfertile males

• Elevated intratesticular temperature seems to be the most plausible and widely accepted hypothesis

• Most are left-sided, may be bilateral. Be suspicious of a right-side-only varicocele

• Rare prior to puberty

VARICOCELES

History: • Painless v. throbbing pain; pain worse at night• Discomfort increases with activity/standing• Aggravated with Valsalva• Infertility

Diagnostic Tools:

1. Examination:• “Bag of worms”,“vascular thrill”

• Grade I: Palpable with Valsalva• Grade II: Palpable without Valsalva• Grade III: Visible • Abdominal mass

1. Scrotal ultrasoundThe finding of a varicocele by ultrasound only (i.e., not palpable

on physical examination) does not require intervention.

VARICOCELES

Indications for surgical intervention: Clinically palpable AND One of:

o Infertilityo Symptomatic o Adolescent varicocele

Surgical options: Retroperitoneal Inguinal Subinguinal Laparoscopy Transvenous embolization

HYDROCELES

• A collection of serous fluid in some part of the processus vaginalis, usually the tunica

• More common in childhood

• 1% of adults

• Congenital:• Processus vaginalis does

not completely close after testicular descent

• Acquired: • Primary (idiopathic) v.

Secondary (testicular disease)• Lymph: defective absorption, increased

production, lymphatic obstruction

HYDROCELES

History: • Painless (unless large)

• Variation during the day (suggests communication)

• Other symptoms (secondary hydrocele)

HYDROCELES

History: • Painless (unless large)

• Variation during the day (suggests communication)

• Other symptoms (secondary hydrocele)

Examination:• Transillumination

• Testis palpable?

Investigations/Diagnostic Tools:• Scrotal ultrasound

HYDROCELES

Treatment: • Adults:

• Symptomatic

• Cosmetic

• Underlying testicular pathology

• Children:• Most resolve within the first year of life

• If persists, may indicate presence of a hernia

Specifics:• Surgical (inguinal vs. scrotal)

• Aspiration

• Sclerotherapy

SPERMATOCELES

• Painless mass containing sperm

• Post puberty

• Common between 40 and 60 years, 30% of males

• Region of caput

• Usually can palpate the testis

separately from the spermatocele

• Dilation of an epididymal tubule,

does not affect transport of sperm

• Mass may transilluminate

• Difference from epididymal cyst

SPERMATOCELES

Diagnostic Tools/Investigations:

• Subjective and objective examinations

• Ultrasound

Treatment:

• Conservative

• Spermatocelectomy (surgical removal)

• Surgery may have adverse consequences so avoid this option if fertility is still desired

EPIDIDYMAL CYSTS

• Anechoic structure, sometimes palpable found by the patient,

physician or by ultrasound

• Clinically difficult to differentiate between a spermatocele and

an epididymal cyst

• Etiology unknown

• Treatment: Same approach as for a spermatocele

ACUTE ORCHITIS, EPIDIDYMITIS, EPIDIDYMO-ORCHITIS

History:

• Insidious onset

• Fever

• Recent instrumentation

• Sexual activity

• LUTS

Examination:

• Painful epididymis +/- testis

• Testis in normal position

• Urethral discharge

• + Prehn’s sign

Diagnostic Tools/Investigations:

• CBC

• U/A, C&S, urethral swab for GC / Chlamydia

• Ultrasound

• Tuberculosis

KEY POINT: May resemble torsion! Ultrasound will indicate

whether arterial and venous flow is present

Etiology• <35 years: N.gonorrhea,

C.trachomatis, E.coli• >35 years: E.coli• Mumps:

• 30% of patients with mumps• Risk of infertility

Treatment• Rest• Analgesics / Anti-inflammatories• Scrotal support

Antibiotics:GC: •ceftriaxone 250 mg IM•Cipro 500 mg PO

Non-GC:•Azithromycin 1 g PO•Doxycycline 100 mg BID x 7 days

E.coli:•Antibiotics IV if severe•Fluoroquinolone x 10-14 days

Complications: Abscess, Chronic pain, Venous thrombosis,

Epididymitis progressing to orchitis

TESTICULAR TORSION

Why is the diagnosis of torsion so important?

• Risk of testicular loss! ** 6 hours from onset of pain **

• >97% salvage if <6 hours, <10% if >24 hours

• Hormonal and fertility problems if contralateral testicular involvement

• Necrosis/Abscess

TESTICULAR TORSION

Extravaginal vs. Intravaginal Torsion

TESTICULAR TORSION

EXTRAVAGINAL•Pediatric/neonatal population only

•Complete torsion of the spermatic cord before the tunica vaginalis fuses to the dartos

History/Physical:

• Indurated testis, scrotal erythema, +/- edema

• Often asymptomatic, may be associated with a hydrocele

Diagnostic Tools:

• Clinical examination

• Ultrasound

• Surgical exploration +/- removal

TESTICULAR TORSION

INTRAVAGINAL

History:

• Acute pain at rest, with activity or during the night

• Nausea and vomiting

• History of ipsilateral pain

• 12-16 years (higher incidence), 85-90% of intravaginal torsions occur after age 10, but can affect any age group

Examination:

• Patient in pain

• Tender, erythematous, swollen testicle

• High riding, transverse lie

• Absent cremasteric reflex

• Bell-clapper deformity

TESTICULAR TORSION

INTRAVAGINAL

TESTICULAR TORSION

INTRAVAGINAL

Diagnostic Tools/Investigations: Subjective and objective examinations +/- Urinalysis +/- Ultrasound

o Duplex Doppler

Treatment: If suspected clinically, surgical

exploration is indicated Orchiectomy Orchiopexy bilaterally

TESTICULAR TORSION

TORSION OF THE APPENDAGES

•Torsion of the appendix testis (Mullerian remnant) or the appendix epididymis (Wolffian remnant)

•Local tenderness, blue dot sign

•Self-limited, supportive care

TESTICULAR CANCER

• 1-2% of cancers in males in the United States; incidence 5/100,000

• Age at presentation: childhood, 30-34 years and 60 years+

• Over 90% of tumours are intratesticular, 2-5% with extratesticular presentation

• Most common neoplasm in males20 to 40 years

TESTICULAR CANCER

Clinical Presentation:• Painless testicular mass

• Rarely painful (hemorragic cancer)

• Hydrocele

• Gynecomastia (5%)

• 10-30% with metastatic cancer (supraclavicular lymph node, difficulty breathing, low back pain)

Investigations:• Subjective and objective examinations

• Ultrasound

• Chest film

• Testicular markers: AFP, HCG, LDH

• Blood tests: liver function, CBC, creatinine, urea

• CT Scan

TESTICULAR CANCER

Risk Factors:• Cryptorchidism• HIV• Intratubular germ cell neoplasia• Family history of testicular cancer• History of testicular cancer (ipsi and/or contralateral)• Infertility• Gonadal dysgenesis

NOT ASSOCIATED WITH TESTICULAR CANCER:• Trauma• Microlithiasis

TESTICULAR CANCER

STAGING:

STAGE I•confined to the testis

STAGE II•involves the testis with metastasis to the retroperitoneal lymph nodes

STAGE III•involves the testis, with metastasis beyond the retroperitoneal lymph nodes

TESTICULAR CANCER

SEMINOMA

•50% of testicular tumours in adults

•Elevated BHCG in 10% of cases, all other testicular markers are negative

Treatments:

•Radical orchiectomy

•Pathology and staging of cancer will determine treatment approach

• Observation (stage IA-IB)

• Chemotherapy or radiation therapy (stage IB,IS, IIA, IIB)

• Chemotherapy (IIC, III)

TESTICULAR CANCER

NON-SEMINOMA

•Age of presentation and marker status varies based on histology

•Treatment:• Radical orchiectomy• Pathology and staging of cancer will determine treatment approach

• Observation (Stage IA-IB)• Dissection of retroperitoneal lymph nodes (IB-IIB)• Chemotherapy (IS, IIC, III)

• RADIATION THERAPY IS NEVER AN OPTION FOR NONSEMINOMA TUMOURS

TESTICULAR CANCER

AGE AFP B-HCG

Embryonal (15-20%) 25-35y + +

Yolk Sac tumour <2y + N

Choriocarcinoma (<1%) Histologic component of syncytiotrophoblast and cytotrophoblastAggressive, metastases

20-30y N +

Teratoma (5-10%) 25-35y N N

Mixed (40%)Histology: endoderm, mesoderm and/or ectodermRESISTANT TO CHEMOTHERAPY AND

RADIATION THERAPY

varies

TESTICULAR CANCER

GONADOBLASTOMA

•Benign tumour, rare, present only with gonadal dysgenesis•Treatment: bilateral orchiectomy since 60% of these tumours will undergo malignant transformation

LYMPHOMA

•most common bilateral tumor, often in older age group•Treatment: orchiectomy for pathology, treatment with chemotherapy

TESTICULAR CANCER

WHAT HAPPENS AFTER DIAGNOSIS AND TREATMENT?

•Follow-up• Varies depending on pathology and treatment• Urologist, Oncologist, Radiation Oncologist• Every 3 months for the first year• Blood tests (tumour markers, liver test, renal function)• Chest film and CT Scan of the abdomen and pelvis

•Support• http://testicularcancercanada.ca/index• http://oneball.ca/• Social worker

TESTICULAR CANCER

WHAT HAPPENS AFTER DIAGNOSIS AND TREATMENT?

•Biopsychosocial impact• Fertility• Self-image (implant)• Education (torsion, trauma, testicular pain)• At risk for cancer in the contralateral testicle (2-5% risk 15 years

post orchiectomy)• SELF EXAMINATION

POINTS TO REMEMBER

• Scrotal mass• Anatomy is key• Painful versus Painless• Testicular torsion Urological emergency!!

PRATICAL POINT• Learn how to perform a thorough examination of the male

reproductive system

Thank you!

Questions or comments?

Ravin Bastiampillai, PGY-3

rbastiampillai@toh.on.ca

Unit II: Reproduction Scrotal Pathology Ravin Bastiampillai, PGY-3 Division of Urology Original...

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