It s all in the bag!

Transcription

1 Faculty/Presenter Disclosure Faculty: Dr. Ted Jablonski Relationships with financial sponsors: Grants/Research support: Pfizer, Lilly, Cortria Speakers Bureau/Honoraria: Abbott Laboratories, Aralex(Tribute), AstraZeneca, Bayaer, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen Ortho, Luncbeck, Merck Frosst, Mylan, Novartis, Paladin Labs, Pfizer, Sanofi Aventis, Schering, Servier, Shire, Solvay, Takeda, Valeant, Watson and media companies Antibody, CTC Communications, Edelman, mdbriefcase MedPlan, Meducom, RxMedia, Science and Medicine Consulting Fees: N/A Patents: N/A Other: The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses. 1 SCROTAL HEALTH 2019 contact@drtedjablonski.com It s all in the bag! 2 1

2 . 3 Ted Jablonski MD CCFP FCFP Associate, Crowfoot Village Family Practice, Calgary AB Medical Lead Calgary Foothills PCN Clinical Assistant Professor, University of Calgary, Department of Family Medicine Clinical Associate Men s Sexual Health Clinic SAIU (Southern Alberta Institute of Urology, RVH Calgary) Medical Director Jablonski Health Medical Director Skipping Stone Foundation 4 2

3 We are all standing on the shoulders of giants With great thanks and appreciation let this serve as formal acknowledgement that I have borrowed generously from the Undergraduate course of the CUA (Canadian Urologic Association) THANKS 5 CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure Faculty: Dr Ted Jablonski MD CCFP FCFP #91934 Conflict of Interest Declaration / Disclosure 2019 Relationships with commercial interests: Prinicipal Investigator ( ) Prinicipal Investigator in Clinical studies funded by Pfizer, Lilly, Cortria Speaker s Bureau, Advisory Board Honoraria Abbott Laboratories, Acerus Pharma, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Edelman, Eli Lilly, GlaxoSmithKline, Janssen Ortho, Lundbeck, Merck Frosst, Novartis, Paladin labs, Pfizer, Sanofi Aventis, Schering, Servier, Shire, Solvay, Takeda, Valeant, Watson 6 3

4 CFPC CoI Templates: Slide 2 Disclosure of Commercial Support This program has not received financial support This program has not received in kind support Potential for conflict(s) of interest Commercial products for companies that I have worked for on clinical studies, advisory boards, CHE development and CHE presentations will be mentioned including on, and some off label uses pf pharmacotherapies 7 CFPC CoI Templates: Slide 3 Mitigating Potential Bias Within the discussion of any medical diagnosis I will mention non pharmacologic and pharmacologic therapies that are of use, compare and contrast them and discuss the pros and cons of each, presenting the information in the most non biased way possible. 8 4

5 OBJECTIVES By the end of this interactive session, the engaged participant will learn to: 1. Identify patients to consider screening for testicular cancer, and counsel patients on screening techniques 2. Evaluate common patient presentations relating to scrotal health 3. Assess features of scrotal masses that should be considered for investigation and referral 9 How DO you keep a scrotum and all of it s contents healthy? 10 5

6 How DO you keep a scrotum and all of it s contents healthy? BOXER s vs BRIEFS COTTON vs SYNTHETICS SELF EXAM vs JUGGLING DRYING CLEANING SHAVING LOTIONS / POWDERS / CREAMS / SPRAYS HOT TUBS

7 CRITICAL CRITICAL things you can t miss 14 7

8 15 5 (other) important things to know about 16 8

9 17 Which one is NOT like the others year old male, married in monogamous relationship with occasional aching pain on either testicle year old post vasectomy with enlarged testicle year old with painless lump on L testicle found while playing in the shower 18 9

10 Which one is NOT like the others year old male, married in monogamous relationship with occasional aching pain on either testicle year old post vasectomy with enlarged testicle 3.28 year old with painless lump on L testicle found while playing in the shower 19 Which one is NOT like the others year old with painful L testicle lasting for hours after getting hit during a hockey game year old with increasing size scrotum, can no longer feel R testicle year old with a new lump on the skin of his scrotal sac, worried re STI or cancer 20 10

11 Which one is NOT like the others 1.14 year old with painful L testicle lasting for hours after getting hit during a hockey game year old with increasing size scrotum, can no longer feel R testicle year old with a new lump on his scrotal sac, worried re STI or cancer 21 Clinical Questions: 1) What is the patients age? 2) Is the onset acute or chronic? 3) Is it painful? 4) Is it intra or extra testicular? 5) Does it transilluminate? 6) Are there urinalysis findings? 22 11

12 CANCER 23 TESTICULAR CANCER vs Everything else Scrotal, testicular, extra testicular 24 12

13 25 ACUTE TESTICLE vs Everything else Scrotal, testicular, extra testicular 26 13

14 ANATOMY What exactly IS in the bag and what does everything do in there?? 27 The SCROTUM is a genius It has but one humble task

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16 SCROTAL SAC 31 CREMASTERIC MUSCLE 32 16

17 TESTICLES

18 TUNICA VAGINALIS 35 EPIDIDYMAL GLANDS 36 18

19 SPERMATIC CORD / VAS DEFERENS 37 APPENDIX TESTICLE 38 19

20 EXAMINATION SELF CLINICAL U/S Other

21 41 Which one is NOT like the others year old male, married in monogamous relationship with occasional aching pain on either testicle year old post vasectomy with enlarged testicle 19 year old with painless lump on L testicle found while playing in the shower 42 21

22 TESTICULAR CANCER 43 Epidemiology 2 3 new cases per 100,000 males per year Marked variation in incidence among different countries/races 90 95% are germ cell Most common solid tumor in males ages Rare in asians, blacks Higher incidence in northern Europeans 44 22

23 Risk Factors Cryptorchidism: 7 10% of patients with testicular cancer have a history of cryptorchidism Abnormal germ cell morphology Elevated temperature Interference with normal blood supply 5 10% of patients with testicular cancer and a history of cryptorchidism develop cancer in the contralateral testis Orchidopexy does not prevent development of cancer just allows for detection 45 CONT. Gonadal Dysgenesis 20 30% develop cancer (gonadoblastoma) Trauma prompts evaluation Hormones DES/OCP probably do not increase risk Atrophy (nonspecific vs. mumps orchitis) Speculative Testicular cancer in 1 st degree relative (father / brother) 46 23

24 Presentation Painless swelling/mass with or without hydrocele (5 10%) 30 40% report dull/aching sensation 10% present with metastatic symptoms Avg. delay in diagnosis 4 6 months Gynecomastia 5% germ cell 30 50% Sertoli/Leydig 1 2% have bilateral disease at diagnosis More common on the right All solid intratesticular lesions must be considered malignant until proven otherwise! (90% are cancer) 47 History & Physical Assess risk factors Check for lymphadenopathy, abdominal masses Examine both testes (2 5% bilateral) Try to transilluminate If hydrocele prevents exam, get ultrasound If in doubt, GET AN ULTRASOUND! UROLOGY RULE DON T biopsy / breach the scrotum 48 24

25 Testicular Cancer: Clinical Questions Age? Acute or Chronic? Painful? Transilluminates? Intra Testicular? Urinalysis? years Chronic No No Yes! Negative 49 Work up Exam U/S CXR +/ Chest CT Abdominal CT Can identify small nodal deposits <2 cm MRI and PET scan no advantage over CT Markers Elevation after orchiectomy generally represents metastatic disease Conversely normalization does not rule out metastatic disease 50 25

26 Metastatic Evaluation Initial Management Tumor markers CXR Radical (Inguinal) orchiectomy CT scan of chest, abdomen and pelvis Further staging after orchiectomy Repeat markers serially 51 Tumour Markers fetoprotein Normal <20ng/ml Elevated in: 80% of embryonal carcinoma yolk sac and teratocarcinoma NOT in seminoma or choriocarcinoma 2. HCG Elevated in almost all choriocarcinomas Elevated in 5% of pure seminomas 3. Others LDH, PLAP etc

27 Clinical Staging: TNM T1: Limited to testes & epididymis. No vascular invasion T2: Invades beyond tunica or vascular invasion T3: Invades spermatic cord T4: Invades scrotum N0: No nodes N1: Lymph node met s <2cm and <5 nodes N2: >5 nodes, or nodal mass >2cm or <5cm N3: Nodal mass >5cm 53 Clinical Staging: Walter Reed Stage I: Confined to testes Stage IIa: Retroperitoneal nodes <2cm (small) Stage IIb: Retroperitoneal nodes >2cm (large) Stage III: Visceral metastases or supra diaphragmatic nodes 54 27

28 Lymph Node Metastases: Pattern of Spread Right lesion Left lesion 55 Primary Testicular Cancer GERM CELL Seminoma 30 60% Embryonal 3 4% Yolk sac Teratoma 5 10% Choriocarcinoma 1% Mixed 40% NONGERM CELL Leydig 1 3% Sertoli <1% Gonadoblastoma 0.5% 56 28

29 Testicular Cancer: Seminoma Typically later age of onset 30 s Grossly: Gray, coalescing nodules Micro: Sheets of clear cells May contain syncytiotrophoblasts (8% BHCG production) 57 Treatment: Testicular Cancer Stage I: Radical orchiectomy 75 90% cure alone PLUS Surveillance (CXR, markers q1month, CT q3months OR Retroperitoneal lymph node dissection (RPLND) for resection of small volume nodal disease (25%) 58 29

30 Treatment: Testicular Cancer Stage II and III Radical Orchiectomy AND Chemotherapy (Cisplatin based) Perform RPLND for patients with residual retroperitoneal nodes after chemo (if tumour markers normalize) 59 Prognosis Most curable of all solid neoplasms Almost 100% cure rate for low stage disease Seminoma (at 5 years) I: 98% IIA: 92 94% IIB III: 33 75% NSGT (at 5 years) I: % IIA: >90% IIB III: 55 80% 60 30

31 QUESTIONS? 61 Which one is NOT like the others 14 year old with painful L testicle lasting for hours after getting hit during a hockey game 52 year old with increasing size scrotum, can no longer feel R testicle 39 year old with a new lump on his scrotal sac, worried re STI or cancer 62 31

32 TESTICULAR TORSION 63 Scrotal Lesions: Testicular Torsion Urologic emergency Sudden onset scrotal pain Incidental trauma Prior episodes Visceral stimulation (nausea) Bell clapper deformity (congenital narrowing of spermatic cord) 64 32

33 Testicular Torsion: Clinical Questions Age? (75%) Acute or Chronic? Acute Painful? Yes, markedly Transilluminates? No Intra Testicular? No (Yes pain) Urinalysis? Negative 65 Testicular torsion: Treatment Requires prompt surgical exploration: Reduction of torsion & bilateral testicular fixation 97% testicular salvage if <6 hours 55 85% if 6 12 hours <10% if >24 hours Torsion 66 33

34 Testicular Torsion: Doppler Ultrasound Imaging if diagnosis uncertain Duplex ultrasound: ~82 100% sensitivity Operator dependent Heterogenous testicle with absent flow on Doppler Normal waveform Absent waveform: Torsion 67 Approach to Suspected Torsion 68 34

35 QUESTIONS? 69 And the other

36 Infective Cutaneous Lesions: Fournier s gangrene 71 Fournier s gangrene Necrotizing fasciitis of the deep cutaneous structures and fascia **A LIFE THREATENING CONDITION!** Requires prompt diagnosis Painful, necrotic, foul smelling lesions Treatment: Extensive debridement of affected tissues Broad spectrum antibiotics 72 36

37 EPIDIDYMITIS / ORCHITIS 73 Epididymitis Inflammation of the epididymis (<6weeks duration) Generally due to ascending bacterial infection Etiology <35 years: C. trachomatis or N. gonorrhea >35 years: Gram negative (E. Coli) 74 37

38 Epididymitis: Clinical Questions Age? >20 years Acute or Chronic? Sub Acute Painful? Yes Transilluminates? No (only if reactive hydrocele present) Intra Testicular? No Urinalysis? Positive (50%) 75 Epididymitis: Treatment NEED TO RULE OUT TESTICULAR TORSION! Doppler ultrasound or scrotal exploration Bedrest, scrotal support NSAID s Age <35 years: Ceftriaxone 1g IV then Doxycycline 100mg po bid x 14 days Age >35 years: TMP SMX or fluoroquinolone x14 days 76 38

39 Epididymitis: Complications Abscess Infertility Testicular infarction Chronic pain 77 Orchitis Infected or inflamed testicle. Like epididymitis, orchitis often results from an infection caused by an STI. Other causes can include tuberculosis, viruses like mumps, fungi, and parasites, along with other diseases that lead to inflammation. testicular pain and tenderness swollen testicle fever nausea vomiting feeling significantly ill Treatment depends on the cause. Ultrasound of the scrotum and testicles can help determine the diagnosis and severity of the condition. Serious infections may require hospitalization or surgery

40 Torsion of APPENDIX TESTICLE 79 Torsion of Testicular Appendages Age? 7 14 Acute or Chronic? Acute Painful? Yes Transilluminates? No Intra Testicular? No Urinalysis? Negative 80 40

41 Torsion of the appendix testes or appendix epididymis Blue dot sign (seen on scrotum) More focal pain (upper hemiscrotum) Often difficult to distinguish from other causes Treatment: Conservative Pain relief (NSAID s) 81 QUESTIONS? 82 41

42 And now EVERYTHING ELSE

43 Scrotal Lesions: Spermatocele A sperm containing cyst arising from the head of the epididymis Caused by ductal obstruction Traumatic Inflammatory Idiopathic Lesion is usually discrete from the testicle (superior) Excise if large & bothersome 85 Spermatocele: Clinical Questions Age? Acute or Chronic? Painful? Transilluminates? Intra Testicular? Urinalysis? >40 years Chronic No Yes No (superior) Normal 86 43

44 87 Scrotal Lesions: Hydrocele Very common benign scrotal mass 1% of all males A collection of serous fluid between the two layers of the tunica vaginalis Etiology: Increased production or decreased absorption of fluid by scrotal lymphatics 88 44

45 Hydrocele: Clinical Questions Age? Acute or Chronic? Painful? Transilluminates? Intra Testicular? Urinalysis <1 years, >40 years Chronic (usually) No Yes No, surrounding Normal 89 Hydrocele: Transillumination 90 45

46 Hydrocele: Ultrasound Ultrasound required if unable to palpate testicle on exam Rule out underlying testicular neoplasm May be aspirated for short term relief 91 Hydrocele: Treatment Surgical excision required if: Large & bothersome Socially embarrassing Uncomfortable 92 46

47 93 Scrotal Lesions: Varicocele 94 47

48 Varicocele: Clinical Questions Age? Acute or Chronic? Painful? Transilluminates? Intra Testicular? Urinalysis? >12 years Chronic No No No (left sided) Negative 95 Varicocele: Treatment Surgical varicocelectomy is required for: Impaired sperm quality (associated with infertility) Loss of testicular volume (in an adolescent) Pain (not a typical indication) Varicocelectomy involves ligating the offending incompetent vessels of the spermatic cord either: Inguinal Subinguinal Laparoscopically Embolization 96 48

49 97 Inguinal hernia Some inguinal hernias follow the path of the spermatic cord into the scrotum thus the small intestine and omentum can end up in the scrotum (indirect inguinal hernia) Symptoms of an inguinal hernia can include: bulging or swelling around inguinal canal sensation of pain sometimes felt as aching or burning uncomfortable groin sensation or pain with cough, laugh, or bending heaviness around your groin area an enlarged scrotum 98 49

50 Generally requires surgical repair the urgency depending on pain / ability to reduce a strangulated / incarcerated hernia requires urgent surgical attention (so really could have been talked about in CRITICAL SECTION )

51 Cutaneous Scrotal Lesions 1 Benign Angiokeratoma Psoriasis Epidermal cysts Licehn simplex chronicus Vitiligo Idiopathic scrotal calcinosis Red Scrotum Syndrome / Scrotal eczema 3. Infectious Lesions: Condyloma STD s Tinea cruris Fournier s gangrene 2. Malignant Squamous cell carcinoma Kaposi s sarcoma 101 Benign Cutaneous Lesions: Angiokeratoma Ectatic dermal blood vessels 1 2mm papules Benign May bleed recurrently & profusely requiring cauterization

52 Benign Cutaneous Lesions: Psoriasis May involve groin & scrotum Red plaques with white scale patches Occurs elsewhere Treatment: Topical steroids Emollients Systemic PUVA 103 Benign Cutaneous Lesions: Epidermal cysts Very common & benign Prone to recurrence Local resection if symptomatic/painful

53 Benign Cutaneous Lesions: Vitiligo ~1% of population Skin depigmentation Genitals commonly involved May regress spontaneously Treatment: Reassurance UV light Corticosteriods prn 105 Infective Cutaneous Lesions: : Condyloma Caused by human papilloma virus (HPV6 & 11) Papillary, cauliflower like proliferations Treat symptomatic lesions: Podophyllin Imiquimod (Aldara ) Cautery/liquid N2 Laser ablation Cannot be cured of the underlying viral infection

54 Infective Cutaneous Lesions: Tinea cruris Dermatophyte (fungal) infection jock itch Causative agent (Trichophyton sp.) Hyperpigmented (chronic) area within the inguinal folds Treated with topical antifungals & local skin care (preventing maceration) 107 Red Scrotum Syndrome / Scrotal eczema

55 Q+A THANKS!