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1 Author(s): Gary Faerber, M.D., 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike 3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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3 Benign and Malignant Diseases of the Testis and Scrotum Gary J Faerber, MD Associate Professor, Department of Urology
4 Physical Exam Palpation- use two hands to palpate the scrotal contents Transillumination- can aid in distinguishing solid from cystic masses Identify-Testis Epididymis Vas deferens Spermatic cord
5 Source Undetermined
6 Male Genitourinary Exam: Scrotal Mass Transillumination Source Undetermined
7 Testicular Cancer Epidemiology Most common solid neoplasm in men <35 yrs of age 1-2% of all neoplasms Highest incidence Caucasian > Asians > African-American
8 Testicular Cancer-Risk Factors Race Age: Highest risk ages Previous Testis cancer: 2-3% risk of development of cancer in contralateral testis Cryptorchidism: 50 times more likely to develop cancer in an UDT. The more undescended the testis the higher the risk Male Infertility: More likely to have testis cancer
9 Source Undetermined
10 Source Undetermined
11 Evaluation Physical Exam: The BEST diagnostic tool Scrotal Ultrasound: Can be used to corroborate PE findings or clarify ambiguous exam Serum Markers: AFP (alpha feto-protein), Beta-HCG (Human chorionic gonadotropin)
12 Source Undetermined
13 Source Undetermined
14 Evaluation Remember: A mass in the testis is a tumor unless proven otherwise A testicular mass warrants surgical exploration.
15 Testicular Neoplasm: Initial Treatment Orchiectomy: This is completed through an inguinal approach. Staging Studies CT scan CXR Tumor markers: taken preoperatively and postoperatively
16 Source Undetermined
17 Source Undetermined
18 Source Undetermined
19 Tumor Markers and Testicular Neoplasm Elevated HCG: Choriocarcinoma, embryonal, occasionally seminoma (5-10%) Elevated AFP: Yolk sac, pure embryonal, teratocarcinoma. AFP is never elevated in a pure seminoma
20 Staging of Germ Cell Neoplasms A: Confined to the testis B: B1: microscopic spread or nodes < 2 cm in size and < 6 nodes B2: >6 nodes, 2-6 cm in size B3 >6 nodes > 6 cm C: Nodal spread beyond retroperitoneum D: Other solid organs, ie lungs, brain, liver, etc.
21 Source Undetermined
22 Source Undetermined
23 Staging of Germ Cell Neoplasms A: Confined to the testis B: B1: microscopic spread or nodes < 2 cm in size and < 6 nodes B2: >6 nodes, 2-6 cm in size B3 >6 nodes > 6 cm C: Nodal spread beyond retroperitoneum D: Other solid organs, ie lungs, brain, liver, etc.
24 Source Undetermined
25 Staging of Germ Cell Neoplasms A: Confined to the testis B: B1: microscopic spread or nodes < 2 cm in size and < 6 nodes B2: >6 nodes, 2-6 cm in size B3 >6 nodes > 6 cm C: Nodal spread beyond retroperitoneum D: Other solid organs, ie lungs, brain, liver, etc.
26 Source Undetermined
27 Source Undetermined
28 Source Undetermined
29 See Netter image Gray s Anatomy
30 Therapy for Seminoma Stage A, B: Radical orchiectomy or % cure Observation with CT scan, serum markers External radiation
31 Therapy for Seminoma Stage B2 or C: Radical orchiectomy Chemotherapy >85% survival
32 Therapy for NSGCT Stage A: Radical orchiectomy or Chemotherapy >85% survival Close observation
33 Therapy for NSGCT Stage A: Radical orchiectomy or or Chemotherapy Close observation Retroperitoneal lymph node dissection >85% survival
34 Therapy for NSGCT Stage B1, B2: Radical orchiectomy or Chemotherapy Retroperitoneal lymph node dissection >70% survival
35 Therapy for NSGCT Stage B3, C, D: Radical orchiectomy Chemotherapy >40-50% survival
36 Testicular Torsion Most commonly seen in males ages yrs. BUT IT CAN OCCUR AT ANY AGE Twisting of the spermatic cord causes testicular ischemia. Twisting of >720 results in complete testicular artery occlusion. Ischemia time of >6 hrs usually results in testicular demise.
37 Tintinalli, Ruiz, Krome. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill, 1996
38 Source Undetermined
39 Source Undetermined
40 Tintinalli, Ruiz, Krome. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill, 1996
41 Testicular Torsion TESTICULAR TORSION IS A UROLOGIC EMERGENCY AND REQURIES SURGICAL EXPLORATION! TESTICULAR TORSION IS A UROLOGIC EMERGENCY AND REQURIES SURGICAL EXPLORATION!
42 Testicular Torsion: Presentation Acute pain: Usually not associated with trauma to testis. I was sound asleep and the pain woke me Nausea, vomiting Low-grade fever
43 Testicular Torsion: Presentation Physical exam: Epididymis anterior Horizontal lie to the testis Testis lying high in the scrotal sac Exquisite tenderness to palpation. Possible associated reactive hydrocele
44 Testicular Torsion: Differential Epididymitis Diagnosis Testicular tumor Orchitis Torsion of appendix testis Traumatic rupture of testis (testis fracture)
45 Source Undetermined
46 Male Genitourinary Exam: Blue dot sign Source Undetermined
47 Testicular Torsion: Diagnostic Tests History and PE often are enough Nuclear testicular scan or Doppler ultrasound
48 Source Undetermined
49 Source Undetermined
50 Source Undetermined
51 Testicular Torsion: Treatment Emergent surgical exploration: If testis is viable then de-torse and perform bilateral orchidopexy If testis is not viable, the perform orchiectomy and perform contralateral orchidopexy.
52 Source Undetermined
53 Epididymitis/Orchitis Infection/Inflammation Usually retrograde infection up the vas deferens Sometimes can be due to systemic illness ie viral Blood-borne infection, ie TB
54 Drawing of an acute epididymoorchitis removed
55 Risk Factors Epididymitis/Orchitis Sexual activity Congenital anomalies Bladder outlet obstruction (BPH) Neurogenic bladder dysfunction
56 Epididymitis/Orchitis: Presentation Scrotal pain and swelling Voiding symptoms Fever PE: Scrotal swelling, hydrocele, erythema, pain on palpation (epididymal > testicular pain), urethral discharge Urinalysis: pyuria, bacteriuria
57 Source Undetermined
58 Source Undetermined
59 Epididymitis/Orchitis: Pathogens Age-dependent Pediatric population: gm negative enteric organisms Young adult: chlamydia, gonorrhea Older adult: gm negative enterics
60 Epididymitis/Orchitis: Treatment Bug-dependent: Gm- enterics: SMX:TMP, quinolones STD s: Tetracycline, Ceftriaxone, quinolones Bedrest, scrotal elevation If symptoms worsen-suspect possible testicular abscess and get a scrotal ultrasound
61 Benign Scrotal Masses Hydrocele Spermatocele Varicocele Hematocele
62 See Netter image
63 Source Undetermined
64 Male Genitourinary Exam: Scrotal Mass Transillumination Source Undetermined
65 Male Genitourinary Exam: Scrotal Mass Transillumination! Source Undetermined
66 Source Undetermined
67 Source Undetermined
68 Varicocele Abnormally dilated internal spermatic vein 10-15% of adult males have varicoceles 90% found on left 10% bilateral Usually asymptomatic, but occasionally may cause a heavy dull pain especially if men have been upright for long periods of time.
69 See Netter image Gray s Anatomy
70 See Netter image Gray s Anatomy, Bartleby
71 Spermatocele Rupture of epididymal ducts Filled with sperm Usually asymptomatic
72 Source Undetermined
73 Source Undetermined
74 Case Study You are called to the ER to evaluate a 21 year old UM undergraduate student with ball pain
75 Case Study 21 yo with scrotal pain. What aspects of the history are important in this case?
76 Case Study 21 yo with scrotal pain. What ancillary tests would you like to perform? What would sway you one way or another about whether these tests need to be performed?
77 Case Study 21 yo with scrotal pain. What is your working diagnosis? What is the differential diagnosis
78 Case Study 21 yo with scrotal pain. Important aspects of the History Acute onset, woke him from a drunken sleep No recent sexual activity Has had similar episodes in past History of UDT No voiding symptoms
79 Case Study 21 yo with scrotal pain. Important aspects of the Physical Exquisite tenderness of testis>epididymis Testis high-riding and more horizontal Epididymis anterior +/- Cremasteric reflex
80 Case Study 21 yo with scrotal pain. Important Test results UA negative
81 Case Study Source Undetermined
82 Case Study Source Undetermined
83 Case Study What do you do now?
84 Additional Source Information for more information see: Slide 5: Source Undetermined Slide 6: Source Undetermined Slide 9: Source Undetermined Slide 10: Source Undetermined Slide 12: Source Undetermined Slide 13: Source Undetermined Slide 16: Source Undetermined Slide 17: Source Undetermined Slide 18: Source Undetermined Slide 21: Source Undetermined Slide 22: Source Undetermined Slide 24: Source Undetermined Slide 26: Source Undetermined Slide 27: Source Undetermined Slide 28: Source Undetermined Slide 29: Gray s Anatomy; Netter, Slide 37: Tintinalli, Ruiz, Krome. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill, 1996 Slide 38: Source Undetermined Slide 39: Source Undetermined Slide 40: Tintinalli, Ruiz, Krome. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill, 1996 Slide 45: Source Undetermined Slide 46: Source Undetermined Slide 48: Source Undetermined Slide 49: Source Undetermined Slide 50: Source Undetermined Slide 52: Source Undetermined Slide 57: Source Undetermined Slide 58: Source Undetermined Slide 62: Netter, Slide 63: Source Undetermined Slide 64: Source Undetermined Slide 65: Source Undetermined Slide 66: Source Undetermined Slide 67: Source Undetermined Slide 69: Gray s Anatomy; Netter, Slide 70:Gray s Anatomy; Netter, Slide 72: Source Undetermined Slide 73: Source Undetermined Slide 81: Source Undetermined Slide 82: Source Undetermined
BENIGN & MALIGNANT TESTIS DISEASES. Gary J. Faerber, M.D. Associate Professor, Dept of Urology March 2009 OBJECTIVES
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