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2011 Scotal Pathology__copy01_

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					     Urology

Scrotal Pathology 2011

     Neal Rowe, MD
    Division of Urology
         Scrotal Mass

     LMCC Key Objective (s):

Differentiate testicular tumor from a
mass of inguinal origin (not possible
to get above it, may reduce), cystic
  lesion (trans-illuminates), and a
 varicocele (easier to palpate with
          patient standing)
    Scrotal Mass
• Through efficient, focused, data gathering:
     •   In boys, ask about pain, trauma, change in scrotal size, difficulty voiding
     •   Elicit history of undescended testicle, infertility, previous testicular tumor, and breast
         enlargement / tenderness
     •   Differentiate from condition that presents primarily with pain
     •   Perform abdominal exam including inguinal areas, and an examination of the male
         genitalia (erect and supine, testes, epididymis, cord, scrotal skin) including rectal
         examination to assess the prostate and seminal vesicles, transilluminate


• List and interpret critical clinical and laboratory findings which
  are key in the processes of exclusion, differentiation, and
  diagnosis:
     •   Select patients requiring ultrasound, CT and explain reasoning; order beta human
         chorionic gonadotrophin, alpha-fetoprotein, and LDH


•   Conduct an effective plan of management for a patient with scrotal
    mass:
     •   Outline management options for masses which are not testicular tumors.
Approach to Scrotal Masses

• Painful vs. painless
• Benign vs. malignant
• Etiology varies with age of patient
   – DDX differs between adults and children

• >>> anatomical approach is probably best
       • where is the lesion originating from?
Anatomy
          • Scrotal Contents:
             – Testes
                • Tunica albuginea
                • Tunica vaginalis
             – Epididymis
             – Spermatic Cord:
                • Vas deferens
                • Arteries:
                    – Testicular
                    – Cremasteric
                    – Artery to the Vas
                • Veins:
                    – Pampiniform plexus
                • Nerves:
                    – Ilioinguinal
                    – Genital br. Of Genitofemoral
                    – Sympathetics
History

• Age of patient                  • Risk Factors
• HPI                                – Infection
                                     – Instrumentation of the
   –   Onset (acute, insidious)
                                       urinary tract
   –   Painful vs. painless
                                     – Congenital anomalies
   –   Radiation
                                     – Prior history of neoplasm
   –   Aggravating Factors
                                     – Recent trauma
   –   Relieving Factors
   –   LUTS
• PMHx
• PSHx
Urology Surgery Clerkship Seminar
Physical Examination

• Vital Signs                               • Scrotum
   – Temp                                       – Skin
• Skin                                          – Testes:
• Abdominal exam                                   • 3.5 cm
• Inguinal                                         • Mass

   – Hernia (may reduce, unable to get above)   – Hydrocele
   – Lymph Nodes                                   • Transillumination
   – Masses                                     – Varicocele
                                                   • Valsalva
• Penis
   – malignancy                             • DRE
Differential Diagnosis

• Painful                             • Painless
   – Trauma                              – Tumor
       • Contusion, rupture                  • Intratesticular
   – Epididymo-orchitis                      • Paratesticular
                                         – Varicocele
   – Hernia
                                         – Hydrocele
       • Incarcerated, strangulated
                                         – Spermatocele
   – Torsion                             – Scrotal wall malignancies
       • Testes                              • SCC, sarcomas
       • Appendages
Testicular Torsion   • Intravaginal (all age groups,
                       puberty)
                     • Extravaginal (prenatal,
                       neonatal)

                     • Hx:
                         –   Acute Painful scrotum
                         –   N&V
                         –   Rx to groin / abdomen
                         –   No or minimal trauma
                     • Px:
                         –   Patient appears unwell
                         –   Tender, swollen testicle
                         –   High riding, transverse lie
                         –   Scrotal erythema
                         –   No cremasteric reflex
Testicular Torsion
                     • If suspected clinically,
                       surgical exploration indicated
                         – Orchidectomy vs
                           orchidopexy
                         – Orchidopexy of contralateral
                           side

                     • INV:
                         – Transcrotal Ultrasound
                              • Duplex Doppler
                         – Nuclear testicular blood flow
                           scan
Epididymitis / Orchitis   • Hx:
                            –   More insidious onset
                            –   Fever
                            –   Recent instrumentation
                            –   Sexual activity
                            –   LUTS
                          • Px:
                            –   Painful epididymis +/- testis
                            –   Testis in normal position
                            –   Urethral discharge
                            –   + Prehn’s sign
                          • INV:
                            – CBC
                            – U/A, C&S, Urethral Swab for
                              GC / Chlamydia
                            – TB
                          • >>May Resemble
                            Torsion!
       Epididymitis / Orchitis
• Etiology                                • Specific Recommendations:
   – <35 years: N.gonorrhea,                – GC:
     C.trachomatis, E.coli                     • ceftriaxone 250 mg IM
   – >35 years: E.coli                         • Cipro 500 mg PO
   – Homosexual: E.coli
                                            – NonGC:
   – Mumps orchitis:
                                               • Azithromycin 1 g PO
        • 30% of patients with mumps
        • Risk of infertility                  • Doxycycline 100 mg BID x 7
                                                 days
• Rx:
   –   Antibiotics                          – E.coli:
   –   Bed rest                                • IV antibiotics if severe
   –   Analgesics / Anti-inflammatories        • Fluoroquinolone x 10-14
   –   Scrotal elevation / support               days
Hydrocele

• A collection of serous fluid in some part of the processus
  vaginalis, usually the tunica
• More common in childhood
• 1% of adult males

• Congenital:
   – Processus vaginalis does not close after testicular descent
• Acquired:
   – Primary (idiopathic) vs. secondary to disease of the testis
   – Defective absorption, increased production, lymphatic
     obstruction
Hydrocele
            • Hx:
              – Painless (unless large)
              – Change during day
                (suggests
                communication)
              – Other symptoms
                (secondary hydrocele)
            • Px:
              – Transilluminates
              – Palpate testes
              – Hernia ?
            • INV:
              – Transcrotal ultrasound
                if testis not palpable
Hydrocele
            • Rx:
               – Adults:
                    • Symptomatic
                    • Cosmesis
                    • Underlying testicular
                      pathology
               – Children:
                    • Most will resolve in 1st
                      year
                    • If persists, repair of
                      hernia may be
                      indicated
            • Specifics:
               – Surgical
               – Aspiration
               – Sclerotherapy
Spermatocele
               • Painless mass
               • Contains fluid and
                 spermatozoa
               • 4th / 5th decades
               • Region of caput
               • Usually can palpate the
                 testis separately from
                 spermatocele
               • Obstruction of efferent
                 duct
               • Mass may transilluminate
Spermatocele


               •Rx:
                  •Conservative
                  •Spermatocelectomy (surgical
                  removal)
                  •Surgery may have negative
                  consequences      >>> delay
                  if reproductive   age
Varicocele

• 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 (multiple theories)
   – Elevated intratesticular temperature widely accepted

• Most Left-sided; May be bilateral; Right-sided only>> be
  suspicious!

• Rare prior to puberty
Varicocele

             • Hx:
                – Painless vs. dull ache; pain rarely present on
                  awakening
                – Discomfort increases with standing / activity
                  over long period of time
                – Exaggerated with Valsalva
                – Infertility


             • Px:
                – “Bag of Worms”, “vascular thrill”
                –   Gr.I: Palpable with valsalva
                –   Gr.II: Palpable without Valsalva
                –   Gr.III: Visible
                –   Abdominal mass


             • Scrotal Ultrasound
Varicocele

             • Rx:
                –   Sx’s
                –   Cosmesis
                –   Infertility
                –   Ipsilateral testicular
                    atrophy

             • Surgical options:
                –   Retroperitoneal
                –   Inguinal
                –   Subinguinal
                –   Laparoscopic
                –   Transvenous
                    embolization
Testicular Tumors

•   Testis CA most common malignancy in males 15 to 35 years

•   Incidence: 3.7 / 100,000 (whites), 0.9 / 100,000 (blacks)

•   R>L, 2-3% bilateral

•   Risk factors:
     – Age (<10, 15-35, >60)
     – Race
     – Cryptorchidism
     – Atrophy
     – Testicular microlithiasis (?)
Risk Factors for Testis CA

•   Maternal exposure to androgens during pregnancy
•   Testicular atrophy
•   Hx prior testis CA (ie. contralateral side)
•   Carcinoma-in-situ (CIS) or Intra-epithelial germ cell neoplasia
•   Cryptorchidism
     – 10-40x increased risk




          Urology Surgery Clerkship Seminar
Classification of Testis CA

•   Primary
     – Germ cell (90-95%)
         • Seminoma - most common (36-65%)
         • Nonseminoma
              – Embryonal (15-20%)
              – Yolk sac
              – Choriocarcinoma (<1%)
              – Teratoma (5-10%)
              – Mixed (40%)
     – Non-Germ cell (5%): most are benign
         • Leydig cell, Sertoli cell, Gonadoblastoma
•   Paratesticular - Sarcoma, Lipoma
•   Secondary
     – Metastasis: prostate, GI, lung, kidney, melanoma
     – Leukemia, lymphoma


          Urology Surgery Clerkship Seminar
Clinical Presentations of Testis CA

•   Local
     – Painless mass
          • Most common (50-55%)
          • Discovered on TSE
     – Testicular pain
          • Dull ache or heaviness (30-55%)
          • Acute pain d/t acute bleed (10%); be aware of Hx of minimal
            trauma!
•   Metastases
     – Respiratory: cough, SOB, hemoptysis
     – Supraclav LN: neck mass
     – Abdomen: mass, pain, N&V, back pain, ileus
•   Endocrine (5%)
     – Gynecomastia / Breast pain



          Urology Surgery Clerkship Seminar
Testicular Self-Examination




     Urology Surgery Clerkship Seminar
Testicular Tumors

• INV:
  – Scrotal U/S
  – CXR
  – Tumor markers
        • BHCG
        • AFP
        • LDH
  – CT Chest / Abdo / Pelvis
• Rx:
  – Radical orchiectomy
Management of Painless Testis Mass
•   Preop
     – Tumor markers
         • AFP: alpha-fetoprotein ^ in 50-70%; produced by yolk
           sac/embryonal/teratocarcinoma; N in seminoma/choriocarcinoma
         • BHCG: human chorionic gonadotropin ^ in 40-60%; all
           choriocarcinoma, 5-10% of seminoma
         • LDH: correlation with NSGCT tumor burden

•   Radical orchiectomy via inguinal approach
     – Possible sperm banking prior to surgery

•   Postop: if malignancy confirmed
     – Plain chest radiograph
     – CT Abdomen / pelvis
         • Staging of retroperitoneal LN and viscera
     – LFTs


          Urology Surgery Clerkship Seminar
     Treatment options for testis CA

• Radical orchiectomy
   – Treatment of primary, staging of primary, histologic Dx

• Additional therapy based on histology and stage

• Staging
   – I: disease limited to testis
   – II: lymphatic spread below the diaphragm
   – III: supradiaphragmatic or extranodal mets




              Urology Surgery Clerkship Seminar
Treatment options for testis CA

•   Seminoma
     – I:
           • Surveillance
           • Radiation to RPLN
     – II or III:
           • Cis-platin based combination chemotherapy
•   Nonseminoma
     – I:
           • Surveillance (30% are understaged)
           • RPLND
           • 2 cycles of cis-platin based chemotherapy
     – II:
           • Low volume: RPLND or 3-4 cycles of cis-platin based chemo
           • High volume: 3-4 cycles of cis-platin based chemo
           • Resection of post-chemo residual masses
•   Regular follow up: P/E, Tumor markers, CXR, CT Abdo/pelvis


           Urology Surgery Clerkship Seminar
Take Home
 Messages
TAKE HOME MESSAGES

• SCROTAL MASS
   – Think Anatomical
   – Painful vs. Painless
   – Testicular torsion >> Urological Emergency

    PRACTICAL POINT
       Learn how to do a scrotal examination




         Urology Surgery Clerkship Seminar
TAKE HOME MESSAGES

• TESTICULAR CANCER
   – Males age 18-35
   – High cure rate
   – 95% are germ cell tumors
   – Ultrasound extension of P/E



   PRACTICAL POINT
      Intra-testicular mass in appropriate age group CANCER until
      proven otherwise




         Urology Surgery Clerkship Seminar
• Special thanks to Dr. James Watterson and Dr. Jeff Warren for
  help with preparation of slides.




                    GOOD LUCK

				
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