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Flashcards in Genituurinary anorectal Deck (66):
1

the most common cause of scrotal pain


epididymitis (posterior and inferior)

2

Hx of epididymitis

1. Gradually increasing pain and swelling (over days)
2. Dysuria/Fever

3

MC ways an epididymitis get's infected

STD

BUT not always infectious can be
Trauma”, Autoimmune dz, Vasculitis

4

Prehn’s Sign

Elevation of the scrotum relieves pain

This is unreliable to differentiate Testicular Torsion but is supposed to help you differentiate

5

Cremasteric Reflex

1. Stroking the thigh on the affected side causes the ipsilateral testis to pull upwards
a. Can use for testicular torsion

6

predominant method of choice for dx testicular complaints

what would epididymitis look like

Ultrasound

Inflammation increases blood flow which shows up on the doppler

if blood is not getting to the testicle you might suspect something like torsion

also STD testing, ULS (hydrocele), urine culture (E.coli, pseudomonas)

7

Tx for epididymitis

UA, STD Testing, ?ULS (reactive Hydrocele Vs.)

Possible Urine culture (E.coli, Pseudomonas,)

Presumptive Therapy:

F/U instructions/expectations

8

Presumptive Therapy for epididymitis

Ceftriaxone 250 mg IM and Doxycycline or azithromyocin 100mg PO BID X days
(can't tell if gonorrhea or chlamydia)

If over age 35, consider Levofloxacin 500 mg qd X 10 days

Analgesics, SITZ baths, Scrotal Support (jock strap so that the testicles don’t bounce)

9

hydrocele is a collection of fluid where

painful or nah?

Collection of fluid between the Parietal and Visceral layers of the Tunica Vaginalis.

arise over a longer period of time
usually asymptomatic BUT increasing pain w/ increasing size

10

hydrocele dx

Dx: Transillumination

on ULS you see tis as

11

tx for a hrydocele

iv. Treatment rarely needed, Aspiration doesn’t work, Surgery will.


Most large hydroceles need to go to the urologist who will decide on surgery but it’s not preferred b/c it causes recurrent hydroceles

12

Varicocel

dilation of the Pampiniform plexus of spermatic veins. Left hemiscrotum.

ii. 20% of men; more common on the L
iii. Occas. Dull, achy pain.

13

DX test for ULS

Put your hands on the scrotum and ask them to grunt or bear down (valsalva) and it should dilate the vessels or can use ULS and have them bear down

14

how would you treat varicocele

Scrotal Support, NSAID, Surgery for infertility.

15

Epididymal cysts and Spermatoceles

are found where

Arise on the head of the epididymis, when larger than 2cm called Spermatoceles

16

Epididymal cysts and Spermatoceles vs cancer presentation

Generally asymptomatic, found on ULS
if they do get too large they can cause discomfort


Testicular Cancer

Usually painless, unless it causes hemorrhage or infarction

17

Testicular cancer ULS

less homogenous on ULS
can look abnormal

want to get a CT to look for METS most commonly to the lungs

18

Orchitis is defined as ___

what sxs do we see associated

Extension of epididymal infection into the testes, or complication of Mumps.

More systemic symptoms:

Fever, myalgias, malaise, parotid swelling

19

inguinal hernia is the result of

Failure of adequate embryonic closure of the Processus vaginalis in the inguinal canal, allowing intestines to force downwards into the scrotal sac.

20

inguinal hernia sx

Uncomfortable but not acutely painful, usually reducible by a push or lying supine. Often gradually enlarge.

21

Inguinal Hernia on PE

supine, and if not palpable, standing.
1. If acutely painful, think:
a. Obstructed vs. Incarcerated vs. Strangulated


"i think it is an inguinal hernia that is likely reducible. I have not reduced one before but could i practice"

22

dx tests for inguinal hernia

ULS/CT --> look with ULS but can’t tell where bowel gets narrow and pinched on the side so CT is very useful for this

23

can you push an inguinal hernia back in

Let the surgeon decide to push -->if you push dead bowel back inside, then the dead bowel gets dead-er

24

tx of inguinal hernia

Scrotal Support, Analgesics, Stool softeners, Surgical Referral.

25

CAT scan with air

necrotizing fasciitis seen as dark black hyperecohoic air

26

blue dot sign for

torsion

27

Torsion of the Appendix Testis

Caused by the infarction/necrosis of the appendix testis. Rare in adults.

28

Most common scrotal pathology in children

Torsion of the Appendix Testis

29

Torsion of the Appendix Testis sxs

7-14 y.o.

Pain usually more gradual than testicular torsion.

Tenderness localized to the anterosuperior testis and no swelling to the testis or epididymis.



30

tx of torsion of the appendix

Pain Control

31

Fournier’s Gangrene

Necrotizing Fasciitis. Mixed aerobic and anaerobic bacterial infection rapidly leading to systemic illness/Sepsis/death.j. Fournier’s Gangrene

32

Fournier’s Gangrene sx

who is at risk

Scrotal pain, tense edema, blisters, hemorrhagic bullae, fever, tachycardia, hypotension

IVDU
DM at risk

33

tx of Fournier's gangrene

IV/Labs/broad spectrum antibiotics/CT. Immediate Surgical consult

OR -- early and aggressive surgical debridement

34

Testicular Torsion

The testis twists on the spermatic cord causing ischemia. Irreversible damage after 12-24 hours.

35

sxs of testicular torsion

Sudden/acute severe pain, often a few hours after physical activity or trauma.

36

findings in PE

high riding’ testis on the affected side with the long axis of the testis oriented ‘sideways’.

A “Bell Clapper Deformity”.

Testicular swelling early, leading to a reactive hydrocele, and lastly scrotal redness.

The Cremasteric Reflex – absent in torsion

37

tx for torsion

Time is Testicle”

2. Analgesics, (UA, etc.)
3. Immediate Urologic/Surgical consultation
4. Manual Detorsion – ‘Opening a book’ until pain relieved. Supposedly dramatic relief.?
5. Color Doppler Ultrasound
6. OR

38

Balanitis

Balanos” is Greek for “Acorn” --Inflammation of the Glans.

\Most common etiology is Candida albicans

39

Balanitis when the foreskin is involved.

Balanoposthitis

40

Balanitis sxs

Increasing tenderness, pain, swelling, and discharge over days.

DM

41

Balanitis

1. Fingerstick glucose, STD labs
2. 1-3 weeks of antifungal.
3. Clotrimazole/Miconazole BID, Hydrocortisone 1% cream.
4. Single dose of Fluconazole PO
5. Better Hygiene

42

When the foreskin tightens over the glans and cannot be retracted it is

Phimosis.


Foreskin tightens over the glans and cannot be retracted

Presentation--> balanitis gone bad, foreskin adheses

43

If the foreskin is retracted and becomes so swollen that it constricts like a tourniquet around the glans it is

Paraphimosis.

44

sxs of Phimosis and Paraphimosis

Balanitis gone bad.
Foreskin adheses, glans swells

45

tx of Phimosis and Paraphimosis

1. Phimosis doesn’t usually need treatment different from balanitis.

2. Paraphimosis requires manual decompression or surgical circumcision
a. Applying sugar/glucose may be helpful

46

priapism lasts

A painful erection lasting more than 4 hours (without sexual excitation)

47

priapism pshyiology

iv. The blood in the corpora cavernosa becomes entrapped and ‘stagnates’ due to impaired relaxation of the smooth muscle.

48

priapism hx

Hx should include duration of erection, prior episodes,
history of Sickle Cell, Leukemia, medications

meds: antidepressants, antipsychotics, antihypertensives, impotence injectables, Atarax, Reglan, and Prilosec),

and recreational drugs… Spinal cord injuries, Black Widow and Scorpion envenomations, Malaria, etc.

49

dx of priapism

Doppler ULS or Cavernosal blood gas if nonischemic priapism suspected (aspirated blood is red instead of black).

CBC, HgB electrophoresis, Utox

50

tx of priapism

Surgical/Urologic Consult

Intracorporeal Aspiration /Irrigation and Phenylephrine 100-500 mcg per ml, injected into the corpus cavernosum every 3-5 minutes for an hour (or until 1 mg total reached)

OR, surgical shunt cut between corpus cavernosum and corpus spongiosum.

51

Hemorrhoids

Dilated AV channels and connective tissue with veins arising from the superior and inferior hemorrhoidal veins in the submucosal layer of the inferior rectum.

52

hemorrhoids tx if thormobosed

feel like a marble and is dark

53

sx of hrmorrhoid

Painless bleeding, Prolapse, Pain, Pruritus

54

PE of hemorrhoid

Risk assessment for GI bleeding (PUD, IBD)
1. Position the pt. so that you can see. Light!
2. If painful look for fissures, abscess, or thrombosed hemorrhoid.
3. If nothing external then anoscopy.

55

tx of hemorrhoid

1.Sitz baths. Increase Fiber, decrease Straining.

2.Fiber supplementation (Methylcellulose/Psyllium, 20-30 G/d)

3.Analgesic/Hydrocortisone Creams or Suppsitories

4.Stool Softeners

5.Surgery Referral:
a. Rubber Band Ligation, Infared Coagulation, Sclerotherapy, Cryosurgery, Surgical Hemmorhoidectomy

56

PeriAnal/Rectal Abscess

Infected Anal Crypt gland.

57

Rectal Abscess sxs

ii. 50% become fistulas!
iii. Sx: Pain, Swelling, Mass, Pus, Fever

58

PE with rectal abscess

Digital Exam. If palpable induration or significantly increased pain, consider CT with Contrast. Surgery Consult. Labs.

Run your finger around the anus and trying to feel for fluctuance

59

PeriAnal/Rectal Abscess tx

Treatment:

I&D with local anesthesia. Elliptical skin excision because of no packing, or use rubber drains… SITZ baths.Analgesics. Stool Softeners.
1. Antibiotics depending on size and comorbidities

60

c. Acute Prostatitis

i. Inflammation of the Prostate gland, often bacterial, can become chronic.

61

sxs of acute prostatis

Sx: Flu-like symptoms - Fever, chills, malaise, myalgia. Dysuria, cloudy urine.Pain in lower abd, perineum, testicles, or penis. Hematospermia.

Swelling of the Prostate can cause ‘obstructive’ symptoms: hesitancy, dribbling, acute urinary retention.

62

tx of prostatitis

Urine Culture and Gram Stain.
1. Labs and blood culture if toxic appearing.

2. PSA not especially helpful

3. Initial antibiotic therapy for gram negatives is Fluoroquinolone or Septra, for 4-6 weeks! Adjust if needed when gram stain/culture done.

4. Add Aminoglycoside if toxic.

5. Analgesics

63

Prolapse of the rectal tube thru the anus.

RF

: Female, Multiparous vaginal deliveries, Pelvic floor Anatomic defects, Prior Pelvic Surgery, Chronic Straining/Diarrhea, Cystic Fibrosis, CVA

ii. Uncommon, 1% adults over 65 y.o.

64

sxs of rectal prolapse

Pain is not typical. Usually pt. c/o’s mass or discharge (fecal incontinence or seepage)

Treatment: Surgery Consult. Colonoscopy referral. Fiber/Fluids/Enemas

65

tx of rectal foreign body

Sedation
1. Imaging, Manual removal attempts
2. Surgical consult

66

dentate line

pectinate line (dentate line) is a line which divides the upper two thirds and lower third of the anal canal. Developmentally, this line represents the hindgut-proctodeum junction.

separate internal from external hemorrhoids