1DDX: LECTURE 35 – FEBRUARY 16TH, 2007

CONDITIONS OF THE MALE GENITALIA AND REPRODUCTIVE SYSTEM

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HYDROCELE
Normal: potential space
Can be non-progressive hydrocele: can be progressive as well. All versions of the same thing.
“scrotal enlargement”: we don’t know what is swollen.
Can’t palpate the testes, therefore, the testes aren’t swollen, it is the area around the testes that is enlarged.
Transillumination: same as we do with sinuses.
More distress to parents than to child.
No problems with fertility or lymph drainage after surgery.

HEMATOCELE
Start seeing redness or and inflammation. History of trauma. Without history of trauma, unlikely to be a hematocele.
Pain, angry-looking. Use this to DDX.
Usually end up in emergency room: rupture of blood vessels is painful.
Once stabilized, non-progression, self-limiting.
Can’t transilluminate: this is the other DDX.

VARICOCELE
Won’t confuse this with something else: feel like varicosities. Usually unilateral, usually on left side because the pressure
of the left renal vein is higher than that of the inferior vena cava. Higher pressure  backflow  varicosities.
More tortuous when standing. Won’t be able to feel “bag of worms” when sitting: indication that this is vascular, not a
mass.
Same risk factors as varicose veins in the legs: decrease in collagen integrity. Increased intra-abdominal pressure
May have some dull pain, but not much. Just from fullness of vessels.
Testicle palpable: DDX feature.
This affects fertility: testes are sensitive to temperature and oxygen.
Can lead to thrombus formation: can dislodge and lodge in brain or lung.
Change in lifestyle can address problem, but if non-compliant, surgery is option. Not as effective as changing lifestyle.

SPERMATOCELE
Sperm-filled cyst. Stored in epididymis.
Cyst forms within scrotum, but can be in different locations around testicle (usually at superior pole).
Painless: happens slowly.
Can grow large, but they are usually less than 1cm.
DDX between spermatocele and hydrocele: can’t feel testes in hydrocele.
Can transilluminate: fluid is not as clear as in hydrocele, but this is NOT opaque.
Does not seem to impact fertility. This is unilateral. Also, does not need to be a complete blockage to form cyst.

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PHIMOSIS
Inability to retract uncircumcised penis. Stricture of the orifice.
Can be congenital, can be the result of scar tissue
Have to watch this. Teach the parents how to care for it.
If child is in pain when he has erections, may need to consider circumcision, increasing diameter of orifice.
Don’t try to increase size of orifice yourself! May be adhesions between the prepuce and the glans. Cleaning with Q-tip
can lead to inflammation if you break these adhesions.

PARAPHIMOSIS
Orifice isn’t so tight that it prevents retraction. Glans can exit prepuce during erection, but can’t retract.
First few times, it might be okay, but as the glans grows, the prepuce causes ischemia in the glans.
Procedure: squeeze glans to force blood back into circulation, glans shrinks, prepuce retracts.
Can lead to necrosis if untreated.
Can make incision in prepuce or circumcise. Will tend to happen until patient seeks permanent solution.

TESTICULAR CANCER
Will cover more in PCD and in 3rd year.
Germ cell tumour: most aggressive and lethal in body: body accepts it as it came from pluripotent cell.
DDX LECTURE 35, FEBRUARY 16th, 2007 – PAGE 1
If patient comes to you with signs and symptoms of testicular cancer, it is too late. Key is to screen for this.
Painless, unless hemorrhage occurs. Hard nodule on one side. Negative transillumination.
Any masses detected on testes should be investigated further. Ultrasound and biopsy (fine-needle).
Tumour markers:
Pluripotent cells will produce alpha fetal protein, and beta HCG. These tests can rule out, but they can’t rule in. Levels of
these markers are used to assess effectiveness of surgery.

CRYPTORCHIDISM
Only 1 decended testicle: the one that descends can grow to fill scrotum, compensate. More chance of testicular cancer if
testicle still undescended by age 2 (not in notes: just talked about it in relation to testicular cancer)

PROSTATIC CARCINOMA
Not as worrisome: doesn’t tend to be that aggressive. Not pluripotent. ‘usually’ takes about 10 years to be fatal (? I
think?), compare to 3 months for testicular.
If your father had prostate cancer, your risk doubles. Not the same data in testicular cancer: doesn’t run in families.
PSA: marker, but not conclusive. May confirm findings of DRE.
Will metastasize first to lumbar/sacral vertebrae. X-ray of the back. Affected vertebrae will be brighter than others.
Many different approaches to deal with prostate cancer. Conservative and more aggressive treatments available.
“Watchful waiting” (aka. “watchful dying” by some). Don’t do anything but monitor: done in older patients.

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Features of inflammation: red and yellow coloured!
Have to be aware of possibility of transferring infection to self, other patients.
BALANITIS
Inflammation of glans? Balanitis. Of glans and prepuce? Balanoposthitis
Diabetes is risk because it lowers your immunity across the board.
Can present as paraphimosis
Swab and smear: first thing to do with any discharge.
Most things that cause balanitis are treatable, but there are some untreatable ones (HSV). HSV can be managed by
lifestyle.

URETHRITIS
Can affect men and women.
Suprapubic pain is positive when you have bladder, kidney infection. There is no suprapubic pain in this condition.
No hematuria (usually associated with bladder issues)
Trying to figure out if it has progressed to cystitis.

REITER’S SYNDROME
Usually reaction to C. trachomatis. Auto-immune reaction to collagen. Can be reaction to lots of organisms (see list)
“Can’t see, can’t pee, can’t dance with me”
SYMMETRICAL presentation (correct notes!), as it is a systemic concern, not a local pathology.

ORCHITIS
Inflammation of testes.

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EPIDIDYMITIS
Increase intra-abdominal pressure (straining during bowel movement).
Increase fibre to reduce need to strain.
Can be uni/bilateral
Order CBC to rule out other things. How bad is the inflammation?
Can look like orchitis: but will feel swelling of epididymis, not of testes

TESTICULAR TORSION
Our bodies don’t handle this type of injury well. Twisting of the spermatic cord (contains vas deferens, testicular artery
and vein)
Cuts off blood supply to the testes. May have 1 hour to resolve this.
Problem is gangrenous tissue that might result from necrotic tissue.
Surgical correction is usually performed
Prehn’s sign: elevate testes and if the pain gets worse, this differentiates between torsion and other types of pain.
DDX LECTURE 35, FEBRUARY 16th, 2007 – PAGE 2
Trauma to testes: pain usually abates in minutes, continuously decreasing. Testicular torsion: increasing pain over time,
does not get better.

PROSTATITIS
Will hear a lot about it as NDs: not well-managed in general.
Relieved by ejaculation: important to distinguish between this and other pathologies. Relieves pressure on prostate
(encapsulated organ)
If other pressure (DRE): could indicate prostatitis.
Pressure on perineum: pain refers to tip of penis (acute)
Keynote for prostatodyna: sense of rectal fullness, may feel like they are going to have bowel movement during
examination
3 glass urinalysis: beginning of stream in 1 (tells you about urethra), mid-stream (bladder), end of stream (squeeze:
prostate). No longer a useful diagnostic tool. This is in board exams, but not really used. Regular urinalysis is enough.

DDX LECTURE 35, FEBRUARY 16th, 2007 – PAGE 3