4. Testicular Torsion
General considerations
Ischemic Urologic Emergency
Typical sudden onset of pain
May have intermittent
torsion & pain
Color flow Doppler
5. Testicular Torsion
Epidemiology
Bimodal Peak
Neonatal Period
Age 12-18 years
Left side more common
Usually preceding physical
exertion or trauma but may be
spontaneous
6. Testicular Torsion
Signs and symptoms
Sudden, severe pain
Swollen & Tender testis
Testes in affected side lies
higher in scrotum &
Transverse position
Absent cremasteric reflex
Nausea & vomiting
NO FEVER
9. Testicular Torsion
Treatment
Immediate urologic consultation
Prepare patient for the OR
Doppler ultrasound if it will not delay surgery
Detorsion may be attempted if the patient is seen
within a few hours of onset
―Open book‖ method
Pain relief should be immediate
Do not delay operative intervention, since testicular
infarction will occur within 6 to 12 h after torsion
10. Testicular Torsion
Prognosis
Less than 6 hours – salvage rate is excellent
Beyond 6 hours – salvage rate becomes worse
After 48 hours – salvage rate is zero
11. Testicular Torsion
Clinical Pearls
Patients may report similar, less severe episodes
that spontaneously resolved in the recent past
Half of all torsions occur during sleep
Abdominal or inguinal pain is sometimes present
without pain to the scrotum
15. Hypogonadism
Signs
Diminished sexual hair growth
Decreased testicular mass
Loss of muscle mass
Diagnostic studies
Morning serum testosterone level
LH and FSH
LH and FSH is high in patients with testicular
dysfunction and low in patients with pituitary
disorders
16. Hypogonadism
Management
Evaluation for prostate cancer
Testosterone replacement
Oral
IM
Transdermal
19. Hypospadias
Testing
Patients with ―Penoscrotal‖ and ―Perineal‖
openings should be considered to have potential
intersex problems and should be karotyping to
establish genetic sex
Treatment
Surgical repair preferred before school age
Over 150 procedures
22. Epispadias
Classification
Glandular – opens on dorsal aspect of glans
Penile – borad and gaping on dorsum of penile shaft
Penopubic – junction with groove extending through
glans
Females will have bifid clitoris & separation
of labia. Most are incontinent
Penile & Penopubic will usually have urinary
incontinence
Surgery is required to correct incontinence
24. CRYPTORCHIDISM
DEFINITION:
A condition in which one or both testes fail to descend
into the scrotum.
FACTS & FIGURES
• Most common congenital condition involving the
testes
• 3% of all full-term males at birth
• 20% of all premature males at birth
• Less than 1% of males by 3 months of age
25.
26. CRYPTORCHIDISM
CLINICAL:
No testis detected with palpation of scrotum.
CONCERNS:
• Impaired fertility
• Risk of testicular cancer 35-50% higher than in
men who have descended testes
DX:
• CT scan
• Ultrasound
27. CRYPTORCHIDISM
TREATMENT:
Administration of HCG (given IM biweekly),
which may initiate descent.
Referral to urologist by 6 months, surgery by age
1 or 2 at the latest
Orchiopexy DOES NOT reduce risk of cancer, but
does facilitate examination and early detection
30. HYDROCELE
DEFINITION: A collection
of fluid within the tunica
vaginalis
Most common cause of
Scrotal Swelling!
•Common in infancy
•Associated with 10% of
testicular tumors
36. VARICOCELE
CLINICAL:
May feel like a “weight in
the testes” or “bag of
worms”
FACTS & FIGURES:
> 15 years old
More common on left side
(95%)
37. VARICOCELE
REMEMBER:
• No scrotal erythema
• No pain (usually)
• DOES NOT transilluminate
• Most common after puberty
• No dysuria
• No systemic symptoms
• In older men = think
bladder/renal tumor
• CAN CAUSE INFERTILITY
39. Erectile Dysfunction
Essentials of Diagnosis
Most causes are organic and not
psychogenic
Increasing incidence with older age
Variety of treatment available, with
multiple oral agents
40. Erectile Dysfunction
General Considerations
Inability to maintain an erect penis with sufficient
rigidity to allow sexual intercourse
Loss of erections occurs from arterial, venous,
neurogenic, or psychogenic causes
Associated with concurrent medical problems
(hypertension, diabetes mellitus), or radical pelvic
or retroperitoneal surgery
Look for concomitant cardiovascular disease
41. Erectile Dysfunction
General Considerations
Antihypertensive medications
Centrally acting sympatholytics (methyldopa,
clonidine, reserpine) can cause loss of erection
Beta Blockers & Thiazide Diuretics are common
Androgen deficiency causes both loss of
libido and erections and lack of emission by
decreasing prostatic and seminal vesicle
secretions
42. Erectile Dysfunction
General Considerations
Psychogenic causes
Anxiety related
Due to a new partner
Unreasonable expectations about
performance
Emotional disorders
44. Erectile Dysfunction
Clinical findings
History
Erectile dysfunction should be distinguished
from problems with ejaculation, libido, and
orgasm
Degree of the dysfunction—chronic, occasional,
or situational
Timing of dysfunction
Determine whether the patient ever has any
normal erections, such as in early morning or
during sleep
45. Erectile Dysfunction
Clinical findings
History
Inquire about hyperlipidemia, hypertension,
neurologic disease, diabetes mellitus, renal
failure, adrenal and thyroid disorders, and
depression
Trauma to the pelvis, pelvic surgery, or peripheral
vascular surgery
Use of drugs, alcohol, tobacco, and recreational
drugs
46. Erectile Dysfunction
Clinical findings
Physical examination
Secondary sexual characteristics
Neurologic motor and sensory examination
Peripheral vascular examination
Examination of genitalia, testicles, and
prostate
Evaluate for penile scarring, plaque formation
(Peyronie's disease)
47. Peyronie’s Disease
Dense fibrous plaque that forms on the tunica
albuginea – causing a curvature of the erect
penis
Etiology of the plaque is unknown
May be scar tissue resulting from microscopic
tears of the tunica albuginea during intercourse
Flaccid penis is usually normal on exam and
the curvature is only noted in the erect penis
50. Erectile Dysfunction
Laboratory Tests
Complete blood count
Urinalysis
Lipid profile
Serum glucose, testosterone, LH/FSH, and
prolactin
Serum testosterone and gonadotropin levels may
help localize the site of disease (CNS vs Testes)
51. Erectile Dysfunction
Imaging studies
Cavernosometry (measurement of
flow required to maintain erection)
Cavernosography (contrast study of
the penis to determine site and extent
of venous leak)
Nocturnal penile tumescence testing
52. Erectile Dysfunction
Medications
Hormone replacement for androgen deficiency
Alprostadil urethral suppository pellets
PDE-5 inhibitors taken 1 hour prior to anticipated
sexual activity
Viagra (sildenafil) 50 mg, Levitra (vardenafil) 5 mg,
or Cialis (tadalafil) 10 mg
Contraindicated in patients receiving nitrates
Some patients who do not respond to one PDE-5
inhibitor will respond to another
53. Erectile Dysfunction
Treatment Procedures
Direct injection of vasoactive substances
into the penis
Prostaglandin E, papaverine, or a combination
54. Erectile Dysfunction
Surgery
Penile prosthesis: rigid, malleable, hinged,
or inflatable
Surgery for disorders of the arterial system
Vascular reconstruction
Endarterectomy and balloon dilation for
proximal arterial occlusion
Arterial bypass procedures for distal occlusion
55. Erectile Dysfunction
Therapeutic
Procedures
Vacuum
constriction device
Behaviorally
oriented sex
therapy for men
with no organic
dysfunction