Penile, Prostate, and Testicular Disorders Notes

NOTES NOTES PENILE, PROSTATE, & TESTICULAR DISORDERS GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ▪ Disorders affecting male genitourinary tract SIGNS & SYMPTOMS ▪ See indiviudal disorders DIAGNOSIS LAB RESULTS ▪ Urinalysis, urine culture TREATMENT ▪ Conservative measures ▫ E.g. decrease fluid intake for benign prostatic hyperplasia ▪ Pharmacological therapy ▪ Surgical therapy DIAGNOSTIC IMAGING ▪ Ultrasound BENIGN PROSTATIC HYPERPLASIA osms.it/benign-prostatic-hyperplasia PATHOLOGY & CAUSES ▪ Characterized by nodular prostatic hyperplasia ▪ Not premalignant ▪ Most common prostatic disease in biologically-male individuals > 50 years old CAUSES ▪ Hyperplasia of prostatic epithelial, stromal cells → formation of nodules in periurethral (transition) zone → narrowing of urethral canal → urine flow constricted ▪ Testosterone, dihydrotestosterone (DHT), estrogens act on stromal, epithelial cells’ androgen receptors → hyperplasia, inhibition of normal cell death ▪ Dysregulation of stromal growth factors → proliferation, hyperplasia of epithelium ▪ ↑ stem cells RISK FACTORS ▪ ↑ age ▪ Family history of benign prostatic hyperplasia (BPH) ▪ Heart disease ▪ Beta-blocker use ▪ Obesity ▪ Diabetes ▪ Erectile dysfunction OSMOSIS.ORG 799

COMPLICATIONS ▪ Chronic bladder outlet obstruction ▫ Bladder hypertrophy → formation of bladder diverticula ▫ Urinary retention → bladder calculi ▫ Residual urine can be infection source → recurrent UTIs ▫ Hydronephrosis → renal failure SIGNS & SYMPTOMS ▪ Urinary ▫ Frequency ▫ Urgency ▫ Nocturia ▫ Dysuria ▫ Emptying bladder feels incomplete ▫ Difficulty starting, stopping urine flow ▫ Weak stream → small amounts of urine lost DIAGNOSIS DIAGNOSTIC IMAGING Ultrasound ▪ Evaluate bladder size, prostate size, degree of hydronephrosis Cystoscopy ▪ Reveal bladder diverticula/calculi before scheduled invasive treatment Figure 130.1 An MRI scan of the abdomen and pelvis in the coronal plane demonstrating massive prostatic hypertrophy. The prostate extends past the pelvic brim and into the abdominal cavity. LAB RESULTS ▪ Urinalysis ▫ Microscopic hematuria may be present ▫ Pyuria, bacteriuria in case of concomitant UTIs ▪ Urine culture ▫ Exclude UTIs ▪ Blood tests ▫ Often ↑ prostate specific antigen (PSA) ▫ Electrolytes, blood urea nitrogen (BUN), and creatinine to evaluate for renal impairment OTHER DIAGNOSTICS ▪ Digital rectal examination ▫ Enlarged, nodular prostate Figure 130.2 The histological appearance of benign prostatic hyperplasia. There is a nodule of hyerplastic stromal tissue surrounded by hyperplastic smooth muscle. 800 OSMOSIS.ORG

Chapter 130 Penile, Prostate, & Testicular Disorders TREATMENT MEDICATIONS ▪ Alpha-adrenergic receptor blockers (terazosin, tamsulosin) → decrease prostate, bladder, urethral muscle tone ▪ 5-alpha reductase inhibitors (finasteride) decrease DHT synthesis → reduce prostate gland size ▪ Phosphodiesterase-5 enzyme inhibitors (e.g., tadalafil) → induce smooth muscle relaxation SURGERY ▪ Transurethral resection of prostate (TURP) ▪ Open prostatectomy OTHER INTERVENTIONS ▪ Mild cases ▫ Conservative measures; e.g. decrease fluid intake before bedtime/going out; avoid caffeine, alcohol (mild diuretic effects) CRYPTORCHIDISM osms.it/cryptorchidism PATHOLOGY & CAUSES ▪ Common congenital condition characterized by incomplete/partial descent of testis into scrotal sac ▪ AKA undescended testes ▪ Most cases resolve spontaneously during first year of life CAUSES ▪ Testicles normally develop in abdomen, descend into scrotal sac before birth ▫ Malpositioned testis usually found in inguinal canal but can be anywhere in descent pathway ▪ Impaired spermatogenesis at temperatures >37°C/98.6°F ▪ Leydig cells remain unaffected → normal testosterone levels ▪ Usually unilateral; bilateral in ¼ of cases ▪ Associated conditions ▫ Malformations of genitourinary tract (e.g. hypospadias), inguinal hernia RISK FACTORS Prematurity ↓ birth weight Twining 1st trimester maternal exposure to estrogens ▪ Family history of undescended testes ▪ Genetic syndromes associated with cryptorchidism (e.g. Down syndrome, Klinefelter syndrome) ▪ Disorders of sexual development (e.g. gonadal dysgenesis, ambiguous genitalia) ▪ ▪ ▪ ▪ COMPLICATIONS ▪ Testicular atrophy, dysfunction → infertility ▪ When malpositioned in inguinal canal → prone to trauma, testicular torsion ▪ Left untreated/treatment delayed → germcell tumors, especially seminoma, high risk; contralateral testis also at risk OSMOSIS.ORG 801

SIGNS & SYMPTOMS ▪ Asymptomatic ▪ One/both testes absent from scrotal sac ▪ Undescended testis can be palpable in abdomen LAB RESULTS ▪ ↑ FSH ▪ ↑ LH ▪ Usually normal testosterone; ↓ in bilateral cryptorchidism OTHER DIAGNOSTICS ▪ Physical examination ▫ Testis absent from scrotal sac Figure 130.3 An MRI scan of the abdomen and pelvis in the coronal plane demonstrating bilateral undescended testes. Figure 130.4 A CT scan of the pelvis in the axial plane demonstrating an undescended testicle in the right inguinal canal that has undergone malignant transformation. DIAGNOSIS DIAGNOSTIC IMAGING Ultrasound ▪ Used to localize testis 802 OSMOSIS.ORG TREATMENT SURGERY ▪ Treatment of choice ▫ Orchiopexy, preferably at 9–15 months ▫ Testis does not spontaneously descend → placed in scrotal sac

Chapter 130 Penile, Prostate, & Testicular Disorders EPIDIDYMITIS osms.it/epididymitis PATHOLOGY & CAUSES ▪ Inflammation of epididymis ▫ Due to infectious/non-infectious etiologies ▪ AKA epididymo-orchitis when testicle involved TYPES Infectious Non-infectious Idiopathic Acute ▫ < six weeks ▪ Chronic ▫ > six weeks ▪ ▪ ▪ ▪ CAUSES Mechanism of disease ▪ Urinary tract infection → vas deferens/ lymphatics of spermatic cord → epididymitis ▪ Hematogenous spread (rarely) Infectious ▪ Children ▫ Gram negative pathogens (e.g. E. coli) ▪ Adults (<35 years of age) ▫ Chlamydia trachomatis, Neisseria gonorrhoeae, Paramyxovirus (mumps) ▪ Adults (>35 years of age) ▫ Common urinary tract pathogens (e.g. E.coli, P. aeruginosa), tuberculosis Non-infectious ▪ Trauma ▪ Autoimmune diseases ▪ Vasculitis ▪ Medications (e.g. amiodarone) Idiopathic ▪ Cause unknown RISK FACTORS ▪ ▪ ▪ ▪ Congenital abnormalities of urinary tract ↑ sexual activity Anal intercourse Urinary tract obstruction COMPLICATIONS ▪ ▪ ▪ ▪ ▪ ▪ Hydrocele Abscess Fistulization Necrosis Chronic epididymitis Infertility SIGNS & SYMPTOMS ▪ Gradual onset ▫ Scrotal pain usually unilateral; sometimes radiates to lower abdomen with/without swelling ▫ Fever, chills ▫ Lower urinary tract symptoms (e.g. frequency, urgency, dysuria) ▪ Less common ▫ Urethral discharge, hematuria, hematospermia ▪ Normal cremasteric reflex ▫ Cremasteric muscle contraction → ipsilateral elevation of testicle ▪ Prehn sign ▫ Elevating scrotum relieves pain ▪ Reactive hydrocele can be present DIAGNOSIS DIAGNOSTIC IMAGING Color Doppler ▪ Enlarged, thickened epididymis with increased blood flow; excludes testicular torsion OSMOSIS.ORG 803

LAB RESULTS ▪ ▪ ▪ ▪ ▪ Leukocytosis Pyuria, bacteriuria Positive urine culture Gram staining of urethral discharge Culture,nucleic acid amplification testing (NAAT) of first-catch urine/urethral swab specimens for C. trachomatis, N. gonorrhoeae TREATMENT MEDICATIONS Infectious epididymitis ▪ Antimicrobial therapy ▪ Ceftriaxone, doxycycline to cover C. trachomatis, N. gonorrhoeae ▪ Ceftriaxone, quinolone for > 35 years old, individuals that have anal intercourse SURGERY ▪ Performed when findings are equivocal, testicular torsion cannot be ruled out OTHER INTERVENTIONS Figure 130.5 An ultrasound scan of the scrotum demonstrating increased bloodflow in the epididymis, consistent with epididymitis. Infectious, non-infectious epididymitis ▪ Rest ▪ Analgesia ▫ Hot or cold packs and/or analgesics (e.g. NSAIDs) ▪ Scrotal elevation Non-infectious epididymitis ▪ Treat underlying cause HYPOSPADIAS & EPISPADIAS osmosis.org/learn/hypospadias osmosis.org/learn/epispadias PATHOLOGY & CAUSES ▪ Congenital malformations characterized by abnormal urethral opening found ventrally (hypospadias), dorsally (epispadias) ▪ Hypospadias more common TYPES Hyposadias ▪ Glanular: least severe ▪ Midshaft: moderately severe ▪ Penoscrotal: most severe 804 OSMOSIS.ORG Epispadias ▪ Granular: least severe ▪ Penile: moderately severe ▪ Penopubic: most severe CAUSES Hyposadias ▪ Urethral folds along penile urethra do not close properly → abnormal opening along penile shaft’s ventral surface Epispadias ▪ Genital tubercle grows in posterior direction

Chapter 130 Penile, Prostate, & Testicular Disorders instead of cranial direction → opening along penis’ dorsal surface RISK FACTORS ▪ Family history of hypospadias/epispadias ▪ Genetic factors causing hormonal disturbances ▪ ↓ androgens ▪ Maternal age > 35 years old ▪ Maternal exposure to environmental toxins (e.g., pesticides on fruits and vegetables) COMPLICATIONS ▪ Constriction of abnormal opening → urinary tract obstruction ▪ High risk of ascending urinary tract infections ▪ If orifices are situated near base of penis → abnormal ejaculation and insemination → infertility ▪ Psychosocial problems SIGNS & SYMPTOMS ▪ Depends on location of abnormal urethral opening ▪ Difficulty urinating/incontinence Figure 130.6 The appearance of subcoronal hypospadias. DIAGNOSIS DIAGNOSTIC IMAGING Excretory urogram ▪ Series of X-rays used to visualize substances passing through kidneys, bladder, urethra OTHER DIAGNOSTICS ▪ Clinical examination of newborn infants to reveal abnormal urethral opening TREATMENT MEDICATIONS ▪ Hormone therapy for additional problems (e.g. low androgen levels → micropenis) SURGERY ▪ Reconstruction of urethra within first two years of life ▪ Infants with hypospadias should not undergo circumcision → foreskin may be useful for reconstruction Figure 130.7 A male neonate with epispadias due to non closure of the urethral plate during development. There is also congenital malformation of the external genitalia. OSMOSIS.ORG 805

ERECTILE DYSFUNCTION osms.it/erectile-dysfunction PATHOLOGY & CAUSES SIGNS & SYMPTOMS ▪ Sexual arousal disorder characterized by inability to obtain, maintain erection during sexual intercourse ▪ AKA impotence ▪ Inability to achieve erection suitable for penetration ▪ ↓ libido ▪ ↓ erection rigidity ▪ Inability to achieve orgasm and/or ejaculation ▪ Early ejaculation ▪ ↓ peripheral pulses ▪ ↓ sensation ▪ Small testicles ▪ Penile abnormalities (e.g. Peyronie’s disease, hypospadias) ▪ Nocturnal erections present in psychogenic erectile dysfunction (ED), absent in organic ED CAUSES ▪ Cardiovascular disease/peripheral artery disease → abnormal penile vasculature ▪ Drug side effects ▫ Antihypertensives, selective serotonin reuptake inhibitors (SSRIs), antipsychotics, nicotine, ethanol, betablockers, statins ▪ Psychogenic ▫ Performance anxiety, depression ▪ Neurological problems ▫ Prostatectomy surgery trauma, multiple sclerosis ▪ Penile disorders ▫ Peyronie’s disease, priapism RISK FACTORS ▪ ▪ ▪ ▪ ▪ ▪ ▪ ↑ age Hypertension Smoking Hyperlipidemia Diabetes Alcohol/drug abuse Hypogonadism (↓ testosterone levels) COMPLICATIONS ▪ ▪ ▪ ▪ 806 OSMOSIS.ORG ↓ sexual activity Inability to satisfy sexual partner(s) Psychosocial problems Infertility DIAGNOSIS DIAGNOSTIC IMAGING Duplex ultrasound ▪ Measures blood flow before and after injection of vasodilators LAB RESULTS Hormonal blood tests ▪ ↓ serum testosterone → hypogonadism ▪ Luteinizing hormone (LH) ▫ ↑ LH along with ↓ testosterone → testicular deficit ▫ ↓ LH along with ↓ testosterone → CNS deficit ▫ ↓ prolactin → pituitary dysfunction Other blood tests ▪ Detect risk factors for cardiovascular disease (e.g. glucose, lipids)

Chapter 130 Penile, Prostate, & Testicular Disorders OTHER DIAGNOSTICS ▪ Nocturnal penile tumescence testing to detect nocturnal erections ▪ Intracavernosal injection of prostaglandin E1 ▫ If adequate vasculature → erection in several minutes ▪ Detailed medical, drug history ▪ Physical examination ▪ Psychological testing release → penile smooth muscles relax → ↑ penile blood flow → erection ▪ Intracavernosal injections of vasodilators agents ▪ Hormonal replacement (e.g. androgens) in individuals with hypogonadism SURGERY ▪ Revascularization ▪ Implantation of prosthetic devices PSYCHOTHERAPY TREATMENT ▪ Reduce performance anxiety MEDICATIONS ▪ First line ▫ Phosphodiesterase (PDE) type 5 inhibitors (e.g. sildenafil citrate) ▫ 30–60 minutes before sexual intercourse ▫ Mechanism of action: inhibitions PDE5 → ↑ cGMP levels → ↑ nitric oxide OTHER INTERVENTIONS ▪ External facilitating devices (e.g. vacuum/ constriction devices) help obtain, maintain erection ▪ Treat underlying causes ORCHITIS osms.it/orchitis PATHOLOGY & CAUSES ▪ Inflammation of testicle secondary to infection ▪ May occur with epididymitis (epididymoorchitis) CAUSES SIGNS & SYMPTOMS ▪ Unilateral/bilateral testicular tenderness, pain, scrotal swelling ▪ Fever ▪ Reactive hydrocele ▪ Inguinal lymphadenopathy ▪ Most cases of isolated orchitis seen in children with viral mumps infection ▪ Viral causes may also include coxsackie B virus ▪ May also be caused by bacterial infections ▫ E.g. E. coli DIAGNOSTIC IMAGING COMPLICATIONS LAB RESULTS ▪ Atrophy ▪ Infertility ▪ Reactive hydrocele DIAGNOSIS Color Doppler ultrasound ▪ Exclude testicular torsion ▪ Serum immunofluorescence antibody testing → establish diagnosis OSMOSIS.ORG 807

OTHER DIAGNOSTICS ▪ Suggestive clinical findings of mumps/other infections TREATMENT OTHER INTERVENTIONS ▪ Usually resolves spontaneously after 3–10 days ▪ Conservative measures (e.g. rest, analgesics) Figure 130.8 The histological appearance of the testicular parenchyma in a case of suppurative orchitis. The seminiferous tubules have been almost completely destroyed and there is a massive neutrophilic infiltrate. PRIAPISM osms.it/priapism PATHOLOGY & CAUSES ▪ Involuntary, persistent erection unrelated to sexual stimulation, unrelieved by ejaculation ▪ Urologic emergency TYPES Low flow (ischemic) ▪ Decreased venous outflow; most common High flow (nonischemic) ▪ Increased arterial inflow CAUSES ▪ Often idiopathic/secondary Low flow ▪ Hypercoagulable state (e.g. sickle cell anemia, thalassemia) ▪ Neurologic disease (e.g. spinal cord stenosis) ▪ Metastatic disease (e.g. prostate cancer, bladder cancer) ▪ Medications relaxing smooth muscles (e.g. 808 OSMOSIS.ORG prostaglandin, hydralazine) High flow ▪ Penile/perineum trauma → rupture of cavernous artery rupture → fistulas between cavernosal artery, corpus cavernosum COMPLICATIONS ▪ Hypoxic damage → penile necrosis ▪ Erectile dysfunction ▪ Corporeal fibrosis → loss of penile length SIGNS & SYMPTOMS ▪ Persistent erection usually lasting 30 minutes to three hours Low flow ▪ Usually painful ▪ Rigid erection ▪ Corporeal aspiration → dark blood

Chapter 130 Penile, Prostate, & Testicular Disorders High flow ▪ Not painful ▪ May be episodic ▪ Trauma evidence TREATMENT MEDICATIONS Low flow ▪ Intracavernosal injection of sympathomimetic agent ▫ Phenylephrine → pure alpha agonist effects DIAGNOSIS DIAGNOSTIC IMAGING Doppler ultrasound ▪ Differentiate low/high flow priapism, reveal fistulas CT scan ▪ Detect malignancies LAB RESULTS ▪ Penile blood gas measurement ▫ Low flow: increased pCO2, decreased pO2, pH less than 7.0 ▪ Complete blood count (CBC) ▫ Detect sickle cell anemia ▪ Selective angiography ▫ Identify exact location of fistulas SURGERY Low flow ▪ If other measures fail → surgical decompression High flow ▪ Identification, obliteration of fistulas with selective arterial embolization OTHER INTERVENTIONS Low flow ▪ Treat underlying condition ▪ Corporal aspiration with/without saline irrigation PROSTATITIS osms.it/prostatitis PATHOLOGY & CAUSES ▪ Prostate gland inflammation; usually → Gram-negative bacterial infection TYPES Acute bacterial prostatitis ▪ Usually occurs in younger individuals ▪ More serious condition Chronic bacterial prostatitis ▪ Can be bacterial/abacterial ▪ Usually occurs in individuals aged 40–70 years ▪ Chronic bacterial is the most common form of prostatitis Granulomatous prostatitis ▪ Infectious ▪ Bladder injections of Bacillus Calmette– Guérin (BCG) for treatment of bladder cancer (most common cause) ▪ Fungi in immunocompromised individuals ▪ Noninfectious ▪ Reaction to secretions from prostatic ducts and acini ▪ Acute granulomatous prostatitis ▫ Older adults: Gram bacteria—E.coli (most common), Klebsiella, Proteus, Pseudomonas, Enterobacter, Serratia ▫ Enterococci OSMOSIS.ORG 809

▫ Staphylococci ▫ Young adults: Chlamydia trachomatis, Neisseria gonorrhoeae ▪ Chronic granulomatous prostatitis ▫ Infectious: same causes as acute granulomatous prostatitis ▫ Noninfectious: chemical irritation; secondary to previous infections, nerve problems CAUSES ▪ ▪ ▪ ▪ Ascending urinary tract infection Spread from rectum (direct/via lymphatics) Hematogenous (rare) May follow catheterization, cystoscopy, urethral dilation, prostate resection procedures COMPLICATIONS ▪ Urinary retention ▪ Recurrent exacerbations in chronic prostatitis are common ▪ Prostatic abscess; usually in immunocompromised individuals ▪ Urosepsis; can be fatal ▪ Pyelonephritis ▪ Infertility SIGNS & SYMPTOMS Acute ▪ Fever, chills ▪ Malaise ▪ Urinary symptoms ▫ Frequency, urgency, dysuria ▪ Perineal/low back pain ▪ Digital rectal exam ▫ Boggy, warm, tender, enlarged prostate Chronic ▪ Can be asymptomatic ▪ Intermittent urinary symptoms ▪ History of recurrent UTIs ▪ Perineal/low back pain; suprapubic discomfort ▪ Digital rectal examination ▫ Enlarged, nontender prostate DIAGNOSIS DIAGNOSTIC IMAGING Ultrasound/CT scan/cystoscopy ▪ For individuals with significant voiding dysfunction/suspected abscesses/ neoplasms LAB RESULTS Figure 130.9 The histological appearance of acute prostatitis. There are neutrophils present within the lumina of the prostatic glands. 810 OSMOSIS.ORG ▪ Urinalysis ▫ ↑ WBCs in acute ▪ Prostatic secretion ▫ ↑ WBCs in acute and chronic ▪ Urine cultures ▫ Positive in acute, chronic bacterial prostatitis ▫ Negative in chronic abacterial ▪ Blood tests ▫ CBC, blood cultures if clinical findings suggestive of bacteremia ▫ Blood urea nitrogen, creatinine levels for individuals with urinary retention/ obstruction ▫ Serum prostate-specific antigen (PSA) may be elevated

Chapter 130 Penile, Prostate, & Testicular Disorders TREATMENT MEDICATIONS Acute ▪ Antimicrobial therapy ▫ IV broad-spectrum penicillin, third generation cephalosporin, aminoglycoside, quinolone ▫ PO antibiotics (TMP/SMX or quinolone, doxycycline) ▪ Urinary retention ▫ Alpha-blocking agents/suprapubic catheterization OTHER INTERVENTIONS Acute ▪ Increase fluid intake ▪ Drain abscesses ▪ Prostatic massage should be avoided to prevent hematogenous spread (sepsis) Chronic ▪ Antimicrobial therapy ▫ Prolonged course, usually with quinolone ▪ Chronic prostatitis difficult to treat because antibiotics penetrate prostate gland poorly → recurrences common Figure 130.10 An MRI scan of the pelvis in the coronal plane demonstrating a large prostatic abscess secondary to prostatitis. TESTICULAR TORSION osms.it/testicular-torsion PATHOLOGY & CAUSES ▪ Vascular disorder of testis characterized by rotation of testicle around spermatic cord ▪ Can lead to testicular infarction ▪ Urologic emergency ▪ Rotation of testicle → thick walled arteries remain patent while thin walled veins become obstructed → congestion → hemorrhagic infarction RISK FACTORS ▪ Typically occurs in young adolescents; can also occur in neonates/older individuals ▪ Usually → testes’ congenital failure to strongly attach to scrotum ▪ Occasionally → trauma; also → during sleep COMPLICATIONS ▪ If left untreated/surgery delayed beyond six hours → testicle may not be salvageable → infertility ▪ Recurrent torsions ▪ Contralateral testicle also → torsion risk ▪ Infection ▪ Orchiectomy → cosmetic malformation → psychosocial problems OSMOSIS.ORG 811

SIGNS & SYMPTOMS ▪ Sudden onset of acute, severe pain ▪ Swollen, tender, erythematous scrotum ▪ High riding testis ▫ Moves to a higher scrotal position ▪ Absent cremasteric reflex ▪ Nontender cord DIAGNOSIS TREATMENT SURGERY ▪ Immediate surgical detorsion → best within six hours from onset of symptoms ▪ Orchiopexy of testis to scrotum → prevent recurrence ▫ Orchiopexy of contralateral testis also indicated ▪ If testicle non-salvageable → orchiectomy DIAGNOSTIC IMAGING ▪ Unnecessary if clinical findings are strongly suggestive; surgical detorsion should not be delayed Color Doppler ultrasound ▪ Absent or decreased blood flow in affected testicle Contrast enhanced MRI ▪ Torsion knot or whirlpool patterns; highly sensitive and specific LAB RESULTS ▪ Can help exclude alternate diagnosis (e.g. orchiepididymitis) Figure 130.11 A Doppler ultrasound of the testicles demonstrating complete absence of blood flow on the right side, consistent with testicular torsion. VARICOCELE osms.it/varicocele PATHOLOGY & CAUSES ▪ Common testicular disorder of young adults characterized by dilatation of pampiniform venous plexus, internal spermatic vein ▪ Most common cause of scrotal enlargement in young adults ▪ Impaired venous drainage → ↑ venous pressure → vein dilatation 812 OSMOSIS.ORG ▪ Usually left-sided (> 80%) due to ↑ flow resistance from left testicular vein drainage into left renal vein; right testicular vein drains directly to inferior vena cava (↓ flow resistance) TYPES Large ▪ Easily identified by inspection as distention

Chapter 130 Penile, Prostate, & Testicular Disorders Moderate ▪ Identified by palpation as “bag of worms” Small ▪ Identified only by bearing down → ↑ abdominal pressure → impeding drainage → ↑ varicocele size TREATMENT SURGERY ▪ Indicated if varicocele associated with discomfort/pain, testicular atrophy, infertility ▪ Surgical ligation/embolization CAUSES ▪ Idiopathic ▪ Retroperitoneal pathology (e.g. renal cell carcinoma) → can invade renal vein → leftsided varicocele COMPLICATIONS ▪ Significant impairments in sperm production, quality due to ↑ heat, ↑ pressure, ↓ oxygen, release of toxins ▫ ↓ sperm concentration ▫ ↓ motility ▫ Abnormal morphology of spermatozoa ▪ Testicular damage, atrophy, poor sperm production, quality → infertility ▪ Contralateral testicle can also be affected Figure 130.12 A Doppler ultrasound of the scrotum demonstrating avid flow within the spermatic cord; an appearance typical of a varicocele. SIGNS & SYMPTOMS ▪ Usually asymptomatic ▪ Symptomatic ▫ Scrotal heaviness or scrotal pain DIAGNOSIS DIAGNOSTIC IMAGING Doppler ultrasound ▪ Characteristic reverse blood flow Ultrasound/ CT scan ▪ May be useful in right-sided varicocele → reveals retroperitoneal pathology LAB RESULTS Figure 130.13 The clinical appearance of a varicocele of the right scrotum. There are dilated veins visible on the scrotal surface. ▪ Semen analysis ▫ Impairment in semen parameters (e.g. concentration, motility, morphology) OSMOSIS.ORG 813