Clinical Medicine 216 - Male Pelvic Pain
What are the most urgent causes of male pelvic pain you should rule out?
Testicular torsion, testicular cancer, and epididymitis
What are less likely, but serious conditions that you should consider in a male patient presenting with pelvic pain?
Appendicitis, peritonitis, Fournier’s gangrene, abdominal aortic aneurysm rupture, and an incarcerated inguinal hernia
What is Fournier's gangrene?
An acute gangrenous infection of the scrotum, penis, or perineum following local trauma, operative procedures, an underlying urinary tract disease, or a distant acute inflammatory process
What is an incarcerated inguinal hernia?
When part of the fat or small intestine from inside the abdomen becomes stuck in the groin or scrotum and cannot go back into the abdomen by manipulation
What are the most common causes of acute scrotal pain?
Torsion of a testicular appendage, testicular torsion, and epididymitis-orchitis
What is testicular torsion?
Twisting of the spermatic cord that results in reduction of cessation of blood flow to the testicle. Torsion can be from 180 to 720 degrees; the more degree of torsion the more rapid the onset of ischemia
What is a serious sequelae of testicular torsion?
Ischemia and loss of testis
There is a ________ chance of salvaging the testicle when ischemia has been present for less than 6 hours, which decreases to ________ at 12 hours and ________ at 24 hours.
90%, 50%, 10%
What is a predisposing factor or testicular torsion?
What is Bell-clapper deformity?
Failure of normal posterior anchoring of the gubernaculum, epididymis, and testis leaving the testis free to swing and rotate within the tunica vaginalis of the scrotum
Clinical presentation of testicular torsion?
Acute, severe pain (most present within 6 hours of onset), nausea and vomiting, recurrent episodes, and scrotal edema and erythema depending on duration and degree of torsion
Clinical signs of testicular torsion?
Generalized tenderness of scrotum, absence of cremasteric reflex, elevated testis position, horizontal lie, abnormal epididymis position, pain unrelieved by scrotal elevation, and thickened cord (from twist)
What are the investigations for testicular torsion?
Colour doppler ultrasound and surgical exploration
What is the treatment for testicular torsion?
Orchidopexy or orchiectomy (if testis is not viable)
What is orchidopexy?
Surgical treatment of an undescended testicle by freeing it and implanting it into the scrotum; or surgical anchoring of a testis susceptible to torsion in the scrotum
What is orchiectomy?
Excision of one or both testes, done when a testis is seriously injured or diseased (as in testicular cancer)
What is extravaginal testicular torsion?
When testis, spermatic cord, and tunica vaginalis go through torsion, usually before tunica vaginalis and dartos become fixed to each other; happens in newborns only, often before birth (latest case reported was 9 months).
Symptoms of testicular cancer?
Usually a painless palpable mass on the testis, can have diffuse (dull, heavy) pain, swelling or hardness in the scrotum, and infertility
Signs of testicular cancer?
Hard, palpable mass in scrotum. A hydrocele may accompany testicular cancer and impair the examiner's ability to evaluate the testis
Lab tests for testicular cancer or before an orchiectomy include?
Alpha-fetoprotein (AFP), β-hCG, and lactate dehydrogenase (LDH).
Elevation of what lab tests are found in nonseminoma tumours?
Alpha-fetoprotein (AFP) and β-hCG.
Elevation of what lab tests are found in seminoma tumours?
Reproductive endocrine and semen parameters are not significantly affected in?
What may be affected if chemotherapy is used or if nerve damage from surgery is sustained in treatment of testicular cancer?
Fertility, but keep in mind that subfertility is already associated with testicular cancer before treatment
What are testicular appendages?
Appendix testis and appendix epididymis. These can be pedunculated, thus prone to torsion
What are the early signs of testicular appendage torsion?
Can have 'blue dot' sign, usually a small nodule fixed above the testis, symmetrical cremasteric reflex, and palpable epididymal landmarks
What is the treatment for torsion of testicular appendages?
Limit activities and NSAIDS prn (when needed). The condition usually resolves spontaneously within 2 to 3 days, and any necrotic tissue gets reabsorbed
What are strangulation hernias?
Incarcerated hernia that has compromised blood supply to herniated structures, which can lead to gangrene
What is an inguinal hernia that usually occurs as a consequence of a defect or weakness in the transversalis fascia area of the Hesselbach triangle? The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon.
Direct inguinal hernia
What is an indirect inguinal hernia?
An inguinal hernia that follows the tract through the inguinal canal
What is a hydrocele?
A collection of serous fluid in a sacculated cavity; specifically, a collection of fluid in the space of the tunica vaginalis testis, or in a separate pocket along the spermatic cord
What is a varicocele?
An abnormal dilation and tortuosity of the internal spermatic veins in the scrotum
What is orchitis?
An acute inflammatory reaction of the testis secondary to infection. Most cases are associated with a viral mumps infection; however, it can be caused by other viruses and bacteria
What is likely to occur if bilateral mump orchitis develops?
What is Henoch-Schönlein purpura (HSP)?
An acute immunoglobulin A (IgA)–mediated disorder characterized by a generalized vasculitis involving the small vessels of the skin, the gastrointestinal (GI) tract, the kidneys, the joints, and rarely the lungs and the central nervous system (CNS)
What are some common features of Henoch-Schönlein purpura (HSP)?
Characteristic palpable purpuric rash, abdominal pain with gastrointestinal bleeding, arthritis with refusal to bear weight. Can have renal involvement, usually not evident until several weeks after the initial symptoms. Can cause subcutaneous and scrotal edema.
What is a 'fractured' testis?
This happens when the tunica albuginea has been compromised and testicular contents come out
What is orchialgia?
In men 14 to 35 years of age, epididymitis is most commonly caused by?
Chlamydia or gonorrhea
In males younger than 14 or older than 35, epididymitis is most commonly caused by?
Urinary coliform pathogens; including Escherichia coli
What is cryptorchidism?
It is the most common genital problem encountered in pediatrics, and refers to an undescended or maldescended testis
What are the most serious sequelae of cryptorchidism?
Increased risk (and difficult detection) of testicular cancer, subfertility, increased risk of testicular torsion, and increased risk of inguinal hernia
What can cause diffuse male pelvic pain?
Testicular torsion, varicocele, and hydrocele
What can cause pain in the epididymis?
Epididymitis, epididymal cyst, or post-vasectomy pain
What can cause sharp male pelvic pain?
Testicular torsion or torsion of a testicular appendage
What can cause dull achy male pelvic pain?
Varicocele or a hydrocele
What can cause severe male pelvic pain?
Testicular torsion, strangulated inguinal hernia, and Fournier’s gangrene
What can cause male pelvic pain associated with a fever?
Epididymitis, testicular torsion, trauma, appendicitis, and Fournier’s gangrene
What can cause male pelvic pain associated with hematuria?
What can cause male pelvic pain associated with hematospermia?
What can cause male pelvic pain with nausea and vomiting?
Testicular torsion, trauma, appendicitis and/or peritonitis
What can cause male pelvic pain with scrotal swelling?
Epididymitis, testicular torsion, torsion of testicular appendage, trauma, hydrocele, varicocele, epididymal cyst, inguinal hernia, or mumps
What can cause male pelvic pain and associated abdominal pain?
Testicular torsion, torsion of testicular appendage, Fournier’s gangrene, and Henoch-Schonlein purpura
What is the cremasteric reflex?
Contraction of the ipsilateral cremaster muscle, drawing the testis upward, when the upper inner aspect of the thigh is stroked longitudinally
What is acute pelvic pain?
Pain symptoms below the umbilicus that have been present for < 3 months
What is chronic pelvic pain?
Non-menstrual pain below the umbilicus of at least 3 months in duration
What is a deep pain below the umbilicus that occurs with sexual intercourse?
The most serious causes of pelvic pain usually present ________ .
Chronic pelvic pain is usually _________ .
Radiation from the epigastrium or periumbilical area to the right lower quadrant is suggestive of ________ .
Colicky flank pain that radiates to the anterior abdomen is suggestive of ________ .
Urinary stone disease
The most distressing symptom of interstitial cystitis is __________ .
Urgency and increased frequency of urination
History taking of pelvic pain should include ________ consideration.
Gastrointestinal, urologic, psychological, and gynecologic (female)
Remnants of mullein duct system located on the testicle or epididymis are known as _________ .
A cyst at the head of the epididymis is called an __________.
What is a large spermatocele?
A large epididymal cyst > 2cm
What is known as a severe subcutaneous tissue bacterial infection of the perineum spreading from skin to muscle and underlying structures, causing death of infected tissue?
Appendix testes, appendix epididymis, vas aberrans, and the paradidymis are known as the _________ .
4 testicular appendages
Varicocele, hydrocele, epididymis cyst/spermatocele, inguinal hernia, testicular cancer, epididymitis, post vasectomy, retroperitoneal tumour, neurogenic causes (pudendal nerve entrapment, etc.), and chronic scrotal pain syndrome (idiopathic) are differential diagnosis of _________ .
Non-acute scrotal pain
The more acute, diffuse, and severe the scrotal pain is, the more likely it is due to a __________ cause requiring _________ evaluation.
A benign cause of pelvic pain with _________ is epididymitis .
Nausea and vomiting
Testicular torsion can present with pain that is _________ .
Recurrent that resolves spontaneously
Pain from a varicocele is usually ________ .
What is an enlargement or swelling of breast tissue in males? It is most commonly caused by male estrogen levels that are too high or are out of balance with testosterone levels.
When a male patient presents with gynecomastia, what other serious condition should you think about?
When a male patient presents with arthralgia, what other serious condition should you think about?
Henoch-Schonlein purpura (HSP)
Henoch-Schonlein purpura (HSP) is a disease involving inflammation of _________ . It most commonly occurs in children. The main symptom is a rash with numerous small bruises, which have a raised appearance, over the legs or buttocks.
With Henoch-Schonlein purpura (HSP), _________ causes blood vessels in the skin, intestines, kidneys, and joints to start leaking.
Epididymitis and trauma can result in ________ .
With male pelvic pain, you should also ask about ________ .
Sexual history (current or previous STI's, recent sexual contacts, types of sexual practices, etc.)
With a sexually transmitted infection, physical exam should focus on the _________ area, often the genitalia.
Examination of the ________ may be an important component of examination, particularly in the case of syphilis or gonorrhoea.
Skin and lymph nodes
Evidence of septic arthritis on examination of symptomatic joints may indicate ________ .
Gonococcal arthritis and disseminated gonococcal infection
An infection with chlamydia or gonorrhoea is often ________ .
An infection with chlamydia can also cause ________ .
Urethritis, cervicitis (female), epididymitis, prostatitis, proctitis, and pelvic inflammatory disease (PID) (female)
With chlamydia, the most common infection for men is urethritis with _________ discharge.
With gonorrhoea, the most common infection for men is urethritis and it presents with dysuria, an erythematous meatus, and penile discharge, which is often ________ .
With trichomoniasis, men are often asymptomatic, and rarely do men report purulent ________ .
Patients with _________ genital lesions should be considered to have an STI and should be tested and treated accordingly.
Patients with suspected gonorrhoea infection also should be treated for _________ infection.
Chlamydia is the major cause of prostatitis and nongonococcal urethritis in men younger than _________ .
Patients with benign prostatic hyperplasia (BPH) are more prone to urinary tract infections (UTI's) and __________ .
Kidney and bladder neoplasms often produce painless _________ .
Immunocompromised patients are susceptible to overwhelming infections by both common and atypical organisms, and ________ investigation is warranted.
Hematuria and pain usually indicates the passage of a _________ , and often presents with concurrent infection.
Stone or sloughed renal papilla
Prostate pain is often interpreted by the patient as a vague __________ .
Ache in the perineal area
Discomfort in the __________ area is indicative of bladder involvement, whereas, urinary incontinence is characteristic of __________ irritability caused by inflammation.
Suprapubic; bladder neck
The __________ scrotal sac usually hangs lower that the ________ .
_________ of an affected testicle may relieve discomfort, known as a positive ________ , and is characteristic of epididymitis.
Elevation; Prehn sign
In testicular torsion, elevation of the affect testicle ________ to relieve discomfort, known as a _________ .
Fails; negative Prehn sign
________ testing is available for chlamydia and gonorrhoea as well as other organisms.
Tumour markers, such as _________ may be used to detect or monitor prostate cancer.
Prostate-specific antigen (PSA)
Prostate-specific antigen (PSA) levels higher than ________ or above are abnormal, and are suggestive of malignant activity of the prostate.
_________ suggests pyelonephritis.
White cell casts
Many calculi are ________ and may only cause hematuria, either microscopic or gross.
The patient with _________ is obviously ill, and presents with chills, high fever, urinary frequency and urgency, perineal pain, and low back pain.
Acute bacterial prostatitis
On examination of the prostate gland in acute bacterial prostatitis, the gland is ________ . Do not massage the gland because bacteremia can result from the expression of microorganisms.
Swollen, tender, indurated, and warm
Chronic prostatitis/chronic pelvic pain syndrome (CPPS), is pelvic pain that has been present for at least ________ of the last _________ months with no bacterial cause.
The pain from chronic prostatitis/chronic pelvic pain syndrome (CPPS) may be accompanied by additional symptoms such as ________ .
Dysuria, urgency, frequency, and backache
Lymphatics from the penile and scrotal surfaces drain into the________ . The lymphatics of the testes drain into the ________ , where enlarged nodes are clinically undetectable.
Inguinal nodes; abdomen
________ are more likely to present as emergencies with bowel incarceration or strangulation.
________ is a tight prepuce that cannot be retracted over the glans. ________ is a tight prepuce that, once retracted, cannot be returned. Edema ensues.
________ is inflammation of the glans; ________ is inflammation of the glans and prepuce.
Induration along the _______ surface of the penis suggests a urethral stricture or possibly a carcinoma. Tenderness in the indurated area suggests________ inflammation secondary to a urethral stricture.
The appearance of ________ presents as: single or multiple papules or plaques of variable shapes; may be round, acuminate (or pointed), or thin and slender. May be raised, flat, or cauliflowerlike (verrucous).
Genital warts (condylomata acuminata)
The appearance of ________ presents as: small scattered or grouped vesicles, 1 to 3 mm in size, on glans or shaft of penis. Appears as erosions if vesicular membrane breaks.
Genital Herpes Simplex
The appearance of ________ presents as: small red papule that becomes a chancre, or painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3 to 8 weeks.
The appearance of ________ presents as: red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins; contains necrotic exudate, has a friable base.
Urethritis in males related to a sexually transmitted infection (STI) is classified as either _________ .
Gonococcal or nongonococcal
With an sexually transmitted infection (STI), for patients with a single exposure, a ________ incubation period is characteristic for N. gonorrhoea, and a _________ period for chlamydia.
Short (2 to 6 days); longer (2 to 3 weeks)
A ________ glans penis is indicative of a yeast infection or a fixed drug reaction often caused by tetracycline.
Normally, no ________ are present, except for the commonly found yellowish sebaceous cysts. These can be 1 cm nodules that are firm, non-tender, and often multiple.
________ fluid does transilluminate and shows as a red glow (e.g., hydrocele or spermatocele). ________ do NOT transilluminate (e.g., hernia, epididymitis, or tumour).
Serous; solid tissue and blood
The prostate gland goes through two main periods of growth (i.e., during puberty, and starting around 25 years of age). The male prostate gland ________ during most of the man's life, and rarely causes symptoms before the age of ________ .
Continues to grow; 40
The symptoms of _______ and ________ can be very similar including hesitant, interrupted, or weak urinary stream; urinary urgency; leaking or dribbling; and increased frequency of urination (especially at night).
Benign prostatic hyperplasia; prostate cancer
What is prostate-specific antigen (PSA)?
A substance made by the normal prostate gland, and when cancer develops, the PSA level increases. However, benign or non-cancerous enlargement of the prostate (BPH), age, and prostatitis can also cause PSA to increase.
________ causes a temporary increase in PSA levels, and men need to be instructed to abstain from ________ for 2 days prior to having their PSA levels tested.
There are also ________ that can falsely lower PSA levels.
Medications (e.g., finasteride and dutasteride)
It is recommended that both ________ and a _________ be done together when screening for prostate cancer. As ________ can sometimes find cancers in men with normal _______ levels.
PSA level testing; digital rectal examination (DRE); DRE; PSA
A red-brown half-moon shape with well defined borders within the crural fold, not extending to the scrotum is known as _______ .
Jock itch (Tinae cruris)
A ________ begins within 2 to 4 weeks of infection, as a small, solitary silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. Palpation reveals a non-tender base that can be lifted up like button. Lymph nodes enlarge early but are non-tender.
________ begins as a red, raised, warty growth or as an ulcer, with watery discharge, and as it grows it may necrose and slough. It is usually painless, almost always on the glans or inner lip of the foreskin, and following chronic inflammation. Enlarged lymph nodes are common.
With hypospadias, the newborn infant should not be ________ because surgical correction may use the ________ tissue to extend urethral length.
A ________ tumour of the testicle maintains the shape of testis. It does not transilluminate, is non-tender, firm, and can be smooth. Firm palpation does not cause usual sickening discomfort as with a normal testis.
With a varicocele, there is dull pain, constant pulling or dragging feeling, or it may be asymptomatic. On palpation it has a distinctive feel like a ________ .
Bag of worms
A ________ is a retention cyst in the epididymis. It is filled with thin, milky fluid that contains sperm. Most are small < 1cm, painless, freely movable, round, and transilluminate. If large, it can feel like a third testicle.
A ________ is a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testicle. It is a painless swelling, and transilluminates with a pink or red glow. On palpation, the examiner is able to get fingers above the mass (in contrast to a scrotal hernia).
With a ________ , there is swelling, usually pain with straining, and it does not transilluminate. Palpating fingers cannot get over the mass.
An _________ hernia herniates through the internal inguinal ring; it can remain in the canal or pass into the scrotum. There can be pain with increased straining, and pain may decrease when lying down.
A ________ hernia herniates directly behind and through the external inguinal ring above the inguinal ligament. It rarely enters the scrotum. It is usually painless, round, with a swelling close to the pubis.
A ________ hernia herniates through the femoral ring and canal below the inguinal ligament, and is more often on the right side. Pain may be severe, and it may become strangulated.
On digital rectal examination (DRE), an enlarged, firm, smooth prostate gland with central groove obliterated suggests ________. A swollen, exquisitely painful tender gland suggests ________ . A stone-hard, irregular, fixed nodule indicates ________ .
Benign prostatic hypertrophy; prostatitis; carcinoma