abrupt onset of scrotal, inguinal, or lower abdominal pain (usually < 6h), +- N/V.  

If N/V presents, suspect torsion

(N/V usually absent in epididymitis)

swollen, tender, retracted testicle (+- horizontal lie)

negative Prehn's sign (no pain relief w/ scrotal elevation)

absent (negative) cremasteric reflex

scrotum usualy not swollen

blue dot sign @ upper pole = torsion of appendix of testis

1. testicular doppler u/s : best initial test, avascular testicle (decreased blood flow)

2. radionucleotide scan: gold standard. +- emergency exploration

detorsion & orchiopexy w/n 6h & in obvious cases

orchiectomy if not salvageable

d/t incomplete obliteration of the processus vaginalis

congenital defects usually close w/n 1st yr of life 

may not require treatment 

usually acquired

represent injury, infection, or inflammatory etiology 

painless scrotal swelling (may increase throughout day)

+- dull ache or heavy sensation

communicating: swelling worse w/ valsalva

must r/o testicular tumor (also painless)

usually no treatment needed

aspiration of fluid if compressive 

varicocele

(seen in 30% of infertile men b/c the increased temperature from the increased venous blood flow inhibits spermatogenesis)

"bag of worms" superior to testicle

dilation usually decreases when pt is supine or w/ testicular elevation

usually painless but +- cause a dull ache or heavy sensatiion

 surgery in some cases

genetics

diet: high fat intake

obesity

African americans

Adenoma > 95%

1. often asx until invasion of bladder, urethral obstruction, or bone involvement

2. urethral obstruction: increased urinary frequency, urgency, decreased urinary stream, urinary retention

3. back pain/bone pain

METs to bone, weight loss

(bone/back pain)

via DRE & PSA done if >= 59

African-Americans or family hx >= 40

1. increased prostate specific antigen (PSA)

2. DRE: hard, nodular, enlarged asymmetrical prostate

3. U/S w/ needle bx. if PSA >4. If >10 then bone scan to r/o METS. Gleason grading

10

increased likelihood for prostate cancer & METS

radical prostatectomy

+- active surveillance if low grade

S/E: incontinence & impotence 

external beam radiation therapy, androgen deprivation (orchiectomy + GnRH agonists)

if bone pain/METS --> localized XRT, crytherapy

polycystic kidney disease

vasopressin stimulates cytogenesis --> ESRD over time

1. abdominal/flank pain: may be d/t infection, nephroliasis, or bleeding into cyst.
2. palpable flank mass: large palpable kidneys on PE
3. HTN, hepatomegaly, hematuria, decreased urine concentrating ability, microalbuminuria
4. extrarenal: cerebral "berry" aneurysms, hepatic cysts, mitral valve prolapse, colonic diverticula

1. renal u/s : most widely used test. genetic testing also
2. CT scan: MRI : more sensitive than renal U/S

1. simple cyst: observation, periodic reevaluation
2. multiple: supportive, increased fluid intake - fluids decreases vasopressin (less cytogenesis), control HTN. +- need dialysis or renal transplant 

• heaviness & dull, aching discomfort in the affected hemiscrotum which can radiate up to the ipsilateral flank
• hx of patient may reveal heavy lifting, trauma, or sexual activity
• epididmyis is markedly swollen & exquisitely tender to touch, eventually becoming a warm, erythematous, enlarged scrotal mass
• as disease progressies, it may become difficult to distinguish the testes from the epididymis
• matient may have fever and chills

relief of pain with scrotal elevation

epididymitis

UA reveals pyruia and bacteriuria

cx show positive results for suspected organisms

• in men < 35, ceftriaxone 250 mg IM + doxy 100 mg BID or azithromycin 1 g orally x 3 days.  Test for cure should be done 1 week after conclusion of therapy
• in men > 35, ciprofloxacin 500 mg BID x 10-14 days
• supportive care - rest, scrotal elevation, & analgesics

• exposure to tobacco
• occupational carcinogens from rubber, dye, printing, & chemical industries
• schistosomiasis
• exposure to cyclophosphamide
• chronic infections

transitional cell carcinomas (TCC) 

bladder Ca is more common in men 40-70

painless hematuria MC presenting symptom

bladder irritability & infection other presenting symptoms

• CBC & blood chem - evaluate for infection & renal fxn
• cystoscopy - definitive diagnostic procedure. Bx confirms pathologic dx
• radiologic procedures include IV urogram, pelvic & abd CT, chest radiography, bone scan, & retrograde pyelography for renal pelvic or ureteral tumors & staging

• depends on stage
• superficial lesions - endoscopic resection and fulguration, followed by cystoscopy every 3 months
• recurrent or multiple lesions - treated w/ intravesicular instillation of thiotepa, mitomycin-C, or bacillus Calmette-Guerin (BCG)