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73 Cards in this Set

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Scrotal Transillumination

Scrotal lesions that transilluminate include hydrocele, spermatocele, and varicocele

Hydrocele, observed via scrotal transillumination

Testicular torsion

Acute, unilateral scrotal pain usually occurring in adolescents due to sudden twisting of spermatic cord producing testicular ischemia.


Involved testicle is tender, edematous and indurated


Elevation of testicle does not relieve pain.


Reduced blood flow via doppler US; requires immediate surgery.

US: Testicular torsion with reduced blood flow to left testicle. Will become ischemic if not fixed in <6 hrs


Differential diagnosis: acute epididymitis, renal stone, incarcerated hernia

Deformity which predisposes males for testicular torsion

Bell clapper deformity: tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate

Testicular mass/nodule

Non-tender, solid testicular mass; assumed to be cancer until proven otherwise.




Testicular cancer is the most common solid cancer in men 15-35 yrs of age

Varicocele

Dilatation of pampiniform plexus of spermatic veins causes scrotal enlargement that feels like "bag of worms"


Disappears when lying down (recumbence)


On exam: cannot find sup. margin of lesion


Usu. asymptomatic; more common on left side


Can cause infertility; may signal renal cell carcinoma if cancer invades L renal vein, impedes L testicular venous drainage

Varicocele


Tortuous veins visible on examination


On palpation, feels like "bag of worms"


May be assoc. w/ renal cell carcinoma. Can cause infertility.


Common (15-20% in post-pub. males)


"Nutcracker" syndrome: L renal vein compression by sup. mes. artery/aorta-->varicocele/hematuria

Genital wart

Reflects HPV infection (STD)


HPV infection is also a risk factor for penile carcinoma

Genital warts on upper shaft of penis

Herpes simplex lesion

Usu. occurs as multiple painful vesicles


Due to HSV-2 infxn (most commonly)


Primary infxn: ~6 days post-exposure


-Very painful; assoc. w/ dysuria, fever, inguinal adenopathy, headache, occ. viral meningitis


Recurrent dz: milder symptoms, occ. lesions


Asymp. pt's may shed virus, transmit dz w/ sexual contact (70% attack rate in sero(-) people)

HSV-2 lesions


Painful vesicles on head and shaft of penis

Paraphimosis

Inability to replace retracted foreskin


Usu. very painful, unless there is severe neuropathy


Considered a medical emergency: increasing penile edema-->penile ischemia/necrosis

Paraphimosis


Risk in uncircumsized men


Considered a risk factor for penile cancer


Considered a medical emergency

Penile cancer

Squamous cell carcinoma (most)


Begins as painless papule that progresses


HPV DNA in 30-50% of lesions

Penile cancer on head


Usu. squamous cell carcinoma


Progresses from painless papule


Assoc. w/ HPV in 30-50% of cases

Phimosis

Inability to retract foreskin


Strong risk factor for squamous cell carcinoma of the penis


May use topical steroid cream

Phimosis


Strong risk factor for squamous cell carcinoma of penis


Treat with circumcision

Syphilitic chancre

Painless lesion occurring ~21 days after exposure


Reflects site of spirochete entry (Treponema pallidum)


Solitary papule-->ulceration (indurated, w/out exudate)


Heals in 4-8 weeks w/out treatment

Syphilitic chancre (primary syphilis)


Painless, indurated ulcer without exudate


Occurs ~21 days post-exposure


Heals in 4-8 weeks w/out treatment

Hydrocele

Fluid-filled sac (often painless) surrounding a testicle, causing scrotal swelling


Common in newborns; usu. disappears w/out intervention in 1st yr of life (comm v. non-comm)


May form in reaction to infection or injury


Will cause scrotal transillumination



Spermatocele

Abnormal sac which develops in epididymis


Usu. filled with clear/milky fluid


Usu. asymptomatic unless it becomes large enough to cause discomfort

Spermatocele


Can be observed via transillumination or ultrasound


Typically asymptomatic


May require surgical removal if it becomes large enough to cause discomfort

Testicular cancer

Seminoma is most common malignant testicular tumor--usu. seen in men in their 20s-30s


Typically painless on presentation


Will not transilluminate (solid mass)


Easily curable if detected early


May present w/ mets (10%): supraclavicular lymph nodes, pulmonary symptoms, back/bone pain

Seminoma


Most common malignant testicular cancer; usually seen in men in their 20s and 30s

Direct inguinal hernia

Usu. due to weakness in abdominal wall mms.


Hernia proceeds directly through abd. wall; does not traverse inguinal canal


Hernia sac will touch side of examining finger in inguinal canal


Rare in children

Direct and indirect inguinal hernia routes

Indirect inguinal hernia

Goes down inguinal canal, "indirectly" into scrotal sac


Hernia sac will touch tip of finger in examination of inguinal canal


Most common type of hernia in newborns/babies

Femoral hernia

More common in women


Occurs through femoral canal, inferior to inguinal ligament (differentiates it from inguinal hernia)

Femoral hernia


More common in women


Through femoral canal


Inferior to inguinal ligament

Palpable kidneys: differential diagnoses

1. Adult Polycystic Kidney Disease (APDK)


2. Renal cell carcinoma (also assoc. w/ varicocele)


3. Angiomyolipoma (tubular sclerosis)


4. Xanthogranulomatous pyelonephritis (rare)

Renal cell carcinoma


Associated w/ varicocele in males


Will present with palpable kidney

Adult polycystic kidney disease


30s-40s: Will present w/ palpable kidney, flank pain, hematuria, renal stones


Autosomal dominant: PKD1 (more severe), PKD2


75% hypertensive


Cysts in multiple viscera (30%-liver)


5-10%: intracranial aneurysm (subarachnoid)


50% have renal failure by age 60

Angiomyolipoma (tubular sclerosis)

Benign tumor


Mixed tissue findings on CT

Benign prostatic hypertrophy (BPH)

Common in older men


Presents w/: frequent urination, weak stream, incomplete bladder emptying, nocturia, intermittency, hesitancy


Exacerbated by anticholinergics (benadryl, cogentin, etc.)--distended bladder, anuria


Digital Rectal Exam: diffusely enlarged gland, rubbery consistency, non-tender

Benign Prostatic Hypertrophy (BPH)

Adenocarcinoma of the prostate

Common in older men


Generally asymptomatic


May present w/ mets (e.g. back pain--spine mets)


May coexist w/ benign prostatic hypertrophy


DRE: hard nodule

Prostate adenocarcinoma

Acute prostatitis

Usu. presents as acute illness in young/middle-aged men


Symptoms: fever, malaise, dysuria, pelvic/penile pain, obstructive complaints


This is a medical emergency; give antibiotics


DRE: tender, edematous gland

Costo-vertebral angle tenderness

Swelling of renal capsule; elicited by percussion w/ medial aspect of fist


Due to pyelonephritis (most common), or hydronephrosis

Pyelonephritis

Usu. due to migrating UTI (cystitis), but can also arise from bacteria in bloodstream


Presents w/ palpable kidney, radiating flank pain, fever, chills, and dysuria


Can lead to sepsis, kidney failure, death


Treat w/ antibiotics

Pyelonephritis


Striated nephrogram/CT imaging

Hydronephrosis

Typically due to obstruction in ureter


May be due to congenital structural abnormalities (such as posterior urethral valves in males), injury, infection, or radiation exposure


If left untreated, can lead to ESRD


Increased incidence of UTIs may be only symptom of dysfunction early on



Bilateral hydronephrosis

Abdominal palpation findings

1. Distended bladder (urethral strictures or BPH+anticholinergic medications)--intern's tumor


2. Splenomegaly (spleen will move with respiration; L kidney is retroperitoneal, will not move w/ resp.)

Splenomegaly


On palpation, will move with respiration

Skin findings

1. Impetigo (Staph aureus or Strep pyogenes; risk of post-strep glomerulonephritis)


2. Henoch-Schonlein purpura (IgA vasculitis; risk of glomerulonephritis)


3. Uremic frost

Syphilis Stages

Primary: painless, indurated chancre representing spirochete entry site (~21 days incubation)


Secondary: skin manifestations 2-10 weeks after chancre; often palms/soles; may show constitutional findings


Tertiary: neurologic, cardiovascular

Impetigo

Skin infxn caused by Staph aureus or Strep pyogenes (GAS)


Flaccid vesicles and bullae-->rupture = honey-colored crusts


Commonly seen in low-SES school children in warm climates


If GAS-->risk for post-strep glomerulonephritis

Impetigo

Henoch-Schonlein purpura (HSP)

IgA vasculitis


Usu. in kids


Assoc. rash, glomerulonephritis, risk for GI bleed (20-30%)


Skin finding is palpable purpura

Henoch-Schonlein Purpura


IgA vasculitis


Rash, acute glomerulonephritis, risk for GI bleed


Palpable purpura--not specific to HSP; look for RBC casts in urine

Uremic Frost

Relatively uncommon; only occurs w/ serum BUN >200 mg/dl


Crystallized urea from swet


Indicates severe renal failure

Uremic frost (crystallized urea)


BUN >200 mg/dl


Severe renal failure

Urine sediment types

1. Oxalate crystals


2. Struvite crystals (aka: triple phosphate)


3. White cell casts (aka: coarse granular cast)


4. Uric acid crystals


5. Red cell casts

Oxalate crystals

"Rhomboid crystals"


Ethylene glycol (EG) ingestion


Ethylene glycol-->oxalate w/ EtOH-dehydrogenase catalyzing step 1 of 2-step rxn


EG metabolites-->renal failure, acidosis


Treat w/ fomepizole+dialysis (old tx was EtOH)


Methanol also-->increased AGAP acidosis/retinal injury (but no oxaluria)

Oxalate crystals


Ethylene glycol (anti-freeze) ingestion


Acidosis + renal failure


Tx: fomepizole+dialysis

Struvite lithiasis (aka: triple phosphate)



Composed of Mg, ammonium, and phosphate


Occurs w/ upper UTI with urease-producing organism (PROTEUS)+alkaline urine


Shaped like "coffin lids"


Grows rapidly, forming branching structure ("staghorn" calculus) w/in renal pelvis & collecting system


X-ray: dense calcific lesion

Struvite crystals


Struvite lithiasis


Proteus most common organism involved


Urease-producing organism

Staghorn calculus


Often associated with struvite lithiasis


Proteus infection in upper UT

Uric acid crystals in urine

Usu. seen in acidic urine of patients w/ hyperuricemia, uric acid renal stones, and/or gout



Uric acid crystals


Seen in acidic urine


Hyperuricemia, uric acid renal stones, &/or gout

White cell cast (coarse granular cast)

Assoc. w/ inflammation in kidney tubules


Usu. acute pyelonephritis

White cell casts (coarse granular casts)


Assoc. w/ inflammation of kidney tubules, acute pyelonephritis

Red cell cast

Specific for acute glomerulonephritis

Red cell cast


Assoc. w/ acute glomerulonephritis (not 100% sensitive)

Malignant hypertension

Nephrosclerosis due to vascular damage, fibrin and platelet deposits-->inadequate blood perfusion (DON'T GIVE DIURETICS--already intravascular volume depletion)


Ischemia-->activation of renin-aldosterone system-->angiotensin II-->renal vasoconstriction, further elevation of blood pressure


Onion-skin glomerular lesions on kidney biopsy; visual impairment/papilledema

Onion-skin lesion


Typical finding in disorders which cause thrombotic microangiopathy


Malignant hypertension, scleroderma renal crisis, eclampsia, etc.


Arterioles would show damage w/ necrosis

Lindsay's nails ("half-and-half" nails)

Assoc. w/ renal failure

Metab. acidosis + hyperkalemia


Hyperkalemia-->peaked T waves, QRS complex widening-->sine wave pattern-->death


Address w/ IV calcium, lower serum [K] w/ insulin/glucose, albuterol, dialysis


Lindsay's nails


Associated w/ hyperkalemia, renal failure

Xanthogranulomatous pyelonephritis

Due to recurrent UTIs


Associated w/ palpable renal mass


Xanthogranulomatous Pyelonephritis


Will present w/ palpable kidney


Due to recurrent UTIs

Tumor Lysis Syndrome

Risk usu. following chemo for some aggressive cancers (~58%)


Lysis-->spillage of intracell'r contents (K, P, uric acid)-->acute tubular necrosis + hyperkalemia


Acute tubular necrosis: urine shows "muddy brown casts"


After 2-3 days: Intravasc. volume overload, high AGAP metab. acidosis, uremia