Differential Diagnosis Genital Wart Scrotum

Figure 18-33 Position of the examining finger in the inguinal canal.

examine the patient's right side and the left index finger for the patient's left side. Try both techniques to see which one is more comfortable for you.

If there is a large scrotal mass that appears opaque on transillumination, an indirect inguinal hernia may be present in the scrotum. Auscultation of the mass can be performed to determine whether bowel sounds are present in the scrotum, a useful sign in diagnosing an indirect inguinal hernia.

Examination of the prostate is discussed in Chapter 17, The Abdomen. If the rectal examination has not yet been performed, this is the appropriate time to examine the rectum and prostate.

Clinicopathologic Correlations

Gross hematuria that is usually painless is often the first indication of a urinary tract tumor, commonly located in the bladder. Table 18-1 lists the common causes of gross hematuria in different age groups and by sex.

Scrotal disorders are relatively common. In a man with scrotal swelling, a careful history and a thorough physical examination often provide enough information for a correct diagnosis. Intrascrotal masses are common findings on physical examination. Although most masses are benign, testicular cancer is the leading solid malignancy in men younger than 35 years of age.

Some of the important considerations in the history include the patient's age, time of onset of symptoms (if any), associated problems (e.g., fever, weight loss, dysuria), past medical history, and sexual history.

Intrascrotal masses can be categorized as acute or nonacute, intratesticular or extratesticular, and neoplastic or non-neoplastic.

The most common pathologic disorders in the category of acute, non-neoplastic lesions include testicular torsion, epididymitis, and trauma. Testicular torsion is a surgical emergency in which a twisting of the testis leads to venous obstruction, edema, and eventual arterial obstruction. Prompt recognition (within 10 to 12 hours) of this condition enables physicians to salvage the testis in 70% to 90% of cases. Torsion is most commonly seen in adolescents from 12 to 18 years of age. Patients complain of acute, unilateral testicular pain that is often

Table 18-1 Causes of Hematuria by Age and Sex

Age (Years)

Younger than 20

Congenital urinary tract anomaly Acute glomerulonephritis Acute urinary tract infection

Male

Female

20-40

Acute urinary tract infection Kidney stone Bladder tumor

40-60

Bladder tumor Kidney stone

Acute urinary tract infection

Acute urinary tract infection Kidney stone Bladder tumor

Older than 60

Prostatic disorder

Bladder tumor

Acute urinary tract infection

Bladder tumor

Acute urinary tract infection accompanied by nausea and vomiting. On physical examination, the testis is enlarged and extremely sensitive. It may be retracted and is often lying in a horizontal position.

Epididymitis is the most common cause of acute scrotal swelling. It accounts for more than 600,000 visits to physicians annually in the United States. It occurs in young, sexually active men and in older men with associated genitourinary problems. Patients usually complain of recent onset of testicular pain that is associated with fever, dysuria, and scrotal swelling. On examination, the epididymis is tender and indurated. The testis may also be enlarged and tender;this variant is called epididymo-orchitis.

Trauma is the third major cause of acute scrotal swelling. Trauma may produce a scrotal or testicular hematoma. An important fact to keep in mind is that 10% to 15% of patients with testicular tumors seek medical attention after trauma.

The most common types of intrascrotal pathologic conditions are the nonacute, non-neoplas-tic lesions. These include hydrocele, spermatocele, and varicocele. A hydrocele (see Fig. 18-28) is a collection of fluid within layers of the tunica vaginalis. It manifests as a painless swelling of the scrotum. A hydrocele may be congenital, acquired, or idiopathic. Acquired hydroceles may result from trauma, infection, renal transplantation, and neoplasm. Idiopathic hydroceles are the most common; patients may have no symptoms or may complain of a dull ache or scrotal heaviness. In general, hydroceles are anterior to the testis. They are smooth walled and can be transilluminated. Figure 18-29 depicts a transilluminated hydrocele.

Spermatoceles are cystic collections of fluid in the epididymis. They are frequently found on routine physical examination because they usually produce no symptoms. Because they are fluid filled, they can often be transilluminated.

A varicocele is a common intrascrotal mass resulting from abnormal dilatation of the veins of the pampiniform plexus. A man with a varicocele is usually asymptomatic but may have a history of infertility or a sensation of heaviness in the scrotum. The varicocele can best be visualized by observing the patient in a standing position. A mass resembling a bag of worms may be seen and palpated superior to the testis. These varicosities typically enlarge during a Valsalva maneuver and are reduced when the patient lies down. Varicoceles are found predominantly on the left side. A right-sided varicocele suggests some obstruction of the inferior vena cava, whereas an acute left-sided varicocele may indicate a left-sided hypernephroma or other left renal tumor. Figure 18-27 shows a patient with a varicocele. Notice the markedly dilated veins in the scrotum.

Most testicular neoplasms are asymptomatic, but some patients may seek medical attention because of acute pain related to trauma, hemorrhage, hydrocele, and epididymitis. Other men may present with weight loss, fever, abdominal pain, lower extremity edema, or bone pain resulting from advanced metastatic disease. A history of cryptorchidism is important because of a high association between this condition and testicular malignancies. The most common finding on physical examination is a nodule or a painless swelling of one testicle. About 1% to 3% of testicular neoplasms are bilateral. If found early, testicular carcinoma is almost always curable. Extratesticular tumors are uncommon and are usually benign. Pure seminomas constitute approximately 40% of all testicular cancer cases. Forty percent of testicular cancers have mixed histologic characteristics.

Table 18-2 Differential Diagnosis of Common Scrotal Swellings

Diagnosis

Epididymitis

Torsion of testes

Testis tumor

Hydrocele

Spermatocele

Hernia (see Figs. 18-42 and 18-43)

Usual Age (Years)

15-35

Any Any

Able to Be Transilluminated

No No

Yes No

Scrotal Erythema

Yes No No

No No

Pain

Severe, increasing severity

Severe, sudden

Minimal or absent

None

None

None to moderate*

Varicocele (see Fig. 18-27) >15

None

•Unless the hernia is incarcerated, in which case pain may be severe.

Table 18-2 provides a differential diagnosis of common scrotal swellings.

Sexually transmitted diseases are common. Of every 100 outpatient visits to a venereal disease clinic, 25% of men have gonorrhea, 25% have nongonococcal urethritis, 4% have venereal warts, 3.5% have herpes, 1.7% have syphilis, and 0.1% have chancroid. The incidence of both gonococcal and nongonococcal urethritis has increased dramatically since the early 1980s. On college campuses, 85% of urethritis is nongonococcal in origin.

Genital lesions of venereal diseases may be ulcerative or nonulcerative. The incidence of genital lesions has changed greatly since the 1950s. At one time, chancroid was common, and herpes was rare;today, herpes simplex virus type 2 (HSV-2) infection is common, and chancroid is rare. Figure 18-34 shows the vesicular stage of a herpetic infection. Another example of HSV-2 infection is shown in Figure 18-35. Anal ulcerative lesions are becoming more common, particularly among gay men.

Molluscum contagiosum is a common, usually self-limited, cutaneous eruption affecting the skin and mucous membranes. It is often seen in the pediatric population and is caused by a

Condylomata Lata
Figure 18-34 Herpes simplex virus type 2 infection.

Figure 18-35 Herpes simplex virus type 2 infection.

Condylomata Acuminata Man

large DNA poxvirus. Adults can acquire the infection through sexual contact with infected adults. The characteristic lesions are flesh-colored papules that range in size from pinpoint to 0.4 inch (1 cm) in diameter. The central depression is the most important diagnostic sign. The painful lesions may occur anywhere on the body: on the face and trunk in children and around the genitals of adults. Any adult with this disease must be screened for other sexually transmitted diseases. The lesions, as the name indicates, are highly contagious. As the lesions develop, there may be a surrounding patch of eczema. In patients with AIDS, the lesions become widespread, attaining sizes up to 0.8 inch (2 cm) in diameter. Figure 18-36 shows lesions of molluscum contagiosum of the penis. Figure 18-37 is a close-up photograph of the classic, umbilicated lesions of molluscum contagiosum. Table 18-3 lists a differential diagnosis of genital papular lesions.

The primary lesion of syphilis is the chancre (see Fig. 18-13), which occurs from 10 days to 3 weeks after infection at the site of the inoculation. The chancre is a painless ulcer with an indurated edge. It usually heals spontaneously within a month. If the patient is not treated for syphilis, the disease may evolve to the secondary stage. This occurs about 2 months after the appearance of the chancre. The patient may present with a widespread, nonpruritic, maculo-papular rash over the genitalia, trunk, palms, and soles. There is a tendency for cropping of the lesions. The healed chancre may still be evident. There is also generalized lymphadenopathy. In the genital and perianal areas, the papules may coalesce and erode. These large, moist, painful papules, which look as if they were ''pasted'' on the skin, are called condylomata lata. They are covered with an exudate and are teeming with active spirochetes. If untreated, the patient may recover but may have a relapse of the eruption within 2 years. After this period, there is a long latent period during which the disease may progress to cardiovascular syphilis or neurosyphilis, a condition known as tertiary syphilis.

Syphilis Penis

Table 18-3 Differential Diagnosis of Genital Papules

Condition

Appearance

Pain

Lymphadenopathy

Herpes (see Figs. 18-34 and 18-35)

Multiple, ulcers, vesicles

Painful

Present

Condylomata lata (see Fig. 18-39)

Multiple, moist, flat, round

Painful

Present

Condylomata acuminata (see Figs. 18-15, 18-21, and 18-40)

Multiple, verrucous

Absent

Absent

Molluscum contagiosum (see Figs. 18-36 and 18-37)

0.04- to 0.2-inch (1- to 5-mm) umbilicated papules, often in clusters; caseous material expressible from center

Painful

Rarely

The skin lesions of syphilis are important to recognize. Figure 18-38 shows the typical skin lesions of secondary syphilis on the feet. Figure 18-39 shows condylomata lata in the perineum of the same patient. The healing chancre of primary syphilis is also seen on the penis of this patient.

Human papillomavirus (HPV) infection of the genital tract is one of the most common sexually transmitted diseases among young adults and is the cause of venereal warts. In the United States, it is estimated that 20 million people have genital HPV infections at any one time, with 5.5 million acquiring it annually. Risk factors associated with HPV infection include younger age, belonging to an ethnic minority, alcohol consumption, and a high frequency of anal or vaginal sexual encounters. The annual cost burden in the United States of genital HPV infection is $6 billion, which makes it the second most costly sexually transmitted disease after human immunodeficiency virus (HIV) infection. Condylomata acuminata are typically caused by HPV type 6 or HPV type 11, which are considered low-risk HPV types because these strains are rarely found in association with genital dysplasias or invasive cancer. Patients with immunodeficiencies are at higher risk for persistent HPV infection and progressive disease. Figure 18-40 shows the classic cauliflower lesions of condylomata acuminata on the penis of a renal transplant recipient (see also Figs. 18-15 and 18-21).

Reiter's syndrome is defined as the classic triad of nongonococcal urethritis, arthritis, and conjunctivitis. It most often affects men (20:1) during the third decade of life, and there is a high prevalence of human leukocyte antigen (HLA)-B27. It is one of the most common causes of acute inflammatory arthritis in men. Approximately one third of patients with Reiter's syndrome have a prodromal enteric or urethral inflammation. The most common enteric pathogens are Shigella, Salmonella, Yersinia, and Campylobacter; the most common urogenital

Figure 18-38 Secondary syphilis lesions on the feet.

Figure 18-39 Condylomata lata. Note the healing primary chancre on the penis.

pathogens are Chlamydia and Ureaplasma. Reiter'syndrome is often associated with a psoriasislike dermatitis on the palms and soles known as keratoderma blennorrhagicum. This painless, papulosquamous, ''barnacle-like'' eruption is pictured in Figure 18-41.

Hernias are common. The major types of external hernias are indirect and direct inguinal hernias and femoral hernias. Figure 18-42 shows a patient with a left indirect inguinal hernia. Figure 18-43 shows a patient with a small right direct inguinal hernia. Figure 18-44 illustrates and lists the major differences in the types of hernias.

Figure 18-41 Keratoderma blennorrhagicum in a patient with Reiter's syndrome.

Figure 18-40 Condylomata acuminata of the penis.

Figure 18-41 Keratoderma blennorrhagicum in a patient with Reiter's syndrome.

Figure 18-42 Left indirect inguinal hernia.

Joe Barton Penis

Figure 18-42 Left indirect inguinal hernia.

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