00:00
So let's look at a patient who's having scrotal pain. This is a 61-year-old man presenting to
his physician with pain to his scrotum. It's associated with swelling most notably on the right
side of his scrotum. We're going to want to perform our comprehensive male genital system
exam here. And I'll just remind you from this image the proximity of the prostate to both the
rectum and to the base of the penis. We'll start off by looking at causes of penile pain.
00:28
Patients can, of course, either be circumcised or uncircumcised and those that are
uncircumcised are at risk of both phimosis and paraphimosis. With phimosis, the patient is
unable to retract the foreskin potentially due to some fibrotic changes happening in the
foreskin itself. But of much greater concern would be paraphimosis in which the foreskin
is in a retracted position that cannot be alleviated, which puts the glans penis at risk of
ischemia. You may also find on the physical exam that plaques on the shaft of the penis may
lead to an abnormal curvature called Peyronie's disease in the penis as well. There are a
myriad of infectious diseases which can manifest on the penis and those would include HPV
causing condyloma acuminata or genital warts, HSV with genital herpes, syphilitic chancres
which tend to be painless, and of course patients can get infections with either gonorrhea or
Chlamydia that could manifest with urethritis. Moving on to the scrotum, patients with scrotal
enlargement can have a variety of different things going on. It could simply be a hydrocele
which we do oftentimes see in folks with heart failure, with transudative fluid accumulating
in the scrotal sac, a spermatocele which is associated with cystic epididymitis, or a varicocele
with this classic palpable bag of worms finding on physical exam. The scrotum is also a place
where a hernia may manifest. While patients oftentimes get direct hernias particularly
through prior surgical incisions and indirect hernia is where abdominal contents, intestines,
are actually herniating into the scrotal sac itself which, as you can imagine, can be quite
painful if that intestinal bowel gets strangulated. Other causes of scrotal pain are those that
are infectious like epididymitis involving inflammation of just the epididymis on the upper
pole of the testis or involvement of the entire testis so-called orchitis which can also be
caused by gonorrhea and Chlamydia. Likewise, patients can present with acute, severe pain
of one testis when the testis rotates on itself and cuts off the blood supply so-called
testicular torsion and we want to make sure we know how to identify that on physical exam.
02:54
Moving on to different things that we may find in terms of the rectum that can cause pain,
largely external hemorrhoids, are a common cause of pain in the rectum; internal
hemorrhoids may be identified on physical exam but are less likely to be painful; HPV can
cause anal warts, and then anal fissures, these breaks in the skin that can make defecation
particularly painful can also be identified on the physical exam. And now moving on to
diseases of the prostate, there is benign prostatic hyperplasia or hypertrophy which we will
be able to detect on physical exam. Such patients may present with urinary hesitancy or
increased urinary frequency, acute prostatitis which can be a smoldering painful course and
patients may also have pain specifically with urination and they may just be generally
experiencing malaise. And lastly, prostate cancer with an irregularly enlarged firm prostate
palpated on physical exam. So, the differential diagnosis for this particular patient may
include an inguinal hernia, epididymitis, orchitis, a hydrocele, varicocele, or testicular torsion.
04:04
We're going to need to move on with our physical exam to define what's going on with this
patient.