Presentación del tema: "Patología Genital en el Varón"— Transcripción de la presentación:
1Patología Genital en el Varón Dr. Christian Mauro StamatiServicio UrologíaHospital Dr. R.A.Calderón Guardia
2Bolsa Escrotal Pene Epididimitis Hernia inguinal Hidrocele Quiste de epidídimoQuiste de CordónVaricoceleTorsión testicularCáncer de TestículoFimosisParafimosisCurvaturaITS
3Varicocele Varices del plexo pampiniforme 95% izq Puede producir orquialgia, infertilidadDiagnóstico al examen físico o por US (vasos > 3mm)Único tratamiento cirugíaRecomendaciónCirugía para preservar la fertilidad.Cirugía por dolor: solo en casos intratables.
4Epididimitis Inflamación del epidídimo Dolor testicular y fiebre Etiología< 35 años ITS> 35 años ITUChlamydiaE.coliGonococoTratamiento: Antibióticos-AINE-Reposo-Hielo.Importante:En niños y adolescentes sin inicio de vida sexual descartar torsión
6Hidrocele Acumulación líquido en cavidad vaginalis Puede producir dolor y molestia al caminar.EtiologíaAdultosNiñosSecuela de trauma o infeccióntesticular o del epididimo.Persistencia 1/3 distalconducto peritoneo vaginalTratamientoÚnico tratamiento cirugíaRecomendaciónEn adultos si no produce molestias no es necesario operar
7Quiste epidídimoDilatación quística de un conducto epididimario, secundario a obstrucción.Generalmente asintomáticos, ocasionalmente con dolor.La gran mayoría no requiere tratamientoTratamientoCirugía es el único tratamientoSe recomiendacuando es muy grande o produce dolor
8Torsión testicular Dolor testicular súbito, intenso. Es un giro anormal del testículo y del cordón espermático sobre su eje longitudinal, dentro de la cavidad escrotal.Dolor testicular súbito, intenso.Maniobra de destorsión: hacia afuera.La destorsión debe realizarse antes de las 4 horas.Requiere cirugía siempre en ambos testículos
9Quiste del cordónPeristencia del 1/3 medio del conducto peritoneo vaginalGeneralmente asintomáticoAmerita tratamiento solo si es sintomático o existe duda diagnóstica.
10Torsión hidatide de Morgani Torsión de apendice testicular o epidímo (restos embriológicos)Dolor testicular súbito, intenso.Tumoración dolorosa en polo superior del testículo o cabeza de epidídimo.Debe operarse solo ante duda diagnóstica de torsión testicular.
11Cáncer de Testículo Tumor más frecuente de hombres jóvenes. Tumor intratesticular a la palpación.El ultrasonido confirma el diagnóstico.Tratamiento oportuno ofrece una tasa de curación de mas del 95%.
14Patología de escroto Estudios diagnósticos Ultrasonido: En casos de duda diagnóstica.Diferencia entre tumoraciones sólidas y quísticas intra y extratesticularesRecordar:95 % de lesiones sólidas intratesticulares son cáncer95 % de lesiones extratesticulares son benignas
15Patología de escroto Estudios diagnósticos Ultrasonido Doppler: Permite valorar la irrigación y por ende la viabilidad del testículo en casos de torsión.Además, permite diferenciar entre torsión testicular y torsión hidatide de Morgani
16Bolsa Escrotal Diagnóstico Epididimitis Hernia inguinal Hidrocele EFUSEpididimitisHernia inguinalHidroceleQuiste de epidídimoQuiste de CordónVaricoceleTorsión testicularCáncer de Testículo
17RecomendacionesDe todos los diagnósticos los más importantes de definir rápidamente son tumor testicular y torsión testicular.Si existe duda el ultrasonido nos dará la respuesta y sabremos si el manejo es quirúrgico o médico y si debemos referir urgente o electivo.
18Infección por Dermatofitos Tiña CrurisTrichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum
24PapilomaITS viral más frecuente 30 a 50 % de los adultos sexualmente activos infectados50% de pacientes con lesiones genitales múltiples que practican sexo oral tienen papiloma oral.Genital WartsHuman papillomavirusHuman papillomavirus (HPV) causes warts. HPV can reside in epithelial basal cells and lead to subclinical or latent infection. More than 80 genotypes have been identified; HPV 6, 11, and 16 are most commonly associated with genital warts. HPV 6 and 11 are rarely associated with cervical cancer. HPV 16 and 18 are more likely to be present in subclinical infection and are the types most commonly associated with genital cancer. Bowenoid papulosis is most commonly caused by HPV 16. The rare verrucous carcinoma (Buschke-Löwenstein tumor) that resembles a large wart is locally aggressive but rarely metastatic. It is associated with HPV types 6 and 11.IncidenceThe incidence of genital warts is increasing rapidly and exceeds the incidence of genital herpes. It is the most common viral sexually transmitted disease. It is estimated that 30% to 50% of sexually active adults are infected with HPV. Only 1% to 2% of that group have clinically apparent anogenital warts. Most cervical dysplasias and cancers are related to oncogenic HPV.TransmissionRisk factors for acquisition of condyloma in women have been identified as the number of sexual partners, frequency of sexual intercourse, and presence of warts on the sexual partner. Men have been found to be at increased risk if they fail to wear a condom. Condoms reduce the transmission of HPV but they do not eliminate it. Transmission of HPV during infant delivery may rarely occur.Clinical presentationGenital warts (condyloma acuminata or venereal warts) are pale pink with numerous, discrete, narrow-to-wide projections on a broad base. The surface is smooth or velvety, moist, and lacks the hyperkeratosis of warts found elsewhere (Figures 11-1 to 11-5     ). The warts may coalesce in the rectal or perineal area to form a large, cauliflower-like mass ( Figures 11-6 and 11-7 ). Perianal warts may be present in persons who do not practice anal sex.Another type is seen most often in young, sexually active patients. Multifocal, often bilateral, red- or brown-pigmented, slightly raised, smooth papules have the same virus types seen in exophytic condyloma, but in some instances these papules have histologic features of Bowen's disease. (See discussion of bowenoid papulosis later in this chapter.)Warts spread rapidly over moist areas and may therefore be symmetric on opposing surfaces of the labia or rectum ( Figure 11-7 ). Common warts can possibly be the source of genital warts, although they are usually caused by different antigenic types of virus. Warts may extend into the vaginal tract, urethra, and anal canal or the bladder, in which case a speculum or sigmoidoscope is required for visualization and treatment. Condylomas may spontaneously regress, enlarge, or remain unchanged. Genital warts frequently recur after treatment. There are two possible reasons. Latent virus exists beyond the treatment areas in clinically normal skin. Warts that are flat and inconspicuous, especially on the penile shaft and urethral meatus, escape treatment.Oral condyloma in patients with genital human papilloma virus infectionOne study showed that 50% of patients with multiple and widespread genital HPV infection who practiced orogenital sex have oral condylomas. All lesions were asymptomatic. Magnification was necessary to detect oral lesions. The diagnosis was confirmed by biopsy. The tongue was the site most frequently affected. Oral condylomas appeared as multiple, small, white or pink papules, sessile or pedunculate, and as papillary growths with filiform characteristics. The size of oral lesions was greater than 2 mm in more than 50% of lesions, and, in 61% of cases, more than five lesions were present. HPV types 16, 18, 6, and 11 were found.Si el papiloma afecta el meato debe realizarse uretroscopía
27PapilomaTreatmentHPV cannot be completely eliminated because of the surrounding subclinical HPV infection. Removal of visible lesions decreases viral transmission. All treatment methods are associated with a high rate of recurrence that is likely related to surrounding subclinical infection. Therapies with antiviral/immunomodulatory activity (e.g., imiquimod cream) may be associated with lower recurrence rates.Management of sexual partnersExamination of sexual partners is not necessary for the management of genital warts because the role of reinfection is probably minimal. Many sexual partners have obvious warts and may desire treatment. The majority of partners are probably already subclinically infected with HPV, even if they do not have visible warts. The use of condoms may reduce transmission to partners likely to be uninfected, such as new partners. HPV infection may persist throughout a patient's lifetime in a dormant state and become infectious intermittently. Whether patients with subclinical HPV infection are as contagious as patients with exophytic warts is unknown. One study showed that the failure rate of treating women with condylomata acuminata did not decrease if their male sexual partners were also treated.PregnancyThe use of podophyllin and podofilox is contraindicated during pregnancy. Genital papillary lesions have a tendency to proliferate and to become friable during pregnancy. Many experts advocate the removal of visible warts during pregnancy. HPV types 6 and 11 can cause laryngeal papillomatosis in infants. The route of transmission is unknown, and laryngeal papillomatosis has occurred in infants delivered by caesarean section. Caesarean delivery should not be performed solely to prevent transmission of HPV infection to the newborn. In rare instances, cesarean delivery may be indicated for women with genital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding.ChildrenSpontaneous resolution of pediatric condyloma occurs in more than half of cases in 5 years. Nonintervention is a reasonable initial approach to managing venereal warts in children.Patient-applied therapiesIMIQUIMOD.Improved efficacy and lower recurrence rates occur with imiquimod (Aldara) by inducing the body's own immunologic defenses. Imiquimod has an immunomodulatory effect and does not rely on physical destruction of the lesion. It has antiviral properties by induction of cytokines, including interferon, tumor necrosis factor, interleukin (IL)-6, IL-8, and IL-12. Imiquimod enhances cell-mediated cytolytic activity against HPV. The cream is applied at bedtime every other day, for a maximum of 16 weeks. On the morning after application, the treated area should be cleansed. Local mild-to-moderate irritation may occur. Systemic reactions have not been reported. Imiquimod has not been studied for use during pregnancy.PODOFILOX.Podofilox, also known as podophyllotoxin, is the main cytotoxic ingredient of podophyllin. Podofilox gel (Condylox) is available for self-application and is useful for responsible, compliant patients. Patients are instructed to apply the 0.5% gel to their external genital warts twice each day for 3 consecutive days, followed by 4 days without treatment. It is recommended that no more than 10 cm2 of wart tissue should be treated in a day. This cycle is repeated at weekly intervals for a maximum of 4 to 6 weeks. Approximately 15% of patients report severe local reactions to the treatment area after the first treatment cycle; this is reduced to 5% by the last treatment cycle. Local adverse effects of the drug, such as pain, burning, inflammation, and erosions have occurred in more than 50% of patients. Podofilox is not recommended for perianal, vaginal, or urethral warts and is contraindicated in pregnancy.Provider-administered therapiesCRYOSURGERY.Liquid nitrogen delivered with a probe, as a spray, or applied with a cotton applicator is very effective for treating smaller, flatter genital warts. It is too painful for patients with extensive disease. Exophytic lesions are best treated with excision, imiquimod, or podofilox. Warts on the shaft of the penis and vulva respond very well, with little or no scarring. Cryosurgery of the rectal area is painful. A conservative technique is best. Freeze the lesion until the white border extends approximately 1 mm beyond the wart. Over-aggressive therapy causes pain, massive swelling, and scarring.A blister appears, erodes to form an ulcer in 1 to 3 days, and the lesion heals in 1 to 2 weeks. Repeat treatment every 2 to 4 weeks as necessary. Two to three sessions may be required.Use EMLA cream and/or 1% lidocaine injection for patients who do not tolerate the pain of cryotherapy.Cryotherapy is effective and safe for both mother and fetus when applied in the second and third trimesters of pregnancy. An intermittent spray technique, using a small spray tip, is used to achieve a small region of cryonecrosis, limiting the run off and scattering of liquid nitrogen. Cervical involvement that requires cervical cryotherapy does not increase the risk to mother or fetus.SURGICAL REMOVAL AND ELECTROSURGERY.Scissors excision, curettage, or electrosurgery produce immediate results. They are useful for both extensive condylomas or a limited number of warts. Small isolated warts on the shaft of the penis are best treated with conservative electrosurgery or scissor excision rather than subjecting the patient to repeated sessions with podophyllum. Large, unresponsive masses of warts around the rectum or vulva may be treated by scissor excision of the bulk of the mass, followed by electrocautery of the remaining tissue down to the skin surface. Removal of a very large mass of warts is a painful procedure and is best performed with the patient under general or spinal anesthesia in the operating room.TRICHLOROACETIC ACID.Application of trichloroacetic acid (TCA) and bichloracetic acid (BCA) 80% to 90% is effective and less destructive than laser surgery, electrocautery, or liquid nitrogen application. It is most effective on small, moist warts.This is an ideal treatment for isolated lesions in pregnant women. A very small amount is applied to the wart, which whitens immediately. The acid is then neutralized with water or bicarbonate of soda. The tissue slough heals in 7 to 10 days. Repeat each week or every other week as needed. Excessive application causes scars. Take great care not to treat normal surrounding skin.PODOPHYLLUM RESIN.Podophyllin is a plant compound that causes cells to arrest in mitosis, leading to tissue necrosis. Podophyllun resin 10% to 25% in compound tincture of benzoin used to be the standard provider-administered therapy. Patient applied medications are now commonly used. The medication can be very effective especially for moist warts with a large surface area and lesions with many surface projections. Podophyllun is relatively ineffective in dry areas, such as the scrotum, penile shaft, and labia majora. It is not recommended for cervical, vaginal, or intraurethral warts. The compound is applied with a cotton-tipped applicator. The entire surface of the wart is covered with the solution, and the patient remains still until the solution dries in approximately 2 minutes. When lesions covered by the prepuce are treated, the applied solution must be allowed to dry for several minutes before the prepuce is returned to its usual position. Powdering the warts after treatment or applying petrolatum to the surrounding skin may help to avoid contamination of normal skin with the irritating resin. The medicine is removed by washing 1 hour later. The patient is treated again in 1 week. The podophyllum may then remain on the wart for 8 to 12 hours if there was little or no inflammation after the first treatment.Overenthusiastic initial treatment can result in intense inflammation and discomfort that lasts for days. The procedure is simple and it is tempting to allow home treatment, but in most cases this should be avoided. Very frequently patients overtreat and cause excessive inflammation by applying podophyllum on normal skin. To avoid extreme discomfort, treat only part of a large warty mass in the perineal and rectal area. Warts on the shaft of the penis do not respond as successfully to podophyllum as do warts on the glans or under the foreskin; consequently, electrosurgery or cryosurgery should be used if two or three treatment sessions with podophyllum fail. Many warts disappear after a single treatment. Alternate forms of therapy should be attempted if there is no improvement after five treatment sessions.Warning.Systemic toxicity occurs from absorption of podophyllum. Paresthesia, polyneuritis, paralytic ileus, leukopenia, thrombocytopenia, coma, and death have occurred when large quantities of podophyllum were applied to wide areas or allowed to remain in contact with the skin for an extended period. Only limited areas should be treated during each session. Very small quantities should be used in the mouth, vaginal tract, or rectosigmoid. Do not use podophyllun on pregnant women.Alteration of histopathology.Podophyllum can produce bizarre forms of squamous cells, which can be mistaken for squamous cell carcinoma. The pathologist must be informed of the patient's exposure to podophyllum when a biopsy of a previously treated wart is submitted.5-FLUOROURACIL CREAM.Application of a 5-fluorouracil cream (Carac, Efudex) may be considered in cases of genital warts that are resistant to all other treatments. A thin layer of cream is applied one to three times per week and washed off after 3 to 10 hours, depending on the sensitivity of the location. Treat for several weeks, as necessary. Irritation makes it intolerable for some patients.Vaginal warts are treated by inserting an applicator (such as the one supplied by Ortho Pharmaceutical Corporation for the treatment of vaginal candida) one-third full of 5% 5-fluorouracil cream (approximately 3 mL) deeply into the vagina at bedtime, once each week for up to 10 consecutive weeks. The vulva and urethra are protected with petrolatum. A tampon should be inserted just inside the introitus. In one study, there was no evidence of disease in 85% of patients 3 months after treatment. Resistant cases were treated twice each week. Mild irritation and vaginal discharge may develop. The vulva should be protected with zinc oxide or hydrocortisone ointments if the twice-each-week regimen is used. Application to the keratinized epithelium (vulva, anus, and penis) twice weekly on 2 consecutive days is well tolerated but less effective; such treatment should not be used for pregnant women. Patients should be warned to avoid thick coverage because the excess cream causes inflammation or ulceration in the labiocrural or anal folds. Protective gloves are not necessary, provided that the hands are carefully washed after applying the 5-fluorouracil cream. A single intravaginal dose of 1.5-gm, 5% 5-fluorouracil cream contains only 75 mg of 5-fluorouracil. This is less than 10% of the usual systemic dose and far lower than the toxicity level of the drug even if rapid and complete absorption occurs.CARBON DIOXIDE LASER.The CO2 laser is an ideal method for treating both primary and recurrent condyloma acuminata in men and women because of its precision and the wound's rapid healing without scarring. The laser can be used with an operating microscope to find and destroy the smallest warts. For pregnant women, this is the treatment of choice for large or extensive lesions and for cases that do not respond to repeated applications of trichloroacetic acid.ISOTRETINOIN.Oral isotretinoin (Accutane) was used in one study for the treatment of condylomata acuminata. A total of 56 males with a history of condylomata acuminata refractory to at least 1 standard therapeutic regimen were treated orally with isotretinoin (1 mg/kg daily) during a 3-month period. At the end of treatment 40% had complete response, 13 % had partial response and 47 % had no response. Immature and small condylomata acuminata respond best.INTERFERON ALFA-2B RECOMBINANT (INTRON-A).Warts that do not respond to any form of conventional treatment and patients whose disease is severe enough to impose significant social or physical limitations on their activities may be candidates for treatment with interferon. Alfa interferon is approved by the U.S. Food and Drug Administration for the treatment of condyloma acuminata in patients 18 years of age or older. There are two commercially available preparations available for intralesional injection into the base of the wart. Alferon N injection (Interferon alfa-n3) is available in 1-mL vials; 0.05 mL per wart is administered twice weekly for up to 8 weeks. Intron-A (Interferon alfa-2b, recombinant) is available is several size vials, but the vial of 10 million IU is the only package size specifically designed for use in treatment of condyloma acuminata. Intron-A (0.1 mL of reconstituted Intron-A) is injected into each lesion three times per week on alternate days for 3 weeks. Influenza-like symptoms usually clear within 24 hours of treatment. Total clearing occurs in approximately 40% of treated warts. The medication is very expensive.
30Prueba de Ácido Acético para Papiloma Prueba: Embeber una gasa con ácido acético al 5 % y colocarla en pene, prepucio y escroto por 15 minutos. Las lesiones por papiloma se verán blanquesinas.Falso positivo:LiquenPsoriasisCandidiasisPerlas córneaLesiones traumáticas
31Perlas CórneasSon angiofibromas que aparecen en surco balanoprepucianoPresentes en el 10 % de los hombresPearly penile papulesDome-shaped or hairlike projections, called pearly penile papules, appear on the corona of the penis and sometimes on the shaft just proximal to the corona in up to 10% of male patients. These small angiofibromas are normal variants but are sometimes mistaken for warts. No treatment is requiredSon confundidas con papilomaNo requieren tratamiento