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Case 14 testicular pain
http://www.hmc.psu.edu/ume/fcmonline/case14/index.htm

1.救急に来る陰嚢、睾丸の痛み?
Acute:
  * acute epididymitis 精巣上体炎
  * orchitis 睾丸炎
  * testicular torsion 睾丸捻転
  * inguinal hernia 鼡径ヘルニア(大人は内)
  * trauma/testicular rupture/hematocele 外傷
  * folliculitis/sebaceous cyst 皮脂嚢胞
Subacute:
  * hydrocele 陰嚢水腫
  * varicocele 精索静脈瘤
  * spermatocele 精液瘤
  * hematocele 陰嚢血腫
  * cryptorchidism 停留睾丸
  * atrophy/dysgenesis/endocrinopathy
  * testicular cancer
  * fibrous plaques and cysts of tunica albigunea (actually quite common and entirely benign)
  * epididymal cyst
Less common:
  * squamous cell carcinoma of scrotum
  * malignant melanoma/basal cell
  * epididymal tumor/malignancy
  * Fournier's gangrene (necrotizing fascitis) 壊疽性筋膜炎

Tips:陰嚢にできる扁平上皮癌と疫学。

2.ありそうなのは?
急性のもの!

陰部を見るときには癌のスクリーニングも忘れないようにしよう。

3.何を聞く?
感染の原因を探る。
  a. sexual history? does he use condoms? has he had multiple partners? ever had an STD? IV drug use? homosexual contact?
  b. contraception use? (this gives you an opportunity to reinforce the importance of contraception and disease prevention)
  c. any urinary or other associated symptoms? history of urinary tract infections?
  d. any history of trauma to the genitals or lower abdomen?
  e. any bowel problems? constipation, cramping, vomiting, diarrhea, nausea?
  f. recent viral illness?
  g. any significant past medical/surgical history, especially related to genitourinary tract?; history of cryptorchidism?

「ライター症候群」
[原因]感染性下痢疾患後に発症する流行型(Shigella Flexneri)と、性交後に発症する型(主にクラミジア)
[診断基準]
1.  血清反応陰性の非対称関節炎(主として下肢関節)
2.  次の項目の1つまたはそれ以上を満たす
a. 尿道炎
b. 赤痢
c. 炎症性眼疾患
3.  除外項目
強直性脊椎炎、乾癬性関節炎、その他のリウマチ性疾患
[治療]
急性期にはNSAID
治療抵抗性なら免疫抑制剤
[予後]
3-40%では症状持続。他は半年たたずに自然治癒。

4.診察
  *  general appearance
  * vital signs
  * abdominal exam
  * inguinal, perineum, lower extremity exam
  * genital exam

5.どこを確かめる?
  1. testicles
  2. epididymis
  3. spermatic cord/vas deferens
  4. penis
  5. skin of penis, scrotum, and perineum 会陰
  6. external/internal inguinal ring and floor of inguinal canal
陰部の診察は視診と触診。
視診は、感染、外傷、皮膚の変化、腫瘤、萎縮、奇形。
触診は、
  1. testicular descent (cryptorchidism) 
  2. testicular size (<3.5cm on long axis is small, consider hypogonadism)
  3. testicular shape, lumps/masses
  4. symmetry (remember left testicle usually sits lower and more posterior in relation to the right)
  5. testicular tenderness
  6. epididymis (located superior and posterior to testicle) size, tenderness, masses
  7. vas deferens (check for swelling, tenderness, masses) 輸精管
  8. scrotal skin versus intrascrotal masses/cysts
あと、Cremasteric reflex(挙睾筋反射)
大腿内側面を上から下にピンでこすると同側の睾丸が挙上