5.05 Urology - The Genital Tract Flashcards
What is epididymitis?
Inflammation of the epididymis, usually caused by local extension of infection from the lower urinary tract.
Give the most common causative organisms for epididymitis, for males aged:
a) <35 years
b) >35 years
a) sexual transmission (ie. Neisseria gonorrhoea, Chlamydia trachomatis)
b) enteric organisms (ie. Escherichia coli, Pseudomonas aeruginosa)
What is mumps orchitis?
A common complication of mumps viral infection in post-pubertal boys is mumps orchitis.
What are the risk factors for epididymitis?
Risk factors for non-enteric causes:
- MSM
- multiple sexual partners
- known contact of gonorrhoea
Risk factors for enteric causes:
- catheterisation
- bladder outlet obstruction (e.g. BPH)
- immunocompromised
What are the clinical features of epididymitis?
- unilateral scrotal pain
- swelling
- fever / rigors
OE affected side is red and swollen, with epididymis tender on palpation. May be associated hydrocoele.
Cremasteric reflex intact; Phren’s sign +ve (pain relieved by elevating testis).
What are the differentials for epididymitis?
- testicular torsion
- testicular trauma
- hydrocoele
- testicular tumour
How should a patient presenting with epididymitis be investigated?
- urine dipstick
- NAAT to assess for N. gonorrhoea + further STI screening
- routine bloods
- blood cultures if systemic infection
- ultrasound imaging
How should epididymitis be managed?
- antibiotic therapy
- sufficient analgesia
- abstain from sexual activity
- counsel on use of barrier contraception
What is urethritis?
Inflammation of the urethra, most commonly due to infection.
Can be classified as either gonococcal or non-gonococcal urethritis.
What is the cause of
a) gonococcal urethritis
b) non-gonococcal urethritis
a) Neisseria gonorrhoea
b) Chlamydia trachomatis
What are the risk factors for urethritis?
- age <25years
- MSM
- previous STI
- new sexual partner
- multiple sexual partners
What are the clinical features of urethritis?
- dysuria
- penile irritation
- discharge from urethral meatus
What are the common complications of urethritis?
- epididymitis
- reactive arthritis
What is reactive arthritis?
A sterile inflammatory arthritis caused by distant infection, producing an autoimmune response at certain joints.
Most commonly caused by Chlamydia trachomatis, Chlamydia pneumoniae.
Presents as an oligoarthritis, affecting the lower limbs, alongside other extra-articular manifestations:
- conjunctivitis
- prostatitis
- painless oral ulcers
- malaise
- fatigue
How should urethritis be investigated?
- MSU
- STI screening
- NAAT of first-void urine for N. gonorrhoea, C. trachomatis
- urethral gram stain under microscopy
Describe the gram stain findings in gonoccocal urethritis.
Most commonly caused by Neisseria gonorrhoea.
Therefore Gram negative diplococci
What is the management of urethritis?
- antibiotic management, specific to causative organism
- abstain for sexual activity throughout antibiotic course
- notify sexual partners
- contact tracing
What is the pathophysiology of testicular torsion?
A mobile testes rotates on the spermatic cord, leading to reduced arterial blood flow, impaired venous return, venous congestion, oedema and infarct of the testes.
Which anatomical deformity increases the risk of testicular torsion?
Bell clapper deformity
The testis lacks a normal attachment to the tunica vaginalis and is therefore more mobile, increasing the likelihood of it twisting on the spermatic cord.
What are the risk factors for testicular torsion?
- age (12-25yrs)
- previous testicular torsion
- family history of testicular torsion
- undescended testes
What are the clinical features of testicular torsion?
- sudden onset
- severe unilateral testicular pain
- n+v
- referred abdominal pain
OE testis in a high position with a horizonal lie. Cremasteric reflex is absent and Phren’s test -ve (pain not relieved when testis raised).
SURGICAL EMERGENCY
How is suspected testicular torsion investigated?
As testicular torsion is a surgical emergency, any suspected case should be taken to theatre for scrotal exploration.
Urine dipstick and Doppler ultrasound can be used to exclude if low suspicion.
How is testicular torsion managed?
Urgen surgical exploration and untwisting of the testis.
The testis are fixed to the scrotum to prevent further torsion episodes.
If the testis is non-viable, orchiectomy may be warranted. Prosthesis can be inserted at the time of surgery or at a later date, at the patient request.
Within how long from the onset of symptoms should testicular torsion be surgically managed?
Within 4-6 hours.
What are the complications of testicular torsion?
- testicular infarction
- atrophy
- chronic pain
- subfertility
- risk of future torsion
What pathology does the ‘blue dot’ sign classically suggest?
Torsion of the hydratid of Morgagni.
The hydatid of Morgagni is a remnant of the Mullerian duct, which can become torted and present similarly to testicular torsion.
Torsion of these structures is more common in younger males, and the scrotum is usually less erythematous with a normal lie of the testes.
The blue dot sign may be present in the upper half of the hemiscrotum, which is the visible infarcted hydratid.
What age group is most commonly affected by testicular tumours?
Males aged 20-40yrs
What are the types of primary testicular tumours?
Germ cell tumours (GCTs) (95%):
- seminoma GCT (SGCT)
- non-seminomatous GCT (NSGCT)
Non-germ cell tumours (NGCTs) (5%):
- Leydig cell tumours
- Sertoli cell tumours
Outline the prognosis of:
a) SGCT
b) NSGCT
c) NGCT
a) remain localised until late; good prognosis
b) metastasise early; poor prognosis
c) benign; very good prognosis
What are the risk factors for testicular tumours?
- cryptorchidism (undescended testes)
- previous testicular malignancy
- positive family history
- Caucasian ethnicity
What are the clinical features of testicular cancer?
- unilateral testicular lump
- painless
OE lump will be irregular, firm, fixed, and does not transilluminate.
Evidence of metastasis may be present with weight loss, back pain, or dyspnoea.
How is suspected testicular cancer investigated?
- tumour markers (ß-HCG, AFP, LDH)
- scrotal ultrasound
- CT CAB imaging with contract
How is testicular cancer staged?
Royal Marsden Classification
1 - disease confined to testes
2 - infra-diaphragmatic lymph node involvement
3 - supra-diaphragmatic lymph node involvement
4 - extra-lymphatic metastatic spread
How is testicular cancer managed?
Should be discussed in specialist MDT. Options include:
- surgery (orchidectomy)
- radiotherapy
- chemotherapy
Give some examples of NSGCTS.
- yolk sac tumour
- choriocarcinoma
- embryonal carcinoma
- teratoma
