Class 7 (2/18/21) Part 2

Question 1

Testicular torsion

Answer 1

• Torsion of the spermatic cord structures
  and subsequent loss of the blood supply to
  the ipsilateral testicle
• Urological emergency, early diagnosis and
  treatment to save the testicle and fertility
• Mostly between 12-18 years of age

Question 2

Symptoms of testicular torsion

Answer 2

• Several unilateral scrotal pain

- Nausea, vomiting

Question 3

Physical examination of testicular torsion

Answer 3

• Unilateral tender, firm testicle
• Scrotal erythema, edema and swelling
• Affected testicle typically higher than the
  unaffected one
• Negative Prehn’s sign
  
  • Relief of scrotal pain by elevating testicle
  • Negative Prehn’s sign indicates no pain relief with lifting the affected testicle, which points towards testicular torsion
• Loss of cremasteric reflex

Question 4

Cremasteric reflex

Answer 4

• Stimulation of the skin on the front and inner thigh retracts the testis on the same side.
• Stimulus usually causes cremasteric muscle
  contraction
• Normal: Cremasteric reflex present (testicle rises).
• Abnormal: Cremasteric reflex absent (no testicle rise)
  -> Suggests Testicular Torsion

Question 5

Treatment of testicular torsion

Answer 5

• Immediate surgery for detorsion
• If not immediately available; Manual Detorsion
• Medial to lateral; “opening a book”
• May need to rotate 2-3 times for complete detorsion

Question 6

Varicocele

Answer 6

• A varicocele is an enlargement of the veins within the loose bag of skin that holds the testicles (scrotum).
• A varicocele is similar to a varicose vein
  you might see in leg.
• Varicoceles are a common cause of low sperm production and decreased sperm quality, which can
  cause infertility.
• Represents the most common cause of infertility in the male.
• Dilated, elongated & tortuous veins
  of the spermatic cord

Question 7

Varicocele causes

Answer 7

• Idiopathic: 90% in the left side
• Tall, thin male
• Obstruction at the place of drainage

Question 8

Varicocele: clinical features

Answer 8

• Most are asymptomatic
• If they do cause symptoms it is usually a vague or annoying discomfort
• Examination shows the typical ‘bag of worms’
• Heavy sensation after walking or standing
• Reduces in size in the supine position
• Varicocele can be associated with infertility

Question 9

Varicocele treatment

Answer 9

• Conservative treatment
  
  • Reassurance
  • Scrotal support
• Surgical treatment
  
  • Varicoceles only need treatment if symptomatic
  • Veins can be ligated via either a scrotal or inguinal approach
  • Recent laparoscopic ligation has been reported
  • Recurrence can occur

Question 10

Hydrocele

Answer 10

• A hydrocele is a collection of fluid in the scrotum.
• A hydrocele is a collection of fluid in a sac in the scrotum next to a testicle (testis). It usually occurs on one side but sometimes a hydrocele forms over both testicles (testes).

Question 11

Pathophysiology of Hydrocele

Answer 11

• The normal testis is surrounded by a smooth protective tissue sac.
• It makes a small amount of ‘lubricating’ fluid to allow the testis to move freely. Excess fluid normally drains away into the veins in the scrotum.
• If the balance is altered between the amount of fluid that is made and the amount that is drained, some fluid accumulates as a hydrocele.

Question 12

CAUSES AND PREDISPOSING FACTORS of Hydrocele

Answer 12

• Most hydroceles are present at birth (congenital), and babies who are born prematurely have a higher risk of having a hydrocele.
• Risk factors for developing a hydrocele later in life include: Scrotal injury (Traumatic/Iatrogenic), Infection including sexually transmitted infections, Tumors.

Question 13

Clinical presentation of Hydrocele

Answer 13

• In the early stages hydroceles are usually asymptomatic. As they enlarge they bulge out and can become a cosmetic problem.
• Symptoms can develop, as the swelling increases in size, which include: Heaviness, fullness, or dragging sensations due to an enlarged scrotum.
• There may be mild discomfort radiating along the inguinal area to the mid portion of the back.
• If pain develops in a Hydrocele it is usually an indication of acute epididymal infection or due to overstretched scrotal skin in huge hydroceles.
• The size may decrease with recumbency or increase in the upright position.
• Fever, chills, nausea, or vomiting indicate an infection of a hydrocele.

Question 14

Physical assessment of Hydrocele

Answer 14

• Smooth, cystic mass completely surrounding the testis and not involving the spermatic cord is characteristic of a hydrocele.
• The consistency of hydroceles can vary with position. Sometimes a hydrocele can become smaller and softer on lying down and become larger and tenser after prolonged standing.
• When the fluid in the hydrocele is clear, Transillumination is positive.

Question 15

Diagnosis differentiation of hydrocele

Answer 15

• Hydroceles are generally painless.
• The presence of pain, redness and edema is suggestive of an inflammatory lesion like epididymitis or
  epididymo-orchitis.

Question 16

Treatment of Hydrocele

Answer 16

• In infancy, Hydrocele usually resolves spontaneously by the time the child reaches the age of 1 years old.
• A hydrocele that persists longer than 12 to 18 months is usually requires treatment.
• In Adults, Treatment depends upon the age of the patient and the degree of discomfort caused by the hydrocele. Surgical excision forms the definitive therapy for hydroceles.
• When they are small and asymptomatic, hydroceles require no treatment other than reassurance.

Question 17

Epididymitis

Answer 17

• Epididymitis is an inflammation of the coiled tube (epididymis) at the back of the testicle that stores and carries sperm.
• Males of any age can get epididymitis.
• Epididymitis is most often caused by a bacterial infection, including sexually transmitted infections (STIs), such as gonorrhea or chlamydia.
• Sometimes, a testicle also becomes inflamed — a condition called epididymo-orchitis.

Question 18

Symptoms of epididymitis

Answer 18

• A swollen, red or warm scrotum
• Testicle pain and tenderness, usually on one side, that usually comes on gradually
• Painful urination or an urgent or frequent need to urinate
• Discharge from the penis
• Pain or discomfort in the lower abdomen or pelvic area
• Blood in the semen
• Less commonly, fever

Question 19

Diagnosis of Epididymitis

Answer 19

• STI screening. A narrow swab is inserted into the end of penis to obtain a sample of discharge from the urethra. The sample is checked in the laboratory for gonorrhea and chlamydia.
• Urine and blood tests. Samples of your urine and blood are analyzed for abnormalities.
• Ultrasound. This imaging test might be used to rule out testicular torsion. Ultrasound with color Doppler can determine if the blood flow to your testicles is lower than normal — indicating torsion — or higher than
  normal, which helps confirm the diagnosis of epididymitis.

Question 20

Treatment of Epididymitis

Answer 20

• Antibiotics are needed to treat bacterial epididymitis and epididymoorchitis.
• If the cause of the bacterial infection is an STI, the sexual partner also needs treatment.
• Resting, supporting the scrotum with an athletic strap, applying ice packs and taking pain medication can help relieve discomfort.

Question 21

Surgery for Epididymitis

Answer 21

• If an abscess has formed, surgery might be needed to drain it.
• Sometimes, all or part of the epididymis needs to be removed surgically (epididymectomy).
• Surgery might also be considered if epididymitis is
  due to underlying physical abnormalities.