Genitalia

Question 1

DDX for lump in scrotum

Answer 1

Testicular cancer until proven otherwise!
Hydrocoel
Epididymal cyst or spermatocele
Hernia
Varicocoel
Benign tumour - lipoma
Lymphoma 
Skin: 
- Idiopathic scrotal oedema 
- Skin cancer
- Sebaceous cyst

Question 2

Presentation of testicular cancer

What investigations?

Answer 2

Hard PAINLESS lump in scrotum, appearing over history of months (fast growing)

Young male

Past HX cryptochordism

INV:
- scrotal U/S looking for distorted architecture
- Serum tumour markers alpha fetoprotein, beta-HCG and LDH
- Abdo CT and CXR (staging - mets to lungs, and retroperitoneal lymph nodes)
+/- brain CT and bone scan (mets to brain, bone)

Question 3

Markers of testicular cancer

Answer 3

Alpha fetoprotein
BEta-HCG

LDH is non-specific tumour market

*not always elevated but performed for surveillance and progress purposes)

Question 4

Treatment of testicular cancer

Answer 4

Inguinal orchidectomy
Bleomycin, Etopicide and Plisplatin (BEP) x4 courses

+/- Retroperitoneal lymph node dissections

Question 5

DDX for acute scrotum (new onset scrotal pain +/- swelling, tenderness, erythema)

Answer 5

Testicular torsion 
Appendage torsion 
Epididymitis
Scrotal edema 
Orchitis
Hernia
Trauma
Hydrocoel 
Varicocele

Question 6

Investigations for acute scrotum?

Answer 6

Dipstick 
MSU urinalysis
Urethral swab
Testicular U/S w doppler 
Surgical exploration

Question 7

What are factors pre-disposing to testicular torsion?

Answer 7

Bell-clapper deformity (Testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels)

Cryptochordism

Question 8

Presentation of testicular torsion

Answer 8

15-20 year old males
Rapid onset unrelenting testicular pain, nausea and vomiting
Testes higher than normal, tender, firm +/- swelling
thickened spermatic cord with ABSENT cremasteric reflex

Question 9

Treatment of testicular torsion

Answer 9

○ Urological emergency - 6 hour window before irreversible ischaemia occurs.

○ Needs surgery
Fixation +/- dartos pouch -> DO BOTH SIDES WHILE YOU’RE THERE!

Question 10

Appendage torsion:
- clinical presentation

Treatment

Answer 10

8-10 year old boys
Testicular pain
Palpation reveals small firm nodule on upper portion of testes with characteristic “blue dot” sign

Active cremasteric reflex

Treatment:

• analgesia with self-resolution within 2-3 days
• OR surgical dissection

Question 11

Presentation of epidymitis and orchitis

Answer 11

Sudden onset scrotal pain +/- radiation along cord to flank
Scrotal erythema, tenderness +/- lump if large abscess present
FEVER
Storage or inflammatory LUTS, purulent discharge

Resembles testicular torsion!

Question 12

Causes of and investigations for epidymitis and orchitis

Answer 12

young people: N. gonorrhoea or chlamydia trachoma’s

older people: With penetrative anal intercourse: GI organisms (E Coli), or urinary tract pathogens (KEEPS)

Mumps, Tb

INV:

• U/A for MCS
• urethral D/C swap for gram stain and PCR
• Doppler U/S or surgical exploration if torsion is a DDX

Question 13

Risk factors epididymitis and orchitis

Answer 13

1. UTI
2. Unprotected sexual intercourse
3. Instrumentation/catheterisation
4. Reflux
5. Immunocompromised

Question 14

Presentation of prostatitis

Answer 14

Acute bacterial: acute onset fever, chills, malaise, rectal/lower back/perineal pain and LUTS

Chronic: Pelvic pain, ejaculatory and post-ejaculatory pain + storage LUTS. Recurrent exacerbations of acute bacterial prostatitis or recurrent UTI.

Question 15

Investigations and Treatment of prostatitis

Answer 15

Investigations: Pelvic x-ray +/- U/S, Urinalysis, blood FBE and cultures.

Supportive care
PO or IV antibiotics depending on severity
+/- catheterisation depending on level of obstruction

Consider alpha blocker with chronic prostatitis

Question 16

Treatment of epidymitis

Answer 16

Elevation
Analgesia
Empiric antibiotics for GNB and STI coverage (Trimethoprim, cephalexin or augmentin, AND cefriazone or azithromycin)

STI screen and contact tracing

Question 17

What is Fournier’s gangrene?

Answer 17

○ Necrotising fasciitis of testes and perineum

○ Life-threatening spreading cellulitis and necrosis of skin and subcut fat

○ Typically presents with “crackling” of skin on examination

○ Needs aggressive debridement with skin grafts etc

○ Often in diabetic patients

Question 18

What is a haematocoel and how can it be caused?

Investigations and treatment?

Answer 18

Caused by trauma -> bleeding into space under tunica vaginalis .

Visualise any testicular rupture with U/S -> surgical exploration and evaculation/repair or orchidectomy + empirical antibiotics to prevent secondary abscess formation

Question 19

What leads to hydrocoeal?

Answer 19

in infants - congenital Patent processus vaginalis means free fluid in abdomen can leak into the space next to the testes causing painless enlargement

In adults, can be due to infection/inflammation, or neoplasm in testes

Question 20

What causes a varicocele? How does this present?

Answer 20

Abnormal enlargement of the pampiniform venous plexus (veins or spermatic cord) in the scrotum due to defective valves.
RARELY caused by RCC leading to venous congestion.

Presents as achy scrotal pain, worse at end of day, palpable and sometimes visible tortuous vein(s) in scrotum (‘bag of worms’) - often L side of scrotum

Question 21

What are the 3 most common forms of testicular cancer?

Answer 21

Seminoma
Mixed germ cell
lymphoma

Question 22

Why are most varicocoels on the left?

Answer 22

Because the L testicular vein drains into the L renal vein at a 90 degree angle which is can be difficult (vs R testicular veins drains into the R SVC at a lesser angle)

Question 23

What is idiopathic scrotal oedema?

Answer 23

Unilateral but more often bilateral swelling, red, warmth but non-tender testes

Causes:

• Wall thickened due to allergic response to insect bite, common in boys under 10
• or due to CCF or nephrotic syndrome in older patients