Genitalia

Question 1

Describe clinical features of inguinal hernia (vs. hydrocele)

Answer 1

Inguinal hernia (patent processus vaginalis large enough to allow bowel to pass through

• indirect
• boys, premature
• common on right side
• intermittent swelling in groin or scrotum on coughing/ straining
• thickening of scrotum (m)/ round ligament (f)

Hydrocele (patent processus vaginalis narrow enough to prevent formation of inguinal hernia- periteoneal fluid tracking)

• asymptomatic bilateral scrotum swellings
• sometimes blueish colour
• tense or lax, non-tender, transilluminate
• may be present after viral or GI illness

Question 2

Torsion of testes

Answer 2

• causes: bell clapper testes- anatomical predisposition to torsion as testes not anchored properly. Undescended testes.
• common in adolescents
• can occur at any age
• pain scrotum/ groin/ lower abdomen
• sudden onset
• must be relieved within 6-12h - testicular viability
• diagnosis: clinically, surgical exploration, expert doppler of testicular artery

NB torsion of testicular appendage occurs with torsion at the hyatid of Morgagni (embryological remnant on the upper pole of the testis). Affects boys just prior to puberty - enlargement of hyatid due to gonadotrophins. BLUE DOT SIGN. Surgical exploration and excision of appendage leads to rapid resolution of problem

Question 3

Epididymo-orchitis aetiology

Answer 3

• viral/ bacterial
• retrograde passage of urine from the prostatic urethra to the epididymis via the ejaculatory ducts and vas deferens
• Infants: urinary coliforms (eg, E coli, Pseudomonas species, Proteus species, Klebsiella species).
• Ureaplasma urealyticum, Corynebacterium species, Mycoplasma species, and Mima polymorpha have also been isolated.

Question 4

Differentials in acute scrotum

Answer 4

• torsion of testis
• torsion of testicular appendage
• viral/ bacterial epididymo-orchitis/ epididymitis
• idiopathic scrotal swelling
• incarcerated inguinal hernia

Question 5

Natural history of foreskin pathology

Answer 5

• at 1 year, approx. 50% males have non-retractable foreskin
• at 4 years this has declined to 10%
• by 16 year 1% are left with non-retractable foreskin
• ballooning on micturition (physiological)
• preputial adhesions (foreskin partially adherent to the glans)
• white pearls (trapped epithelial sqames)
• both above conditions are asymptomatic and resolve spontaneously

Question 6

Management of Balanitis vs. BXO

Answer 6

Balanposthitis

single attack of redness and inflammation of the foreskin +/- purulent discharge. Warms baths and broad spectrum ABx

BXO

Localised skin disease (balanitis xerotica obliterans)- involves glans penis and urethral meatal stenosis. Circumcision.

Question 7

Management of inguinal hernia

Answer 7

• irreducible hernias can be successfully reduced with opioid analgesia and sustained gentle compression
• surgery delayed 24-48 hours (reduce oedema)
• if no reducible emergency surgery is indicated due to risk of strangulation of bowel and damage to testis
• hernia + undescended testis is operated on to avoid damage to testis
  *

Question 8

Palpable vs. impalpable undescended testes and management

Answer 8

• descent of testes through inguinal canal occurs in third trimester and continues in early childhood
• therefore more common in preterm
• bilateral (cryptochidism) or unilateral
• types:
  
  • ​retractile: testis can be manipulated into the scrotum without tension, subsequent retraction by pulling of cremaster mm. With age testis resides permanently in the scrotum
  • palpable: testis palpable in the groin but cannot be manipulated into the scrotum. Can be ectopic (perineum or femoral triangle)
  • impalpable: no testis felt on detailed examination- either in inguinal canal, abdomen or absent
• management:
  
  • orchidoplexy- surgical placement of testis in the scrotum
    
    • fertility
      
      • optimises spermatogenesis
      • correct temperature
      • after 6m of life descent unlikely
      • orchidoplexy at secon year of life said to optimise fertility
      • unilateral undescended- normal
      • bilateral palpable undescended- 50%
      • bilateral unpalpable undescended- sterile
    • malignancy
      
      • histological abnormalities
      • risk of malignancy
      • bilateral undescended (abdominal) = greatest risk
    • cosmetic and psychological
      
      • prothesis if absent

Question 9

Medical indications and complications of circumcision

Answer 9

Indications

• ​phimosis: whiteish scarring of foreskin. Rare before 5 yo. Localised skin disease (balanitis xerotica obliterans)- involves glans penis and urethral meatal stenosis
• recurrent balanoposthitis: single attack of redness and inflammation of forskin +/- purulent discharge. Common. Responds well to warm baths and broad spec ABx. Recurrent attacks = circumcision indication.
• recurrent urinary tracts: reduces bacterial colonisationwith upper urinary tract anaomlaies and recurrent urinary infection. Spina bifida- urinary catheter

Complications

• healing takes up to 10 days
• bleeding
• infection
• damage to glans
• risk of psychological trauma

Question 10

Clinical features and management of labial adhesions

Answer 10

• asymptomatic
  
  • left alone
  • lyse spontaneously
• perineal soreness or urinary irritation
  
  • ​topical oestrogen BD 1-2 weeks- dissolves adhesions
  • aactive seperation under GA

Question 11

Clinical features and risks of varicociele

Answer 11

• varcosities of testicular veins develop in boys around puberty
• left side
• association with subfertility
• dragging, aching, impaired testicular growth and infertility in later life
• Tx: obliteration of testicular veins (conventional surgery, laparoscopic techniques or radiological embolisation)