Reproductive System - Level 1 Flashcards
Definition of testicular torsion?
- Torsion of spermatic cord which occludes testicular blood vessels and leads to ischaemia, resulting in loss of testis
- Testicular torsion must be excluded in children with acute scrotal pain
Epidemiology of testicular torsion?
- Peak incidence at 12-25 years old
- Usually around puberty
- Left side most common
Pathology of testicular torsion?
- Suggested to be due to increase in scrotal mass at puberty
- Trauma could precede torsion
Types of testicular torsion?
Intravaginal
Secondary to lack of normal fixation of posterior lateral aspect of testes to tunica vaginalis
Testis being free to swing and rotate within tunica vaginalis of scrotum
Bell-clapper deformity
Extravaginal
Often in neonates and occurs in utero or around birth before testis is fixed in scrotum by gubernaculum
Symptoms of testicular torsion?
Sudden onset unilateral severe scrotal pain
Walking uncomfortable, may radiate into abdomen, groin and leg
Often comes on during sport or physical activity
Nausea & Vomiting
Signs of testicular torsion?
• Tender, hot, swollen testis
• May lie higher than other testes
• Overlaying scrotal skin may be reddened and oedematous
• Lifting testis up over symphysis increases pain (unlike epididymitis where it is relieved)
• Bell clapper’ deformity.
Horizontal long axis
• Absence of cremasteric reflex
How to differentiate between of testicular torsion & epididymitis?
- Epididymitis
• Distinguished from testicular torsion as there is no improvement of the pain on elevating the scrotum, whereas the pain improves in cases of epididymitis (Prehn’s sign)
How to differentiate between of testicular torsion & torsion of epididymal appendage?
- Torsion of Epididymal Appendage (Hydatid of Morgani)
• Usually between 7-12y and tiny blue nodule under skin, due to surge in gonadotrophins
How to differentiate between of testicular torsion & hydrocele?
- Hydrocele
• Swelling usually painless, scrotum transilluminates
Assessment of testicular torsion?
Urinalysis
• Exclude infection and epididymitis
Do not delay referral – early referral & surgery
• Doppler USS to look at blood flow may differentiate between epididymitis
Management of testicular torsion?
If testicular torsion is suspected, admit immediately to urology for surgery
• NBM and analgesia
• Urgent Surgical exploration
Midline scrotal incision, untwisted and assessed for viability, if viable bilateral fixation (orchidopexy) and possible orchidectomy (if not viable)
Contralateral testis should also be fixed
Prognosis of testicular torsion?
- If surgery performed within 6h – salvage rate 90-100%
- If >24h – 0-10%
Complications of testicular torsion?
- Infarction, atrophy and cosmetic deformity of testis
- Subfertility/Infertility (absence of one testicle usually has no effect on fertility
Definition of ectopic pregnancy?
- Gestational sac implantation outside the uterus
- Consider in any young female presenting with abdominal pain and vaginal bleeding especially with syncope
Pathology of ectopic pregnancy?
o Implantation of gestational sac in Fallopian tubes may have three results:
Extrusion (tubal abortion) into peritoneal cavity
Spontaneous involution of pregnancy
Rupture through the tube causing pain and bleeding
o Implantation in uterine horn is particularly dangerous, may reach 10-14 weeks pregnancy before rupture
Epidemiology of ectopic pregnancy?
- Commonest cause of maternal mortality in first trimester
- Occurs in about 1% of pregnancies
o 96% fallopian tubes, 2% interstitial part of uterus, 1.5% intra-abdominally - 1 in 2000 lead to death
Risk factors of ectopic pregnancy?
o PID o Pelvic surgery/adhesions o Previous ectopic o Endometriosis o Assisted fertilisation o IUCD o Progesterone-only pill o Anatomical variants o Ovarian and uterine cysts o Smoking
Symptoms of ruptured ectopic pregnancy?
o Sudden severe lower abdominal pain
Can be more chronic
May be worse on defecation
o Collapse or fainting
o Vaginal bleeding – may have history of amenorrhoea 6-8 weeks
May be fresh, dark (like prune juice) and irregular
o Haemorrhage may cause shoulder tip pain (from blood irritating diaphragm)
o Nausea and vomiting
o Symptoms of pregnancy – breast tenderness
Symptoms of chronic unruptured ectopic pregnancy?
Often asymptomatic (e.g. unsure dates)
Amenorrhea (usually 6-8 weeks)
Pain (lower abdominal, often mild and vague, classically unilateral)
Vaginal bleeding (usually small amount, often brown)
Shoulder tip pain (diaphragmatic irritation from intra-abdominal blood)
Diarrhoea
Often have no specific signs:
Uterus usually normal size
Cervical excitation/tenderness occasionally.
Adnexal tenderness
Adnexal mass (very rarely)
Signs of ectopic pregnancy?
o Hypovolaemic shock
o Abdominal tenderness – peritonism
o Bimanual vaginal examination - Tender adnexa and sometimes a mass
o Speculum shows vaginal blood
When to refer to A&E of ectopic pregnancy?
- Refer to A&E if haemodynamically unstable or significant degree of pain or bleeding
When to refer to EPAU in ectopic pregnancy?
o If pregnancy test positive and pain/pelvic tenderness/cervical motion tenderness
o Bleeding and pain/pregnancy of >6 weeks gestation/pregnancy of unknown gestation
Investigations in ectopic pregnancy?
Pregnancy test – usually positive
Transvaginal/transabdominal USS (if uterine enlarged, or woman does not accept TV)
o Adnexal mass (moving separate to ovaries (sliding sign)), with gestational sac with yolk sac
o Empty uterus
o Fluid in uterine cavity
o Free fluid in pouch of Douglas
o Transvaginal better
May need laparoscopy
Initial management of ruptured ectopic pregnancy?
o Oxygen and IV access (two wide bore cannulas)
o Bloods (FBC, group and save (cross-match 6U of blood))
o Request Rhesus status and antibody status
o IV fluids (Crystalloid)
o Refer to gynaecology
o Urgent surgery – alert anaesthetist and surgeon/theatre team
Laparoscopy
Laparotomy if haemodynamically unstable
If contralateral tube healthy then salpingectomy, if not then salpingotomy
Management of ectopic pregnancy - when to offer expectant therapy?
• If asymptomatic, hCG <1000IU/l, <3.5cm on scan with no visible heartbeat and able to return for follow-up
o Consider if hCG between 1000-1500 too
Management of ectopic pregnancy - what is expectant therapy?
Take serum hCG on day 2, 4 and 7 and if:
o hCG drops >15% from previous value, repeat weekly until <20IU/L or
o hCG does not fall by >15%, stay the same or rises, review condition and seek advice
Management of ectopic pregnancy - when to offer medical management?
Offer medical (Methotrexate) or surgery
o Can return for follow up with no significant pain, adnexal mass <35mm, no heartbeat, serum hCG<1500IU/l, no intrauterine pregnancy
o If hCG 1500-5000 – offer choice of methotrexate or surgery
Management of ectopic pregnancy - what is the medical management?
o Methotrexate
o Measure serum hCG at day 4, 7 after treatment and then weekly until negative result attained
o Sexual intercourse should be avoided during treatment and reliable contraception used for 3 months after as methotrexate is teratogenic
Management of ectopic pregnancy - when to offer surgery?
o If unable to return to follow-up or significant pain, adnexal mass >35mm, foetal heartbeat, serum hCG >5000
o Give choice if bHCG 1500-5000
Management of ectopic pregnancy - what surgery to perform?
Performed laparoscopically
Offer salpingectomy unless other risk factors for infertility
Take urine pregnancy test after 3 weeks, return if positive
Salpingotomy alternative if risk factors (contralateral tube damage)
Measure serum hCG at 7 days and weekly until negative
Management of ectopic pregnancy - when to offer Anti-D prophylaxis?
Anti-D rhesus 250IU to all Rh negative women with surgical procedure
Prognosis of ectopic pregnancy?
o If untreated, spontaneous abortion in 50% of cases
o Recurrence rate in 20%
Complications of ectopic pregnancy?
o Tubal rupture
o Recurrent ectopic pregnancy
o Psychological effects
