Reproductive System - Level 1

Question 1

Definition of testicular torsion?

Answer 1

• 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

Question 2

Epidemiology of testicular torsion?

Answer 2

• Peak incidence at 12-25 years old
• Usually around puberty
• Left side most common

Question 3

Pathology of testicular torsion?

Answer 3

• Suggested to be due to increase in scrotal mass at puberty

- Trauma could precede torsion

Question 4

Types of testicular torsion?

Answer 4

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

Question 5

Symptoms of testicular torsion?

Answer 5

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

Question 6

Signs of testicular torsion?

Answer 6

• 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

Question 7

How to differentiate between of testicular torsion & epididymitis?

Answer 7

• 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)

Question 8

How to differentiate between of testicular torsion & torsion of epididymal appendage?

Answer 8

• Torsion of Epididymal Appendage (Hydatid of Morgani)

• Usually between 7-12y and tiny blue nodule under skin, due to surge in gonadotrophins

Question 9

How to differentiate between of testicular torsion & hydrocele?

Answer 9

• Hydrocele

• Swelling usually painless, scrotum transilluminates

Question 10

Assessment of testicular torsion?

Answer 10

Urinalysis
• Exclude infection and epididymitis

Do not delay referral – early referral & surgery
• Doppler USS to look at blood flow may differentiate between epididymitis

Question 11

Management of testicular torsion?

Answer 11

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

Question 12

Prognosis of testicular torsion?

Answer 12

• If surgery performed within 6h – salvage rate 90-100%

- If >24h – 0-10%

Question 13

Complications of testicular torsion?

Answer 13

• Infarction, atrophy and cosmetic deformity of testis

- Subfertility/Infertility (absence of one testicle usually has no effect on fertility

Question 14

Definition of ectopic pregnancy?

Answer 14

• Gestational sac implantation outside the uterus

- Consider in any young female presenting with abdominal pain and vaginal bleeding especially with syncope

Question 15

Pathology of ectopic pregnancy?

Answer 15

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

Question 16

Epidemiology of ectopic pregnancy?

Answer 16

• 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

Question 17

Risk factors of ectopic pregnancy?

Answer 17

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

Question 18

Symptoms of ruptured ectopic pregnancy?

Answer 18

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

Question 19

Symptoms of chronic unruptured ectopic pregnancy?

Answer 19

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)

Question 20

Signs of ectopic pregnancy?

Answer 20

o Hypovolaemic shock
o Abdominal tenderness – peritonism
o Bimanual vaginal examination - Tender adnexa and sometimes a mass
o Speculum shows vaginal blood

Question 21

When to refer to A&E of ectopic pregnancy?

Answer 21

• Refer to A&E if haemodynamically unstable or significant degree of pain or bleeding

Question 22

When to refer to EPAU in ectopic pregnancy?

Answer 22

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

Question 23

Investigations in ectopic pregnancy?

Answer 23

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

Question 24

Initial management of ruptured ectopic pregnancy?

Answer 24

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

Question 25

Management of ectopic pregnancy - when to offer expectant therapy?

Answer 25

• 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

Question 26

Management of ectopic pregnancy - what is expectant therapy?

Answer 26

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

Question 27

Management of ectopic pregnancy - when to offer medical management?

Answer 27

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

Question 28

Management of ectopic pregnancy - what is the medical management?

Answer 28

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

Question 29

Management of ectopic pregnancy - when to offer surgery?

Answer 29

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

Question 30

Management of ectopic pregnancy - what surgery to perform?

Answer 30

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

Question 31

Management of ectopic pregnancy - when to offer Anti-D prophylaxis?

Answer 31

Anti-D rhesus 250IU to all Rh negative women with surgical procedure

Question 32

Prognosis of ectopic pregnancy?

Answer 32

o If untreated, spontaneous abortion in 50% of cases

o Recurrence rate in 20%

Question 33

Complications of ectopic pregnancy?

Answer 33

o Tubal rupture
o Recurrent ectopic pregnancy
o Psychological effects