Scrotum

Question 1

approach to scrotal lump

Answer 1

cannot get above

• hernia
• infantile hydrocele

can get above
- testes and epididymis felt together
> opaque
--> tender: EO, acute hematocele, torsion
--> non tender: chronic hematocele, gumma, tumor
> transilluminable = hydrocele
- felt separately
> opaque
--> tender: EO
--> non tender
testes swell: tumour
epi swell: TB epididymis
> transilluminable = epididymal cyst

Question 2

testicular tumour

• RF
• types
• tumour markers

Answer 2

RF: cryptorchidism, HIV, gonadal dysgenesis

types: teratoma (20-30yo) vs seminoma (30-40)
others - embryonal, choriocarcinoma, yolk sac, Leydig, Sertoli, lymphoma

tumour markers: LDH, AFP, bHCG

Question 3

staging of testicular tumour

Answer 3

􏰀Stage 1 = testis lesion, no nodes involved
stage 2 = nodes below diaphragm
stage 3 = nodes above diaphragm
stage 4 = pulmonary and hepatic metastasis

Question 4

Hydrocele

• types
• secondary causes

Answer 4

types: vaginal hydrocele (only in tunica vaginalis), cord, congenital, infantile
sec: testicular tumour, torsion, trauma, orchitis, post inguinal hernia repair

Question 5

Tx of hydrocele

Answer 5

conservative:

• congenital: watch for 1year, sx if unresolved by 2.5-3y
• aspirate
• exclude 2nd cause (us scrotum)

sx:

• lord plication of sac
• Jaboulay operation to evert sac

Question 6

typical clinical features in testicular torsion

• epidemiology
• PE

Answer 6

Epidemiology

• in peri pubertal grp (12-18)
• acute abdomen (T10)
• acute testicular pain and swelling w N&V
• previous attack of self limiting pain, ppt by trauma, cycling, straining, coitus

PE

• high riding swollen tender scrotum, testes in transverse lie
• absent cremesteric reflex
• neg prehn

Question 7

RF for testicular torsion

Answer 7

cryptorchidism

mal-descended testes

Question 8

Tx of testicular torsion

- when is it irreversible?

Answer 8

E-exploration if doppler us neg for flow or high clinical suspicion

• untwisting and bilateral orchidopexy
• warm up with warm pad to see reperfusion/ check doppler
• dead > prosthesis

12 h after ischemia - irreversible

Question 9

nutcracker effect?

Answer 9

left renal vein compressed between aorta and SMA (thus higher pressure in L > R renal vein)

Question 10

Classification of varicocele

Answer 10

subclinical: non palpable, vein>3mm on us, doppler reflux on valsava

grade I: palpable w valsava only
grade II: palp at rest, not visible
grade III: easily visible

Question 11

Tx of varicocele

Answer 11

Conservative: scrotal support, NSAID (risk of infertility)
Sx:
- transfemoral angiographic embolisation with coil/sclerosant’
- surgical ligation

Question 12

Fournier gangrene RF

Answer 12

diabetics, alcoholics, immunocompromised

Question 13

Source of infx of Fournier gangrene

Answer 13

idiopathic (36%)
Colorectal (21%) - ruptured appendicitis, CRC, perirectal abscess
Genitourinary (19%) - urethral stone, stricture, fistula
Dermatological (24%)

Question 14

Mgx of Fournier gangrene

Answer 14

wide spectrum abx - penicillin G, ceftazidime, clindamycin

wide surgical debridement of necrotic tissue with aggressive post op support (testes often spared - discrete blood supply)

Question 15

Paraphimosis

• RF
• Cx
• Mgx

Answer 15

RF: Phimosis, tight foreskin
CX: Gangrene, ischemia, Balanitis

1. injection of LA, compression of swollen foreskin for several minutes
2. osmotic agents (50% dextrose), ice, compression bandage applied
3. Manual reduction of constricted foreskin over glands penis