Surgery Flashcards
Peptic ulcer disease:
-Which is most common ulcers?
-Describe the pain felt in duodenal ulcer vs gastric ulcer
-What other features may be seen?
Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)
Appendicitis
-Describe the pain
-Give 3 other features
-What is the clinical sign suggestive of appendicitis?
Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Is acute appendicitis common? Who does this most commonly affect? what is the pathogenesis?
Acute appendicitis is the most common acute abdominal condition requiring surgery. It can occur at any age but is most common in young people aged 10-20 years.
Pathogenesis
lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen → gut organisms invading the appendix wall → oedema, ischaemia +/- perforation
Features of appendicitis:
-Describe the pain?
-Is there vomiting or diarrhoea?
-Is the pyrexia?
-Will the patient be hungry
Abdominal pain is seen in the vast majority of patients:
peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation.
the migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis
patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.
Other features:
-vomit once or twice but marked and persistent vomiting is unusual
diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea
-mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
-anorexia is very common. It is very unusual for patients with appendicitis to be hungry
-around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain
Give 4 examination findings of acute appendicitis? what are 2 classical signs
Examination
-generalised peritonitis if perforation has occurred or localised peritonism
-rebound and percussion tenderness, guarding and rigidity
-retrocaecal appendicitis may have relatively few signs
-digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix
classical signs
-Rovsing’s sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value
-psoas sign: pain on extending hip if retrocaecal appendix
Diagnosis of appendicitis
-What is seen on bloods?
-What is seen on urinalysis?
-What imaging can be used?
Diagnosis
-typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy
-a neutrophil-predominant leucocytosis is seen in 80-90%
-urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
-there are no definite rules on the use of imaging and its use is often determined by the patient’s gender, age, body habitus and the likelihood of appendicitis
-thin, male patients with a high likelihood of appendicitis may be diagnosed clinically
-ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion
-CT scans are widely used in patients with suspected appendicitis in the US but this practice has not currently reached the UK, due to the concerns regarding excessive ionising radiation and resource limitations
Describe the management of appendicitis
Management
-appendicectomy
can be performed via either an open or laparoscopic approach
-laparoscopic appendicectomy is now the treatment of choice
-administration of prophylactic intravenous antibiotics reduces wound infection rates
-patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage.
-patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy
-be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease.
-trials have looked at the use of intravenous antibiotics alone in the treatment of appendicitis. The evidence currently suggests that whilst this is successful in the majority of patients, it is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.
Acute pancreatitis
-what is this usually due to
-What 2 symptoms does this cause
-What may be seen on examination?
Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare
Give 10 causes of pancreatitis?
Popular mnemonic is GET SMASHED
Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Give 3 clinical features of biliary colic?
-Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours
-Obstructive jaundice may cause pale stools and dark urine
-It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation
Acute cholecystitis - give 4 clinical features?
History of gallstones symptoms (see above)
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)
What is ascending cholangitis?
Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.
What is charcots triad of ascending cholangitis? What is seen on bloods?
Charcot’s triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
fever is the most common feature, seen in 90% of patients RUQ pain 70% jaundice 60% hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds' pentad)
Other features
raised inflammatory markers
What is the imaging modality used first line for ascending cholangitis?
Investigation
ultrasound is generally used first-line in suspected cases to look for bile duct dilation and bile duct stones
What is the management of ascending cholangitis?
Management
intravenous antibiotics endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
Diverticulitis:
-describe the nature and the site of pain
-What is seen on blood tests? Is there a pyrexia
Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white
Describe the pain felt in abdominal aortic aneurysm? what may the presentation of this look like? what may be in the past medical history?
Severe central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
Patients may have a history of cardiovascular disease
What is an AAA? what is the normal diameter of the infrarenal aorta in females vs males? what is considered aneurysmal? what is the pathophysiology of AAA?
Abdominal aortic aneurysms occur primarily as a result of the failure of elastic proteins within the extracellular matrix. Aneurysms typically represent dilation of all layers of the arterial wall. Most aneurysms are caused by degenerative disease. After the age of 50 years the normal diameter of the infrarenal aorta is 1.5cm in females and 1.7cm in males. Diameters of 3cm and greater, are considered aneurysmal. The pathophysiology involved in the development of aneurysms is complex and the primary event is loss of the intima with loss of elastic fibres from the media. This process is associated with, and potentiated by, increased proteolytic activity and lymphocytic infiltration.
Give 5 causes of AAA
Major risk factors for the development of aneurysms include smoking and hypertension. Rare but important causes include syphilis and connective tissues diseases such as Ehlers Danlos type 1 and Marfan’s syndrome.
Give the interpetation and action for each aorta width:
<3cm
3-4.4cm
4.5-5.4cm
=>5.5
Aorta width Interpretation Action
< 3 cm Normal No further action
3 - 4.4 cm Small aneurysm Rescan every 12 months
4.5 - 5.4 cm Medium aneurysm Rescan every 3 months
≥ 5.5cm Large aneurysm Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients
When should an AAA be referred urgently within 2 weeks to vascular surgery?
high rupture risk
symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year) refer within 2 weeks to vascular surgery for probable intervention treat with elective endovascular repair (EVAR) or open repair if unsuitable. In EVAR a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. A complication of EVAR is an endo-leak, where the stent fails to exclude blood from the aneurysm, and usually presents without symptoms on routine follow-up.
Intestinal obstruction:
-what may be in the past medical history
-What 2 symptoms will be complained of?
-What will be found oe
History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds
What 2 factors point towards pregnancy in abdo swelling?
Young female
Amenorrhoea
Give 2 risk factors which would point towards ascites as a cause of abdo swelling?
History of alcohol excess, cardiac failure
What 2 features would be assoc with urinary retention as a cause of abdo swelling?
History of prostate problems
Dullness to percussion around suprapubic area
Give 6 clinical features which would point towards ovarian cancer as a cause of abdominal swelling?
Older female
Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating
What is a hydatid cyst?
Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed containing multiple small daughter cysts. These cysts are allergens which precipitate a type 1 hypersensitivity reaction.
Give 4 clinical features of hydatid cysts?
Clinical features are as follows:
Up to 90% of cysts occur in the liver and lungs Can be asymptomatic, or symptomatic if cysts > 5cm in diameter Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction) In biliary rupture, there may be the classical triad of; biliary colic, jaundice, and urticaria
What investigations are used for hydatid cysts?
Investigation
imaging
ultrasound if often used first-line
CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts
serology
useful for primary diagnosis and for follow-up after treatment
wide variety of different antibody/antigen tests available
What is the management of a hydatid cyst?
Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first).
what is a hernia? Give 4 risk factors?
The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.
Risk factors for abdominal wall hernias include:
obesity ascites increasing age surgical wounds
Give 5 features of hernia
Features
palpable lump cough impulse pain obstruction: more common in femoral hernias strangulation: may compromise the bowel blood supply leading to infarction
inguinal hernia:
-Are these common?
-where are these located?
-Is strangulation common?
Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia.
Above and medial to pubic tubercle
Strangulation is rare
give 3 clinical features of inguinal hernia
Features
groin lump
superior and medial to the pubic tubercle
disappears on pressure or when the patient lies down
discomfort and ache: often worse with activity,
severe pain is uncommon
strangulation is rare
Describe the management of inguinal hernia
Management
the clinical consensus is currently to treat medically fit patients even if they are asymptomatic
a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients
mesh repair is associated with the lowest recurrence rate
-unilateral inguinal hernias are generally repaired with an open approach
-bilateral and recurrent inguinal hernias are generally repaired laparoscopically
When can a patient return to work after repair of inguinal hernia? what are early and late complications of repair of inguinal hernia?
The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks
Complications
early: bruising, wound infection late: chronic pain, recurrence
Femoral hernia
-Where is this located?
-who is this most commonly found in?
-what is the management and why?
-Below and lateral to the pubic tubercle
-More common in women, particularly multiparous ones
-High risk of obstruction and strangulation
-Surgical repair is required
What is the difference between umbilical and para-umbilical hernia?
Umbilical hernia Symmetrical bulge under the umbilicus
Paraumbilical hernia Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus
Descibe where an epigstric hernia is found? what are 3 risk factors?
Lump in the midline between umbilicus and the xiphisternum
Risk factors include extensive physical training or coughing (from lung diseases), obesity
How common are incisional hernia?
May occur in up to 10% of abdominal operations
Spigelian hernia
-What is this AKA
-What is this?
Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)
What is an obturator hernia?
A hernia which passes through the obturator foramen. More common in females and typical presents with bowel obstruction
What is a richter hernua?
A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
Richter’s hernia can present with strangulation without symptoms of obstruction
Congenital inguinal hernia
-What is this caused by
-How common is this?
-what is the management?
Indirect hernias resulting from a patent processus vaginalis
Occur in around 1% of term babies. More common in premature babies and boys
60% are right sided, 10% are bilaterally
Should be surgically repaired soon after diagnosis as at risk of incarceration
What is an infantile umbilical hernia? who is this most common in? what is the management?
Symmetrical bulge under the umbilicus
More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
Complications are rare
What screening exists for colorectal cancer in the UK?
Overview
most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce mortality by 16% the NHS offers home-based, Faecal Immunochemical Test (FIT) screening to older adults
the NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening
how does a FIT test work? Wjhat is the advantage over FOB?
eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post
a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb)
used to detect, and can quantify, the amount of human blood in a single stool sample
dvantages over conventional FOB tests is that it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet
only one faecal sample is needed compared to the 2-3 for conventional FOB tests
whilst a numerical value is generated, this is not reported to the patient or GP, who will instead be informed if the test is normal or abnormal
patients with abnormal results are offered a colonoscopy
What are the rates of cancer found at colonoscopy post a positive FIT test
At colonoscopy, approximately:
5 out of 10 patients will have a normal exam 4 out of 10 patients will be found to have polyps which may be removed due to their premalignant potential 1 out of 10 patients will be found to have cancer
Stomas - give location / appearance / output of ileostomy
Location - RIF
Appearance - spouted
Output - liquid
Stomas - give location / appearance / output of colostomy
Location - varies, more likely on left side
Appearance - flushed
Output - solid
Stomas - give use and common sites of:
gastrostomy
USE:
-Gastric decompression or fixation
-Feeding
Common site:
Epigastrium
Stomas - give use and common sites of:
loop jejunostomy
use:
-Seldom used as very high output
-May be used following emergency laparotomy with planned early closure
Common site:
any location according to need
Stomas - give use and common sites of:
percutaneous jejunostomy
USE:
Usually performed for feeding purposes and site in the proximal bowel
Common site:
Usually left upper quadrant
Stomas - give use and common sites of:
Loop ileostomy
USE:
Defunctioning of colon e.g. following rectal cancer surgery
Does not decompress colon (if ileocaecal valve competent)
Common site:
Usually RIF
Stomas - give use and common sites of:
end ileostomy
USE:
-Usually following complete excision of colon or where ileocolic anastomosis is not planned
-May be used to defunction colon, but reversal is more difficult
Common site:
RIF
Stomas - give use and common sites of:
end colostomy
USE
Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable
SITE
Either left or right iliac fossa
Stomas - give use and common sites of:
loop colostomy
USE
To defunction a distal segment of colon
Since both lumens are present the distal lumen acts as a vent
SITE
May be located in any region of the abdomen, depending upon colonic segment used
Stomas - give use and common sites of:
Caecostomy
USE
Stoma of last resort where loop colostomy is not possible
SITE
Right iliac fossa
Stomas - give use and common sites of:
Mucous fistula
USE
To decompress a distal segment of bowel following colonic division or resection
Where closure of a distal resection margin is not safe or achievable
Common SITE
May be located in any region of the abdomen according to clinical need
Haemorrhoids
-common location
-treatment
Location: 3, 7, 11 o’clock position
Internal or external
Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy
What are haemorrhoids? Give 4 clinical features1
Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o’clock, 7’o’clock and 11 o’clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic
Clinical features
-painless rectal bleeding is the most common symptom
-pruritus
-pain: usually not significant unless piles are thrombosed
-soiling may occur with third or forth degree piles
What is internal vs external haemorrhoid
External
originate below the dentate line
prone to thrombosis, may be painful
Internal
originate above the dentate line
do not generally cause pain
Give the grading of internal haemorrhoids
Grading of internal haemorrhoids
Grade I Do not prolapse out of the anal canal
Grade II Prolapse on defecation but reduce spontaneously
Grade III Can be manually reduced
Grade IV Cannot be reduced
Give 5 management points for haemorrhoids
Management
-soften stools: increase dietary fibre and fluid intake
-topical local anaesthetics and steroids may be used to help symptoms
-outpatient treatments: rubber band ligation is superior to injection sclerotherapy
-surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Acutely thrombosed external haemorrhoids:
-How do these usually present?
-What is found on examination?
-Describe the management
Acutely thrombosed external haemorrhoids
typically present with significant pain examination reveals a purplish, oedematous, tender subcutaneous perianal mass if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days
Anal fissue
-How does this commonly present
-common site
-what is a chronic fissure?
Typically presents with painful rectal bleeding
Location: midline 6 (posterior midline 90%) & 12 o’clock position. Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae
What are anal fissures?
Give 3 risk factors
Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
Risk factors
constipation inflammatory bowel disease sexually transmitted infections e.g. HIV, syphilis, herpes
Give 3 clinical features of rectal fissures?
Features
-painful, bright red, rectal bleeding
-around 90% of anal fissures occur on the posterior midline.
-if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn’s disease
Give 4 management points of acute anal fissure
Management of an acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
Give 3 management points for chronic anal fissures
Management of a chronic anal fissure
Continue management as per acute fissure topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Ano rectal abscess
-Common organisms 2
-Give 4 positions
E.coli, staph aureus
Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
Anal fistula
-What is this usually due to?
-give 4 locations
Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Goodsalls rule determines location
Rectal prolapse:
-What two things is this assoc with?
Associated with childbirth and rectal intussceception. May be internal or external
Pruritus ani
-What is this most commonly caused by in adults vs children?
Extremely common. In children is often related to worms, in adults may be idiopathic or related to other causes such as haemorrhoids.
What is the commonest anal neoplasm?
Squamous cell carcinoma commonest unlike adenocarcinoma in rectum
solitary rectal ulcer:
-What is this assoc with?
-What is seen on histology?
Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
Scrotal swelling:
what are 3 features of inguinal hernia?
If inguinoscrotal swelling; cannot ‘get above it’ on examination
Cough impulse may be present
May be reducible
Scotal swelling - testicular tumours
-what does this feel like?
-what other symptoms may be present?
-What 3 investigations are necessary?
Often discrete testicular nodule (may have associated hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
Acute epididymo-orchitis
Scrotal swellings, epididymal cysts
-What are these?
-When do these occur?
-Is this painful?
-What site do these occur in and what is found on examination?
-Single or multiple cysts
-May contain clear or opalescent fluid (spermatoceles)
-Usually occur over 40 years of age
-Painless
-Lie above and behind testis
-It is usually possible to ‘get above the lump’ on examination
Epididymal cysts:
-Are these common?
-Give 3 associated conditions
-How may this be diagnosed?
-what is the management?
Epididymal cysts are the most common cause of scrotal swellings seen in primary care.
Features
separate from the body of the testicle found posterior to the testicle
Associated conditions
polycystic kidney disease cystic fibrosis von Hippel-Lindau syndrome
Diagnosis may be confirmed by ultrasound.
Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.
Scrotal swellings, hydrocele
-What does this feel like on examination?
-What other tests can be done at the bedside?
-what may this indicate in young men?
-Non painful, soft fluctuant swelling
-Often possible to ‘get above it’ on examination
-Usually contain clear fluid
-Will often transilluminate
-May be presenting feature of testicular cancer in young men
What is a hydrocele? what is communicating vs non-communicating? What may hydroceles develop secondary to?
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life non-communicating: caused by excessive fluid production within the tunica vaginalis
Hydroceles may develop secondary to:
epididymo-orchitis testicular torsion testicular tumours
Give 4 features of hydrocele? How is this diagnosed?
Features
-soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
-the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
-transilluminates with a pen torch
-the testis may be difficult to palpate if the hydrocele is large
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Testicular torsion
-How does this present?
-Who does this typically affect?
-what is found on examination?
-What is the management?
-Severe, sudden onset testicular pain
-Risk factors include abnormal testicular lie
-Typically affects adolescents and young males
-On examination testis is tender and pain not eased by elevation
-Urgent surgery is indicated, the contra lateral testis should also be fixed
What is a varicocele? Where do these most commonly occur? what may this indicate?
-Varicosities of the pampiniform plexus
-Typically occur on left (because testicular vein drains into renal vein)
-May be presenting feature of renal cell carcinoma
-Affected testis may be smaller and bilateral varicoceles may affect fertility
What are varicoceles classically described as?
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Varicoceles are much more common on the left side (> 80%). Features:
classically described as a 'bag of worms' subfertility
What is the diagnosis and management of varicocele?
Diagnosis
ultrasound with Doppler studies
Management
usually conservative occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility -A solitary right-sided varicocele requires urgent referral to a urologist
Describe the management of testicular malignancy?
Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour.
Describe the management of epididymal cysts
Epididymal cysts can be excised using a scrotal approach
Describe the management of hydrocele
Management
-infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
-in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated
Testicular cancer:
-is this common?
-How are these categorised?
Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into:
seminomas non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma
Non-germ cell tumours include Leydig cell tumours and sarcomas.
When is the peak incidence of teratomas / seminomas? give 5 risk factors
The peak incidence for teratomas is 25 years and seminomas is 35 years. Risk factors include:
infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter's syndrome mumps orchitis
Give 4 features of testicular cancer
Features
a painless lump is the most common presenting symptom
pain may also be present in a minority of men
hydrocele
gynaecomastia
-this occurs due to an increased oestrogen:androgen ratio
-germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone
- leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens
What are the tumour markers found in germ cell tumours?
Tumour markers in germ cell tumours
seminomas: hCG may be elevated in around 20%
non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
LDH is elevated in around 40% of germ cell tumours
what is the diagnosis and management of testicular cancer?
Diagnosis
ultrasound is first-line
Management
-treatment depends on whether the tumour is a seminoma or a non-seminoma
-orchidectomy
-chemotherapy and radiotherapy may be given depending on staging and tumour type
Describe the prognosis of seminomas and teratomas in testicular cancer
Prognosis is generally excellent
5 year survival for seminomas is around 95% if Stage I 5 year survival for teratomas is around 85% if Stage I
Acute bacterial prostatitis - what is this typically caused by? give 4 risk factors?
Acute bacterial prostatitis is typically caused by gram-negative bacteria entering the prostate gland via the urethra.
Escherichia coli is the most commonly isolated pathogen.
Risk factors for acute bacterial prostatitis include recent urinary tract infection, urogenital instrumentation, intermittent bladder catheterisation and recent prostate biopsy.
Give 3 features of acute bacterial prostatisis? what is found on DRE?
Features
-the pain of prostatitis may be referred to a variety of areas including the perineum, penis, rectum or back
-obstructive voiding symptoms may be present
-fever and rigors may be present
-digital rectal examination: tender, boggy prostate gland
What is the management of acute bacterial prostatitis?
Management
Clinical Knowledge Summaries currently recommend a 14-day course of a quinolone consider screening for sexually transmitted infections
What is the management of chronic prostatitis?
A prolonged course of a quinolone is often recommended. There has been some debate as to whether prostatic massage has improved outcomes, though no conclusive data published to date.
