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YR3 Renal + Urology > Testicular conditions > Flashcards

Testicular conditions Flashcards

1
Q

Define epididymitis and orchitis

A

Inflammation of the epididymis (epididymitis) or testes (orchitis)

  • 60% of epididymitis is associated with orchitis
  • Most cases of orchitis are associated with epididymitis
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2
Q

Explain the aetiology/risk factors of epididymitis and orchitis

A

Most cases are INFECTIVE in origin

Bacterial

  • If < 35 yrs: Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium.​
  • If > 35 yrs: enteric pathogens- mainly coliforms (e.g. Enterobacter, Klebsiella)
    • ​associated with bladder outlet obstruction, recent instrumentation of the urinary tract, or systemic illness.
  • RARE: TB, syphilis

Viral

  • Mumps
  • Fungal
  • Candida if immunocompromised

1/3 are IDIOPATHIC

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3
Q

Explain the risk factors of epididymitis and orchitis

A
  • unprotected sexual intercourse
  • bladder outflow obstruction- secondary to bladder neck obstruction, benign prostatic hyperplasia, or urethral stricture
  • instrumentation of urinary tract- increased risk of UTI which spreads
  • immunosuppression- from a variety of causes, including transplant recipients, HIV, and diabetes

LESS COMMON:

  • vasculitis- most commonly Behçet’s syndrome and Henoch-Schönlein purpura.
  • amiodarone (drug induced)
  • mumps- viral epididymitis is rare in the adult population
  • exposure to tuberculosis (TB)
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4
Q

Summarise the epidemiology of epididmytis and orchitis

A

The most common cause of acute scrotal pain is epididymitis.

May present at any age, with the majority of patients aged 20 to 39 years

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5
Q

Recognise the presenting symptoms of epididymitis and orchitis

A

Main symptom:

Unilateral scrotal pain and swelling of gradual onset

  • Pain and swelling typically develops over the course of a few days
  • >6 week’s duration suggests chronic inflammation not epididymitis
  • unlike testicular torsion, which is usually of sudden/acute onset

Other symptoms:

  • Penile/purulent urethral discharge – found on primary catch urine sample
  • Dysuria, frequency
  • Pyrexia
  • IMPORTANT: ask about sexual history
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6
Q

Recognise the signs of epididymitis and orchitis on physical examination

A
  • Tenderness
  • Hot, erythematous, swollen hemiscrotum
  • Eliciting a cremasteric reflex may be painful
  • Fluctuant swelling or induration of scrotal tissue- may represent a reactive hydrocele or abscess formation.
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7
Q

Wat are the goals of treatment for epididymitis and orchitis?

A

The general goals in the treatment of acute epididymitis are:

  1. Symptomatic relief
  2. Eradication of infection if present
  3. Prevention of transmission to others (sexually transmitted epididymitis)
  4. Prevention of potential complications (e.g., abscess formation, infertility, or chronic pain/epididymitis).
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8
Q

Generate a management plan for epididymitis and orchitis

A

Medical

Antibiotics- for 2-4 weeks

  • If <35 yrs, doxycycline (covers chlamydia). If gonorrhoea suspected, add ceftriaxone. Treat sexual partners!
  • If >35 yrs (mostly non-STI), associated UTI is common so try ciprofloxacin or ofloxacin

Analgesia + scrotal support

Surgical

  • Exploration of testicles if testicular torsion cannot be excluded clinically
  • Required if an abscess develops – abscess drainage
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9
Q

Identify possible complications of epididymitis and orchitis

A
  • Pain
  • Abscess
  • Fournier’s gangrene (if the infection is left untreated and
  • spreads)
  • Mumps orchitis could cause testicular atrophy and fertility issues
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10
Q

Summarise the prognosis for patients with epididymitis and orchitis

A
  • GOOD if treated
  • May take up to 2 months for the swelling to resolve
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11
Q

Define hydrocoele

A

Collection of serous fluid between the layers of the membrane (tunica vaginalis) that surrounds the testis or along the spermatic cord.

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12
Q

Explain the risk factors of hydrocoeles

A
  • male sex
  • prematurity and low birth weight
  • infants <6 months of age
  • infants whose testes descend relatively late
  • increased intraperitoneal fluid or pressure (e.g., following shunts, peritoneal dialysis, or ascites) if there is a patent processus vaginalis.
  • Inflammation or injury within the scrotum
  • connective tissue disorders
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13
Q

State some causes of hydroceles

A

Congenital

  • most paediatric, resolved within 1 year

Non-communicating hydroceles

found secondary to :

  • minor trauma
  • infection
  • testicular torsion
  • epididymitis
  • varicocele operation
  • testicular tumour

reactive, inflammatory response.

Communicating hydroceles

May occur following:

  • increased intra-abdominal fluid or pressure (due to shunts, peritoneal dialysis, or ascites)
  • if there is a patent processus vaginalis
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14
Q

Summarise the epidemiology of hydrocoeles

A
  • They are common in male infants and children and in many cases are associated with an indirect inguinal hernia.
    • Approximately 1% to 3% of full-term infants
  • The incidence in adult men is not known
  • Approximately 10% of testicular malignancies are thought to present with hydroceles
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15
Q

Recognise the presenting symptoms of hydrocoeles

A
  • Variable scrotal swelling/mass
    • mass increases in size with activities such as coughing, straining, crying, or raising the arms
    • size of the mass will be smaller in the morning than in the evening and after lying down.
  • vague sensation of heaviness
  • Patients may complain of pain or urinary symptoms due to the underlying cause
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16
Q

Recognise the signs of hydrocoeles on physical examination

A

Non-tender scrotal mass

  • Likely to be soft if the communication is large or tense if it is small.
  • It may be restricted to the scrotum or it may extend into the inguinal canal.

Transillumination

  • Because of the fluid, most hydroceles are easily transilluminated when a focused beam of light is shone on the scrotum.

in cases of tense hydroceles or thick sacs, the testis may not be palpable.

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17
Q

Identify appropriate investigations for hydrocoeles

A

Hydroceles are relatively straightforward to diagnose. History and physical examination should be diagnostic and other tests are rarely needed

  1. Scrotal USS- if there is:
    • inability to palpate the testis
    • suggestion of underlying pathology (e.g.fever, GI symptoms such as D+V or shadow on transillumination)
    • Raise the suggestion of a different diagnosis or some additional underlying pathology
  2. Urine - dipstick and MSU for infection
  3. Blood - markers of testicular tumours:
    • a-fetoprotein
    • b-HCG
    • Lactate dehydrogenase
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18
Q

Define varicocoele

A

An abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis, forming a scrotal mass

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19
Q

Explain the pattern of growth of varicocoele

A

90% of cases on left side; 10% are bilateral because of:

  • Lack of effective valves between the left testicular vein and left renal vein- most commonly thought to be caused by incompetent valves within the left internal spermatic vein.
  • The angle at which the left testicular vein meets the left renal vein
  • The left internal spermatic vein is 8 to 10 cm longer, resulting in increased hydrostatic pressure transmission.
  • Increased reflux from compression of the renal vein (between the superior mesenteric artery and the aorta)
20
Q

Summarise the epidemiology of varicocoele

A
  • Unusual in boys under 10 yrs old
  • Incidence increases after puberty
  • Incidence: 10-15% in general population
  • The majority (>80%) of adult varicoceles are not associated with infertility. However, the prevalence of varicocele is greater in patients with reduced fertility.
21
Q

Recognise the presenting symptoms of varicocoele

A

An adult patient with a varicocele is usually asymptomatic and will typically present after failed attempts at conception, seeking an evaluation for infertility.

  • 2-10% have symptoms
  • Scrotum feels like a bag of worms
  • Scrotal heaviness
  • Often visible as distended scrotal blood vessels
  • May feel dull ache
  • Small testicle- larger varicoceles are associated with higher incidence of testicular growth arrest
22
Q

Recognise the signs of varicocoele on physical examination

A

Patient must be STANDING for examination

  • The side of the scrotum with the varicocoele will hang lower
  • The swelling may reduce when lying down
  • Valsalva manouevre whilst standing will increase dilatation
  • Cough impulse
23
Q

Identify appropriate investigations for varicocoele

A
  • scrotal ultrasound with colour flow Doppler imaging
    • ​Used as adjunct to a physical examination to detect varicocele in men with difficult examination
    • eg due to small scrotum, or to obesity.
  • semen analysis
    • ​for infertile men with a varicocele, 2 or 3 semen analyses are recommended
    • result- variable; reduced sperm count; impaired sperm motility (<50% motile spermatozoa)
  • serum FSH (± GnRH stimulation)
    • ​FSH may be elevated (suggesting testicular dysfunction)
  • serum testosterone
    • ​increasingly recognised as an uncommon cause of decreased testosterone production
24
Q

Define testicular torsion

A

Testicular torsion is a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue

25
Q

Explain the risk factors of testicular torsion

A
  • age under 25 years
  • neonate- risk of extra-vaginal torsion during the perinatal period
  • bell clapper deformity
  • trauma/exercise- only 4-8% of cases of torsion
  • undescended testicle- 10x more likely in patients with undescended testicle (cryptorchidism).
26
Q

Explain the Bell-clapper deformity

A
  • Anatomical anomaly that allows the testicles to rotate freely within the tunica vaginalis
  • The cremasteric muscle creates a rotational pull around the spermatic cord, particularly with a strong contraction, that can also contribute to the development of testicular torsion
27
Q

What might you consider if a left-sided varicocele appears suddenly in a previously normal scrotum?

A

The sudden appearance of a left-sided varicocele is a rare, but important, presentation of renal tumours (clear cell adenocarcinoma in adults and nephroblastoma in children)

as both of these tumours may invade the left renal vein and hence compromise drainage of the left gonadal vein.

28
Q

Explain the 2 classifications of testicular torsion

A

Intravaginal (MOST COMMON)

The spermatic cord twists within the tunica vaginalis

Extravaginal (usually in neonates)

  • The entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord
  • Due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation
29
Q

Summarise the epidemiology of testicular torsion

A

Most common cause of acute scrotal pain in 10-18 yr olds

Most commonly occurs in 11-30 year olds

30
Q

Recognise the presenting symptoms of testicular torsion

A

Usually a history of sudden-onset scrotal pain, often with nausea and vomiting.

Testicular tenderness alone may exist without other signs suggestive of torsion.

  • history of intermittent or acute on-and-off pain may indicate periods of torsion and spontaneous de-torsion
  • Abdominal pain
  • Scrotal swelling or oedema
  • scrotal arythema
  • reactive hydrocele
  • high riding testicle
  • tenderness and a horizontal lie of the affected testicle
  • absent cremasteric reflex- on the affected side is suggestive of torsion
31
Q

Recognise the signs of testicular torsion on physical examination

A
  • Swollen, erythematous scrotum on the affected side – tender, hot and swollen
  • Swollen testicle will lie slightly higher than the unaffected one
  • Testicle might lie horizontal
  • Thickened cord
  • Testicular Appendix- there may be a visible necrotic lesion on transillumination
32
Q

Differentials for torsion?

A
  • Epididymo-orchitis – tends to affect older, more gradual onset
  • Incarcerated inguinal hernia
33
Q

Generate a management plan for testicular torsion

A
  • Exploration of the scrotum within 6 hrs of onset of symptoms – if performed in <6h, salvage rate is 90-100%. If >24h, it is 0-10%.
  • After the testicle is twisted back into place, a bilateral orchidopexy is performed
  • This involves suturing both the testicles to the scrotal tissue to prevent recurrence
  • If the testicle is necrotic, orchidectomy may be performed (surgical removal of one or both testes)
34
Q

Identify possible complications of testicular torsion

A
  • Testicular infarction
  • Testicular atrophy
  • Infection
  • Impaired fertility (due to production of anti-sperm antibodies)
35
Q

Summarise the prognosis for patients with testicular torsion

A
  • Number of rotations (180° -720) + duration of ischaemia both determine the degree of tissue viability
  • If treatment is started within 4-6 hours after the onset of symptoms then the testis will most likely remain viable.
  • If the testis remains twisted for more than 10-12 hours, ischaemia and irreversible testicle damage are likely.
  • After 12 hours, necrosis most likely has occurred.
36
Q

Define testicular cancer

A

The most common malignancy in young adult men (20 to 34 years of age), and highly curable when diagnosed early.

A precancerous condition termed carcinoma in situ is highly specific early in the natural history of the disease.

37
Q

State the commonest types of testicular cancer

A

Germ cell (90% to 95% of all cancers of the testis)

  • Seminoma (56%)
  • Embryonal carcinoma (20%)
  • Teratoma (5% to 10%)
  • Teratocarcinoma (10% to 20%)

Non-germ cell (5% to 10%)

  • Leydig cell or other specialised stromal tumour
  • Gonadoblastoma
38
Q

Explain the risk factors of testicular cancer

A
  • cryptorchidism
  • gonadal dysgenesis
  • family or personal history of testicular cancer
  • testicular atrophy- secondary to trauma, hormones, and viral orchitis.
  • White ethnicity
  • HIV- risk of seminoma is 5-fold higher in men with HIV
39
Q

Summarise the epidemiology of testicular cancer

A

Rare- 1% of all incident cancers and <1% of all cancer deaths in males

Most common cancer diagnosed among men aged 15 to 44 years

White men have, by far, the highest incidence compared with African and Asian men- 4x that in black men.

40
Q

Recognise the presenting symptoms of testicular cancer

A

Testicular mass- usually painless (>85%). About 10% present with acute pain

Around 5-10% of patients have extratesticular manifestations including:

  • bone pain (skeletal metastasis)
  • lower extremity swelling (venous occlusion),
  • supraclavicular lymph nodes
  • symptoms and/or signs of hyperthyroidism
  • gynaecomastia.
  • lumbar back pain- if there is involvement of the psoas muscles and nerve roots.
  • Spinal cord and cerebral metastasis may cause neurological symptoms.
41
Q

Recognise the signs of testicular cancer on physical examination

A
  • Painless, hard testicular mass
  • There may be a secondary hydrocoele
  • Lymphadenopathy (e.g. supraclavicular, para-aortic)
  • Gynaecomastia (tumour produces hCG)
42
Q

Identify appropriate investigations for testicular cancer

A

Bloods

  • FBC
  • U&Es
  • LFTs
  • Tumour Markers
    • a-fetoprotein
    • b-hCG
    • LDH- elevated in 50%

Other

  • Testicular Ultrasound with colour doppler
    • Principal test with sensitivity near 100%
    • Allows visualisation of the tumour
    • Can see associated hydrocoele
  • Urine Pregnancy Test - will be positive if the tumour produces b-hCG
  • CXR - show lung metastases- used for staging
  • CT Abdomen and Thorax -
    • allows staging- staging System: Royal Marsden Hospital Staging
    • If USS negative but suspicion is high
    • Used to assess extratesticular metastasis.
43
Q

Summarise the indications for urinary catheterisation

A
  • Relieve urinary retention
  • Monitor urine output in critically ill patients
  • Collect uncontaminated urine for diagnosis
  • Contraindicated in urethral injury and acute prostatitis
44
Q

Identify the possible complications of urinary catheterisation

A
  • Infection – 5% develop bacteraemia
  • Bladder spasm
45
Q

Match the following tumour marker patterns to the types of testicular tumour:

  • High alpha fetoprotein (AFP)
  • High Placental Alkaline phosphatase (PLAP)
  • High lactic dehydrogenase (LDH)
  • Very high human chorionic gonadotrophin (HCG)
A

Testicular germ cell tumours can be pure seminoma or teratoma, or mixtures of different tumour types.

Each tumour type may produce marker proteins.

Typically:

  • seminoma = PLAP
  • teratoma = AFP
  • Uncommonly teratomas can contain areas of choriocarcinomatous (trophoblastic) differentiation and these produce high levels of HCG
  • LDH levels are non-specifically raised with bulky tumours of both main types
46
Q

Discerne beetween the macro/microscopic appearance of seminomas versus teratomas

A

Typical of a seminoma:

  • Solid homogeneous “cut potato” like appearance of the gross tumour
  • Microscopic mixture of tumour cells and normal lymphocytes is also typical.

Teratoma:

  • Has a more variegated gross appearance with both solid and cystic areas
  • This also shows up clearly on a clinical ultrasound.
47
Q
A

YR3 Renal + Urology (15 decks)

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