Urethra, penis and scrotum

Question 1

How does a urtethral stricture affect urinary outflow?

Answer 1

Can cause overflow incontinence
Slow to start, slow at best and slow to finish
Spraying/splitting of the urine stream may occur

Question 2

Causes of urethral stricture

Answer 2

iatrogenic: catheter, trauma, infections (gonorrhoea), invasive tumours
congenital: meatal and bulber stricture

Question 3

What is phimosis associated with and what symptoms might it present with?

Answer 3

poor hygiene, and chronic balanitis.

obstructive symptoms, pain at the prepuce

Question 4

What is paraphimosis?

Answer 4

Paraphimosis is a foreskin that is unable to be replaced, that is, trapped behind the glans. Associated
with not replacing the foreskin following activity – such as catheterisation or sexual intercourse.
Major symptoms include pain, swelling of the penis distal to the lesion, and flaccidity proximal

Question 5

What is varicocele?

Answer 5

Varicoceles are essentially varicose veins of the testes, varicosities in the pampiniform plexus.
Generally found on the left side, as the testicular vein runs a bending course into the renal vein and
poor flow is more common. May be asymptomatic, or may give a dragging, heavy, aching feeling.

if you find on the right side, check for tumour

Question 6

What is hydrocele?

Answer 6

A hydrocele is a collection of fluid within the tunica vaginalis (don’t forget, it is peritoneum, and
therefore secretes fluid!), which normally sits anterior to the testis. May be caused by trauma,
tumour, infection, or peritoneal dialysis. Presents as a scrotal swelling, with or without pain.

Question 7

What are epididymal cysts or spermatocele?

Answer 7

An epididymal cyst, or spermatocele, is a collection of spermatic fluid within the epididymis. Not
associated with tumours, usually painless, similarly may present as a scrotal swelling

Question 8

Signs and symptoms of testicular torsion?

Answer 8

Sudden, intense pain in the testis, radiating to the abdomen. May be associated
vomiting, and a scrotal/inguinal swelling. The testis may retract, and the cremaster reflex will be
absent.

Question 9

Who is testicular torision most common in and where might it occur anatomically?

Answer 9

It is most common in men <20yo. It generally occurs within the tunica vaginalis.

Question 10

What is the bell clanger position?

Answer 10

The “bell clanger” position of the testis predisposes to torsion

Question 11

Is recurrence of testicular torsion dangerous?

Answer 11

yes. it can lead to atrophy

Question 12

diagnosis of testicular torsion?

Answer 12

Diagnosis should be clinical, and the patient sent to theatre. Urine dip will exclude infection from
DDx. USS can identify the anatomy of the lesion (esp. Doppler) to confirm/reject diagnosis. Torsion
of the hyatid of Morgagni may present with similar pain history, but less physical signs.

Question 13

What is epididymo-orchitis?

Answer 13

Epididymo-orchitis: Leads to scrotal discomfort and dysuria. More common in men >20yo. The most
common causes are Chlamydia and Gonorrhoea in younger men. In more elderly men, it is more
likely to be caused by E.Coli, and other UTI-causing pathogens. It is labelled Epididymo-orchitis if
infection from the epididymis spreads to the testis. Orchitis causes swelling, and the most common
pathogen is paramyxovirus (mumps), which, if bilateral, may lead to infertility. The common
150 Clinical Phase One Objectives 2013 | TJM E: timelonade@gmail.com
pathogens may be diagnosed by ELISA and antigen testing. Presentation is with pain (not as sudden
as torsion), urethritis/discharge, swelling and tenderness.

Question 14

What are the main tumours of the testes?

Answer 14

Germ cell: seminomas or non-seminomas

Non germ-cell: lymphoma, sertoli and leydig cell tumours (functional tumours)

Question 15

symptoms of functional testicular tumours?

Answer 15

increased testosterone leads to increased secondary sexual characterisitcs and aggression

Question 16

discuss non-seminoma germ cell tumours

Answer 16

35% are teratomas (best prognosis), which are well-differentiated.
choriocarcinomas have worser prognosis,
then yolk sac carcinomas
then embryomal carcinomas being totally undifferentiated

choriocarcinomas and yolk sac carcinomas are alpha-FP and beta-HCG secreting

they are shaped irregularly and show focal haemorrhage, spreading via lymphatics to para-aortic nodes and through the blood to the lungs, bone and liver.

Question 17

discuss seminomas

Answer 17

Seminomas (50%) have a peak incidence in patients’ 30s. The testis is uniformly enlarged and on
section looks well circumscribed and uniformly grey/white. Spread is principally along the spermatic
cord through lymphatics and blood vessels.
15% of tumours show both seminomatous and teratomatous change

Question 18

When examining a scrotal swelling, and you can get above it, what does this indicate?

Answer 18

Not a hernia

either a tumour, hydrocele, spermatocele.

Question 19

When examining a scrotal swelling, and there is one lump or two, what does this indicate?

Answer 19

spermatocele, hernia.

not a tumour or hydrocele (tight)

Question 20

When examining a scrotal swelling, and there it’s trans-illuminable, what does this indicate?

Answer 20

it’s hydrocele, not tumour, hernia or spermatocele.

Question 21

define indirect and direct inguinal hernia

Answer 21

Indirect: Viscus traverses entire length of inguinal canal, entering at the deep ring and leaving at the
superficial ring. The deep ring is lateral to the inferior epigastric vessels.

Direct: Viscus breaks through weakness in the transversalis fascia, and passes through the superficial
ring. The breach is commonly medial to the inferior epigastric vessels.

Question 22

List the factors that predispose to the development of inguinal hernia

Answer 22

Increased intra-abdominal pressure (chronic cough, squats, pregnancy, obesity) and weakness of
transversalis fascia (previous hernia, age) are two big factors influencing development of inguinal
hernias

Question 23

Describe the physical findings in patients with reducible inguinal herniae, including examination of
the external ring and descent to the scrotum, and incarcerated inguinal herniae including the signs
of bowel obstruction and possible strangulation

Answer 23

Asking the patient to cough, increasing intra-abdominal pressure, will lead to an impulse through the
hernia.
Reducing the hernia may allow for control at the deep inguinal ring if it is an indirect hernia
(as it will pass through here).
Scrotal continuation of a hernia is more common in indirect hernia but
may occur in either. Incarceration will cause bowel obstruction, characterised by constipation,
distension, vomiting, and pain. On examination there will be increased bowel sounds. Strangulation
and ischaemia will be associated with the four signs of inflammation (pain, redness, swelling,
warmth) and tenderness.