urology 1 Flashcards
what is testicular torsion?
Testicular torsion refers to twisting of the spermatic cord with rotation of the testicle. It is a urological emergency, and a delay in treatment increases the risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility.
how does testicular torsion present?
The typical patient is a teenage boy, but it can occur at any age.
There may be a history of recurrent symptoms in patients where there is intermittent testicular torsion.
Testicular torsion is often triggered by activity, such as playing sports. Ask what the patient was doing at the time when the pain started.
It presents with an acute rapid onset of unilateral testicular pain, and may be associated with abdominal pain and vomiting. Sometimes abdominal pain is the only symptom in boys, and testicular examination to exclude torsion is essential.
what are the examination findings for testicular torsion
Examination findings are:
Firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position
what is a bell-clapper deformity?
A bell-clapper deformity is one of the causes of testicular torsion.
Normally, the testicle is fixed posteriorly to the tunica vaginalis. A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position. It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord. As it rotates, it twists the vessels and cuts off the blood supply.
what is the management for testicular torsion?
urological emergency- urgent treatment.
Nil by mouth, in preparation for surgery
Analgesia as required
Urgent senior urology assessment
Surgical exploration of the scrotum
Orchiopexy (correcting the position of the testicles and fixing them in place)
Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis
what investigations can be done for testicular torsion?
A scrotal ultrasound can confirm the diagnosis. However, any investigation that will delay the patient going to theatre for treatment is not recommended. Ultrasound can show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels.
what is epididymo- orchitis?
Epididymitis is inflammation of the epididymis. Orchitis is inflammation of the testicle.
Epididymo-orchitis is usually the result of infection in the epididymis and testicle on one side.
what is the anatomical relationship and role of the epididymis testicle and vas deferent.
At the back of each testicle is the epididymis. Sperm are released from the testicle, into the head of the epididymis. The sperm travel through the head, then body, then tail of the epididymis.
Sperm mature and are stored in the epididymis. The epididymis drains into the vas deferens.
what are some causes of Epididymo-orchitis?
(E. coli)
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
TOM TIP: Think of mumps in patients with parotid gland swelling and orchitis. Mumps tends only to affect the testicle, sparing the epididymis. It can also cause pancreatitis.
what is the typical presentation of Epididymo-orchitis?
gradual onset, over minutes to hours, with unilateral:
-Testicular pain
-Dragging or heavy sensation
-
Swelling of testicle and epididymis
-Tenderness on palpation, particularly over epididymis
- Urethral discharge (should make you think of chlamydia or gonorrhoea)
- Systemic symptoms such as fever and potentially sepsis
what is the key differential diagnosis of epididymo-orchitis?
testicular torsion.
Both present similarly, with acute onset of pain in one testicle. If there is any doubt, treat it as testicular torsion until proven otherwise.
The key with epididymo-orchitis is to distinguish whether the cause is likely to be an enteric organism (e.g., E. coli) or a sexually transmitted organism (e.g., chlamydia or gonorrhoea).
The features that make a sexually transmitted organism more likely are:
Age under 35
Increased number of sexual partners in the last 12 months
Discharge from the urethra
what are investigations that can be used to establish the diagnosis of epididymo-orchitis?
- Urine microscopy, culture and sensitivity (MC&S)
- Chlamydia and gonorrhoea NAAT testing on a first pass urine
- Charcoal swab of purulent urethral discharge for gonorrhoea culture and sensitivities
- Saliva swap for PCR testing for mumps, if suspected
- Serum antibodies for mumps, if suspected (IgM – acute infection, IgG – previous infection or vaccination)
- Ultrasound may be used to assess for torsion or tumours
what is the management of epididymo-orchitis?
Acutely very unwell or septic patients are admitted to hospital for treatment (IV antibiotics).
Patients with a high risk of sexually transmitted infection should be referred urgently to genitourinary medicine (GUM) for assessment and treatment.
For patients that are at a low risk of STIs, a typical choice is:
Ofloxacin (usually first-line) for 14 days
Alternatives:
Levofloxacin / ciprofloxacin
Doxycycline
Co-amoxiclav
Additional measures:
Analgesia
Supportive underwear
Reduce physical activity
Abstain from intercourse
: Quinolone antibiotics such as ofloxacin, levofloxacin and ciprofloxacin are powerful broad-spectrum antibiotics, often used for urinary tract infections, pyelonephritis, epididymo-orchitis and prostatitis. They give excellent gram-negative cover. It is worth remembering two critical side effects, as these may be tested in exams and are essential to inform patients about:
- Tendon damage and tendon rupture, notably in the Achilles tendon
- Lower seizure threshold (caution in patients with epilepsy)
what are some key causes of scrotal or testicular lumps?
Hydrocele Varicocele Epididymal cyst Testicular cancer Epididymo-orchitis Inguinal hernia Testicular torsion
why is a hydrocele, how does it present and what causes it?
A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes.
usually painless and present with a soft scrotal swelling.
Examination findings with a hydrocele are:
- The testicle is palpable within the hydrocele
- Soft, fluctuant and may be large
- Irreducible and has no bowel sounds (distinguishing it from a hernia)
- Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)
Hydroceles can be idiopathic, with no apparent cause, or secondary to:
Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma
what is the management for a hydrocele
Management involves excluding serious causes (e.g., cancer).
Idiopathic hydroceles may be managed conservatively.
Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases.
