Urology Flashcards
causes of urinary tract obstruction?
Luminal:
stones, blood clots, sloughed papilla
Mural:
congenital / acquired stricture, tumour: renal, ureteric, bladder
neuromuscular dysfunction
extramural:
prostatic enlargement,
abdo/ pelvis mass/ tumour
retroperitoneal fibrosis
presentation of acute upper urinary tract obstruction?
loin pain -> groin
presentation of acute lower urinary tract obstruction?
bladder outflow obstruction precedes severe suprapubic pain w distended palpable bladder
presentation of chronic upper urinary tract obstruction?
flank pain
renal failure (may be polyuric)
presentation of chronic lower urinary tract obstruction?
frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence
distended palpable bladder +/- large prostate PR
ix of urinary tract obstruction?
bloods: FBC, U+E
urine: dip, MCS
imaging:
US: hydronephrosis or hydroureter
Anterograde/ retrograde ureterograms: allow therapeutic drainage
radionucleotide imaging: renal function
CT/ MRI
mx of Upper urinary tract obstruction?
nephrostomy
ureteric stent
mx of lower urinary tract obstruction?
urethral or suprapubic catheter
complications of ureteric stents?
common:
infection, haematuria, trigonal irritation, encrustation
rare:
obstruction, ureteric rupture, stent migration
causes of urethral stricture?
trauma e.g. pelvic #, instrumentation
Infection e.g. gonorrhoea
Chemotx
balantitis xerotica obliterans (male lichen sclerosus)
presentation of urethral stricture?
hesitancy
poor stream
terminal dribbling
strangury: painful, frequent urination of small volumes that are expelled slowly only by straining and despite a severe sense of urgency, usually with the residual feeling of incomplete emptying.
pis-en-deux: residual urine results in a desire to pass urine soon after voiding
examination of urethral stricture?
PR: exclude prostatic cause
Palpate urethra through penis
examine meatus
ix of urethral stricture?
urodynamics:
decreased peak flow rate
increased micturation time
urethroscopy and cystoscopy
retrograde urethrogram
mx of urethral stricture?
internal urethrotomy
dilatation
stent
complications of obstructive uropathy?
Hyperkalaemia
metabolic acidosis
post-obstructive diuresis
Na and HCO3 losing nephropathy
infection
what is post obstructive diuresis?
Kidneys produce a lot of urine in the acute phase after relief of obstruction.
must keep up w losses to avoid dehydration
what is Na and HCO3 losing nephropathy following obstructive uropathy?
diuresis may -> loss of Na and HCO3
may require replacement with 1.26% NaHCO3
causes of urinary retention?
mechanical obstruction:
BPH
urethral stricture
clots, stones
constipation
dynamic obstruction: increased smooth muscle tone
post operative pain
drugs
neurological:
sensory/ motor innervation affected
pelvic surgery
MS
DM
spinal injury/ compression
myogenic:
overdistension of the bladder
Post-anaesthesia
High alcohol intake
features of acute urinary retention
suprapubic tenderness
palpable bladder: dull to percussion, cant get beneath it
large prostate on PR: check anal tone and sacral sensation
<1 L drained on catheterisation
imaging of acute urinary retention?
US: bladder volume, hydronephrosis
pelvic XR
mx of acute urinary retention?
analgesia
catheterise:
use correct catheter, e.g. 3 way if clots
+/- STAT gentamicin cover
hourly UO + replace: post obstruction diuresis
Tamsulosin: decreases risk of recatherisation after retention
TWOC after 24-72ha
presentation of chronic urinary retention?
insidious as bladder capacity increases (> 1.5L)
typically painless
overflow incontinence/ nocturnal enuresis
acute on chronic retention
lower abdo mass
UTI
renal failure
high vs low pressure chronic urinary retention?
high pressure:
high detrusor pressure @ end of micturition
typically bladder outflow obstruction ->
bilateral hydronephrosis and decreased renal function
Low pressure:
low detrusor pressure @ end of micturition
large volume retention w very compliant bladder
kidney able to excrete urine
no hydronephrosis -> normal renal function
mx of high pressure chronic urinary retention?
catheterise if
- renal impairment
- pain
- infection
Hourly UO + replace: post obstruction diuresis
consider TURP before TWOC
mx of low pressure chronic urinary retention?
avoid catheterisation if possible
-risk of introducing infection
early TURP
advantages of suprapubic catheterisation?
decreased UTI risk
decreased stricture formation
TWOC w/o catheter removal
Pt preference: increased comfort
maintain sexual function
disadvantages of suprapubic catheterisation?
More complex: need skills
serious complications can occur
contraindications of suprapubic catheterisation?
known or suspected bladder carcinoma
undiagnosed haematuria
previous lower abdo surgery
-> adhesion of small bowel to abdo wall
causes of false haematuria?
red urine
beetroot
rifampicin
porphyria
PV bleed
urethra causes of haematuria?
infection
trauma
stones
tumour
prostate causes of haematuria?
BPH
prostatitis
tumour
bladder causes of haematuria?
infection
stones
tumour
exercise
general causes of haematuria?
HSP
Bleeding diathesis
renal causes of haematuria?
infarct
trauma
infection
neoplasm
glomerulonephritis
polycystic kidneys
features of haematuria?
timing:
beginning of stream- urethral
throughout stream: renal/ systemic, bladder
end of stream: bladder stone, schistosomiasis
painful or painless?
obstructive symptoms?
systemic symptoms: weight loss, appetite
ix of haematuria?
Bloods: FBC, U+E, clotting
Urine: dip, MCS, cytology
Imaging: renal US, IVU, flexi cystoscopy + biopsy, CT/MRI, renal angio
what is periaortitis?
inflammatory condition which typically involves the infrarenal portion of the abdominal aorta.
various clinical presentations:
idiopathic retroperitoneal fibrosis
inflammatory AAA
perianeurysmal retroperitoneal fibrosis
isolated periaortitis
what is idiopathic retroperitoneal fibrosis?
autoimmune vasculitis
fibrinoid necrosis of vasa vasorum
affects aorta and small/medium sized retroperitoneal vessels
ureters are embedded in dense, fibrous tissue -> bilateral obstruction
associations of idiopathic retroperitoneal fibrosis?
drugs: BB, bromocriptine, methysergide, methyldopa
autoimmune disease: thyroiditis, SLE, ANCA+ vasculitis
smoking
asbestos
presentation of idiopathic retroperitoneal fibrosis?
middle aged male
vague loin, back or abdo pain
raised BP
chronic urinary tract obstruction
mx of idiopathic retroperitoneal fibrosis?
relieve obstruction: retrograde stent placement
ureterolysis: dissection of ureters from retroperitoneal tissue
+/- immunosuppression
ix of idiopathic retroperitoneal fibrosis?
bloods: raised urea and creatinine, raised ESP/CRP, low Hb
US: bilateral hydronephrosis + medial ureteric deviation
CT/MRI: peri aortic mass
biopsy: exclude Ca
pathophysiology of kidney stones?
increased concentration of urinary solute
decreased urine volume
urinary stasis
common anatomical sites for kidney stones?
pelviureteric junction
crossing iliac vessels at pelvic brim
under the vas or uterine artery
vesicoureteric junction
most common type of kidney stone?
calcium oxalate
urate kidney stones assoc w which condition?
gout
staghorn calculi
assoc w proteus infection
what type of kidney stone?
triple stones
ca, mg, ammonium - phosphate
cystine kidney stones
assoc w?
Fanconi syndrome
kidney stones associated factors??
dehydration
hypercalcaemia: primary hyperPTH, immobilisation
increased Oxalate excretion: tea, strawberries
UTIs
hyperuricaemia e.g. gout
urinary tract abnormalities e.g. bladder diverticulae
drugs: furosemide, thiazides
presentation of kidney stones?
severe loin pain radiating to groin
N+V
pt cannot lie still
may cause bladder/ urethral obstruction:
bladder irritability: frequency, dysuria, haematuria
strangury: painful urinary tenesmus
suprapubic pain radiating -> tip of penis or in labia
pain and haematuria worse at end of micturition
ix of kidney stones?
urine: dip - haematuria, MCS
bloods: FBC, U+E, Ca, PO4, urate
imaging: CT KUB gold standard,
USS may show hydronephrosis
prevention of kidney stones?
drink plenty
treat UTIs rapidly
decreased oxalate intake: chocolate, tea, strawberries
indications for conservative tx of kidney stones?
stone < 5mm in size
and in lower 1/3 of ureter
conservative mx of kidney stones?
give all analgesia e.g. diclofenac or opioids
fluids: IV if unable to tolerate PO
abx if infection: e.g. cefuroxime
90-95% pass stone spontaneously
can discharge pt w analgesia
sieve urine to collect stone for OPD analysis
indications of medical expulsive therapy for kidney stones?
stone 5-10 mm
stone expected to pass
what is medical expulsive therapy for kidney stones?
Nifedipine or tamsulosin (alpha blocker)
+/- prednisolone
indications for active stone removal of kidney stones?
low likelihood of spontaneous passage e.g. > 10 mm
persistent obstruction
renal insufficiency
infection
indications for percutaneous nephrolithotomy?
1st line if stone > 20mm in renal pelvis
e.g. staghorn calculi
indications for extracorporeal shockwave lithotripsy?
1st line for stones < 20 mm in kidney or proximal ureter
side effect: renal injury -> may increase BP
CI: pregnancy, AAA, bleeding diathesis
indications for ureteronoscopy + basket removal of kidney stones?
1st line if stone > 10mm in distal ureter or if shock wave lithotripsy failed
or >20 mm in renal pelvis
mx of kidney stones where pt is febrile w renal obstruction?
surgical emergency
percutaneous nephrostomy or ureteric stent
IV abx e.g. cefuroxime
risk factors of renal cell carcinoma?
obesity
smoking
HTN
dialysis
heritable syndrome (e.g. VHL)
most common subtype of renal cell carcinoma?
clear cell
presentation of renal cell carcinoma?
50% incidental finding
triad: haematuria, loin pain, loin mass
systemic: FLAW
clot retention
invasion of L renal vein -> varicocele
cannonball mets -> SOB
paraneoplastic features of renal cell carcinoma?
EPO -> polycythaemia
PTHrP -> high Ca
Renin -> HTN
ACTH -> Cushings syndrome
Amyloidosis
Robson staging for renal cell carcinoma?
(largely replaced by TNM staging)
- confined to kidney
- involves perinephric fat, but not Garota’s fascia
- spread into renal vein
- spread to adjacent/ distant organs
medical mx of renal cell carcinoma?
reserved for pts w poor prognosis
temsirolimus (mTOR inhibitor)
surgical mx of renal cell carcinoma?
radical nephrectomy
consider partial if small tumour or 1 kidney
2nd most common renal cancer?
transitional cell carcinoma
- 50% found in bladder, rest in ureter/ renal pelvis
risk factors of transitional cell carcinoma?
smoking
amine exposure (rubber industry)
cyclophosphamide
presentation of transitional cell carcinoma?
painless frank haematuria
frequency, urgency, dysuria
urinary tract obstruction
ix of transitional cell carcinoma?
urine cytology
CT/MRI
IVU: pelviceal filling defect
mx of transitional cell carcinoma?
nephrouretectomy
regular follow up
What is Wilm’s Tumour?
a nephroblastoma
childhood tumour of primitive renal tubules and mesenchymal cells
may be assoc with Chr11 mutation/ WAGR syndrome (wilms, aniridia, GU abnormalities, retardation)
presentation of wilms tumour?
2-5 yrs
5-10% bilateral
abdo mass
haematuria
abdo pain
HTN
most common type of bladder ca?
Transitional cell carcinomas - 90%
SCCs: assoc w shistosomiasis
Squamous cell carcinoma of bladder assoc w what infection?
schistosomiasis
risk factors for bladder ca?
smoking
amine exposure (rubber industry)
previous renal TCC
chronic cystitis
schistosomiasis -> SCC
pelvic irradiation
presentation of bladder Ca?
painless frank haematuria
voiding irritability: dysuria, freq, urgency
recurrent UTIs
retention and obstructive renal failure
examination findings of bladder ca?
anaemia
palpable bladder mass
palpable liver
diagnostic ix of bladder ca?
cystoscopy with biopsy
mx of T4 Bladder Ca?
T4 - invasion of prostate/ uterus/ vagina
palliative chemo/ radio tx
long term catheterisation
urinary diversions
mx of T2, T3 bladder ca?
T2- superficial muscle involved
T3 - deep muscle
radical cystectomy w ileal conduit is gold standard
adjuvant chemo
mx of T1 Bladder Ca?
superficial
diathermy via transurethral cystoscopy/ transurethral resection of bladder tumour (TURBT)
intravesicular chemo: mitomycin C
intravesicular immunotherapy: Bacille Calmette-Guerin
examination findings of benign prostatic hypertrophy?
PR exam: smoothly enlarged prostate, definable median sulcus
bladder not usually palpable unless acute on chronic obstruction
pathophysiology of benign prostatic hypertrophy?
*DHT (dihydrotestosterone) is a critical mediator.
DHT produced from testosteron in stromal cells by 5a-reductase enzyme
DHT-induced growth factors -> ↑ stromal cells and ↓ epithelial cell death.
-> benign nodular or diffuse hyperplasia of stromal and epithelial cells
affects inner layer of prostate -> may lead to urethral compression
presentation of benign prostatic hypertrophy?
bladder outflow obstruction:
hesitancy, straining, poor flow, terminal dribbling, urinary tenesmus, incomplete emptying (pis en deux)
storage symptoms: nocturia, freq, urgency, overflow incontinence
bladder stones secondary to stasis
UTI secondary to stasis
conservative mx of BPH?
decrease caffeine, alcohol
double voiding
bladder training
medical mx of BPH?
useful in mild disease and while awaiting TURP
1st line: alpha blockers
e.g. tamsulosin
relaxes prostate smooth muscle
2nd line: 5a-reductase inhibitors
e.g. finasterid
inhibits conversion of testosterone -> DHT
preferred if significantly enlarged prostate
examples of alpha blockers?
tamsulosin
doxazosin
surgical mx of BPH?
when symptoms affect QOL
TURP
Transurethral incision of prostate (TUIP)
< destruction → ↓ risk to sexual function
Similar benefits to TURP if small prostate (<30g)
Tranurethral ElectroVaporisation of Prostate
Electric current → tissue vaporisation
Laser prostatectomy
↓ ED and retrograde ejaculation
Similar efficacy as TURP
Open retropubic prostatectomy
Used for very large prostates (>100g)
TURP complications
immediate:
TUR syndrome - absorption of large quantity of fluids -> low Na
haemorrhage
early:
haemorrhage, infection, clot retention
late: retrograde ejaculation, Erectile dysfunction, incontinence, urethral stricture, recurrence
commonest male cancer?
prostate
80% of men > 80yrs
examination findings of prostate cancer?
hard irregular prostate on PR
loss of midline sulcus
what type of bone lesions occur with prostate ca?
sclerotic
which lymph nodes may be affected by prostate ca?
para aortic nodes
medical mx of prostate ca?
used for metastatic or node +ve disease
LHRH analogues
e.g. goserelin
inhibit pituitary gonadotrophins -> decrease testosterone
anti-androgens:
e.g. cyporterone acetate, flutamide
radical tx for prostate ca?
radical prostatectomy
+ goserelin LHRH analogue if node +ve
brachytherapy: implantation of palladium seeds
symptomatic mx of Prostate Ca?
TURP for obstruction
analgesia
radiotherapy for bone mets/ cord compression
examination findings of prostatitis?
pyrexia
swollen/ boggy/ tender prostate on PR
examine testes to exclude eipididymo-orchitis
Mx of prostatitis?
analgesia
levofloxacin for 28d
ix of urinary incontinence in women
urodynamic studies
mx of stress incontinence?
pelvic floor exercises
ring pessary
surgery: tension free vaginal tape
mx of urge incontinence?
bladder training
lifestyle changes, weight loss
anti-achm: tolterodine, imipramine
surgery: Sacral or Tibial nerve stimulation devices when other tx has failed
undescended testes more common in?
premies
(testes remain in abdomen until 7mo)
unilateral more common than bilateral
- should have genetic testing if bilateral
e. g. Noonan’s, prader-willi
what is a maldescended testis?
found anywhere along normal path of descent
testis and scrotum usually underdeveloped
often assoc w patent processus vaginalis
what is cryptorchidism?
complete absence of testis from scrotum
anorchism = absence of both testes
what is retractile testis?
normal development but excessive cremasteric reflex
testicle often found at external inguinal ring
will descend- no tx required
what is ectopic testis?
found outside line of descent
usually in superior inguinal pouch (ant to external oblique aponeurosis)
abdominal, perineal, penile, femoral triangle
complications of undescended testes?
infertility
10 x increased risk of malignancy (remains after surgery)
increased risk of trauma/ torsion
assoc w hernias (90%) or urinary tract abnormalities
mx of undescended testes?
restrores potential for spermatogenesis + makes ca easier to detect
surgical: orchidopexy
+ dartos pouch procedure to prevent future retraction
hormonal: BHCG may be tried if testis is in inguinal canal
presentation of testicular torsion?
usually 10-25 yrs
sudden onset severe pain in one testis
may have lower abdo pain (testis supplied by T10)
N+V
may have hx of previous testicular pain/ torsion
examination findings of testicular torsion?
inflammation of one testis: hot, swollen, extremely tender
testis riding high and lies transversely
sudden onset severe pain in one testis
tiny blue dot visible on scrotum
torsion of hydatid of Morgagni
ix of testicular torsion
Must not delay surgical exploration -> straight to theatre
doppler US may demonstrate absence of flow
mx of testicular torsion?
surgical emergency
4-6h window from onset of pain to salvage testis
inform senior
NBM + IV access: bloods (FBC, U+E, Clotting, G+S, Cross match), Analgesia, IV Fluids
surgery: consent for possible orchidectomy, bilateral orchidopexy
features of epididymal cyst?
lies above and behind testis
(separate lump from testis)
contains clear or milky (spermatocele) fluid
remove if symptomatic
what is a varicocele?
dilated veins of pampiniform plexus
features of varicocele?
bag of worms in scrotum
may be visible dilated veins
decrease in size on lying down
pt may c/o dull ache
may -> oligospermia (decreased fertility)
pathology of varicocele?
primary: left side commoner: drain into left renal vein
secondary: left renal tumour has tracked down renal vein -> testicular vein obstruction
mx of varicocele?
conservative: scrotal support, simple analgesia
refer to a urologist for possible surgery:
clipping of testicular vein
when to refer to urologist urgently for potential surgery?
varicocele
A varicocele appears suddenly and is painful.
The varicocele does not drain when lying down.
There is a solitary right-sided varicocele.
what is a sperm granuloma?
painful lump of extravasated sperm that appears along the vasa deferentia or epididymides in vasectomized men.
what is a hydrocele?
collection of serous fluid within tunica vaginalis
pathology of primary hydrocele?
assoc w patent processus vaginalis
commoner, larger, tense, younger men
pathology of secondary hydrocele?
tumour, trauma, infection
smaller, less tense
ix of hydrocele?
US testicle to exclude tumour
mx of hydrocele?
may resolve spontaneously
surgery:
Lord’s Repair: plication of the sac
Jaboulay’s Repair: eversion of the sac
aspiration: recurs so not 1st line, send fluid for cytology and MCS
what is a haematocele?
blood in the tunica vaginalis
hx of trauma
may need drainage/ excision
features of epididymo-orchitis?
Sudden onset tender swelling
dysuria
sweats, fever
examination findings of epididymo-orchitis?
Tender, red, warm, swollen testis and epididymis
Elevating testicle may relieve pain
Secondary hydrocele
Urethral discharge
ix of epididymo-orchitis?
Blood: FBC, CRP
Urine: dip, MC+S (fist catch may be best)
Urethral swab and STI screen
US: may be needed to exclude abscess
complications of epididymo-orchitis?
infertility
mx of epididymo-orchitis?
bed rest
analgesia
scrotal support
abx: doxycycline or cipro
drain abscess if present
risk factors for penile cancer?
HPV (16, 18, 31) infection
chronic infection secondary to smegma
smoking
phimosis
presentation of penile cancer?
chronic fungating ulcer
bloody/ purulent discharge
50% have inguinal nodes at presentation
mx of penile ca?
surgery:
Moh’s surgery, Laser
+/- LN clearance
Radiotx
Chemotx
most common type of penile ca?
squamous cell ca
what is a hypospadia?
opening of the urethra is on the underside of the penis.
(ventral surface)
what is an epispadia?
opening of the urethra is on the dorsal side of the penis.
what is phimosis?
foreskin is too tight to be pulled back over the head of the penis (glans)
presentation of phimosis in children?
recurrent balanitis (inflammation of head of penis) and ballooning
+/- thick discharge underneath foreskin (balanoposthitis)
mx of phimosis in children?
gentle retraction, steroid creams, circumcision
presentation of phimosis in adults?
dyspareunia, infection
mx: circumcision
what is phimosis assoc w?
STIs
balanitis xerotica obliterans: lichen sclerosus- thickening of foreskin and glans -> phimosis + meatal narrowing
what is paraphimosis?
urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position
decreased venous return -> oedema and swelling of glans
-> gangrene and amputation of the glans penis.
causes of paraphimosis?
catheterisation
masturbation
intercourse
mx of paraphimosis?
manual reduction:
use lignocaine jelly and ice
may require glans aspiration or dorsal slit
what is balanitis?
acute inflammation of foreskin and glans
risk factors for balanitis?
diabetes mellitus, young children w tight foreskin (phimosis)
organisms causing of balanitis?
strep, staph, candida (DM)
mx of balanitis?
hygiene advice
abx
circumcision
presentation of testicular cancer?
Painless testicular lump
Often noticed after trauma
Haematospermia
2O hydrocele
Mets: SOB from lung mets
Abdo mass: para-aortic lymphadenopathy
Hormones: gynaecomastia, virilisation
Contralateral tumour in 5%
risk factors of testicular tumour?
undescended testis
infant hernia
infertility
which type of testicular tumour secretes oestrogens or androgens?
Leydig cell: androgens or oestrogens
Sertoli cell: oestrogens
tumour markers of testicular tumours?
raised AFP and HCG in most germ cell tumours
most effective analgesia in acute renal colic?
Diclofenac IM
initial ix of kidney stones?
urine dipstick and culture
serum creatinine and electrolytes: check renal function
FBC / CRP: look for associated infection
calcium/urate: look for underlying causes
also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis
mx of kidney stones < 20 mm in pregnant women?
Ureteroscopy
A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure.
future prevention of oxalate kidney stones?
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion
future prevention of uric acid kidney stones?
allopurinol
urinary alkalinization e.g. oral bicarbonate
prevention of calcium kidney stones?
high fluid intake
low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet)
thiazides diuretics (increase distal tubular calcium resorption)
best diagnostic ix for hydronephrosis?
US of renal tract
mx of hydronephrosis?
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: Nephrostomy tube
Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty
epididymal cysts are assoc w ?
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
what three things u need to know when working out a scrotal swelling?
if the swelling involves the testicle, if the swelling trans-illuminates when a pen torch is placed below it and if it is possible to palpate above the swelling.
which testicular lump often transilluminates?
hydrocele
PSA test, you should not have:
ejaculated in the past 48 hours
exercised heavily in the past 48 hours
4 weeks following a urinary infection
had a prostate biopsy in the past 6 weeks
1 week after DRE
prostatitis (delay for 1 month)
tx of children with hydrocele?
trans inguinal ligation of Patent processus vaginalis
mx of pt with obstructive kidney stone causing hydronephrosis and pyrexia?
urgent renal decompression and IV antibiotics due to the risk of sepsis via a ureteric stent or percutaneous nephrostomy
What is TURP syndrome?
Transurethral resection of the prostate (TURP) syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are:
- Hyponatraemia: dilutional
- Fluid overload
- Glycine toxicity
Management involves fluid restriction and the treatment of the complications associated with the hyponatraemia.
Prehn’s sign?
relief of pain on elevation of the testis
+ve in epididymo-orchitis
importantly is negative (i.e. the pain is not relieved) in cases of testicular torsion.
