Urology - miscellaneous Flashcards
Testicular cancer - risk factors and types
Most common malignancy in men aged 20-30 years
RF: infertility, cryptorchidism, family history, Klinefelter’s syndrome, mumps orchitis
- Germ cell tumours in 95% cases:
1. seminomas = all ages including elderly
2. nonseminomas = including embryonal, yolk sac, teratoma and choriocarcinoma. More aggressive and develop earlier in life - Non germ cell include Leydig cell tumours and sarcomas
Testicular cancer - features
- a painless lump is the most common presentation
- pain may also be present in a minority of men
- other include hydrocele, gynaecomastia
- AFP is elevated in around 60% of germ cell tumours
- LDH is elevated in around 40% of germ cell tumours
- seminomas: hCG may be elevated in around 20%
Testicular cancer - Investigations and management
Investigations
- bloods: α-FP, β-HCG, LDH
- gold standard: ultrasound
Management
- orchidectomy
- chemotherapy and radiotherapy may be given depending on staging and tumour type
prognosis is generally excellent
Post -op monitoring: CT abdo (abdo LN mets are common)
Hydrocele
Presents as a mass that transilluminates, usually possible to ‘get above’ it on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis (communicating hydrocele –> needs surgery due to risk of forming inguinal hernia)
Can also be due to trauma, inflammation, torsion, with accumulation of fluid (noncommunicating –> can wait until 3+ y/o to operate)
Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis
Testicular torsion - definition
twist of the spermatic cord resulting in testicular ischaemia and necrosis.
most common in males aged between 10 and 30 (peak incidence 13-15 years)
Testicular torsion - features
- pain is usually severe and of sudden onset
- pain may radiate to lower abdomen, groin or loin
- may be a/w nausea, vomiting, mild fever
- on examination there is usually a swollen, tender testis retracted upwards, sometimes in a horizontal lie. The skin may be reddened
- cremasteric reflex is lost
- Prehn’s sign negative - elevation of the testis does not ease the pain (unlike in epididymitis)
What is bell clapper deformity?
A bell clapper deformity is a predisposing factor in testicular torsion in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate. Bell clapper deformity predisposes to intravaginal torsion of the testis.
Testicular torsion - definitive management
If torsion is suspected, urgent exploration must be done without any other investigations
- treatment is with surgical exploration + bilateral testicular fixation. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
What investigations could be done if torsion isn’t suspected?
Investigations
- Bloods (including inflammatory markers)
- Urine Dip & MSSU
- Colour Doppler Ultra Sound (CDUS)? - can be used if dx of torsion is unlikely & will not cause detriment
E.g. if long history already (24-48 hours) +/- features suggestive of epididymo-orchitis
Torsion - complications
Delay in treatment results in permanent ischaemic damage
- infarction of testicle/permanent testicular damage/ loss of testicles - Atrophy - Loss of hormone production - Loss of sperm production / infertility
Epididymo-orchitis - definition
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia
trachomatis and Neisseria gonorrhoeae) or the bladder
Most likely organism and age:
- Sexually active & < 35 - Gonorrhoea, Chlamydia
- Children & men > 35 - E.Coli
Epididymo-orchitis - clinical features
- Fever
- unilateral scrotal swelling and pain, may radiate into groin (spermatic cord). Usually gradual and progressive.
- Erythema of scrotal skin
- Thickening of cord & epididymis
- Reactive hydrocele
- Evidence of underlying infection, eg. penile discharge
or symptoms of urethritis / cystitis
Epididymo-orchitis - investigations
Investigation
- Bloods - FBC, U&Es, CRP etc.
- UDT, urine microscopy & MSSU
- Urethral swabs
- Urine Chlamydia and Gonorrhoea
- Scrotal USS (can be done as o/p)
Epididymo-orchitis - management
British Association for Sexual Health and HIV (BASHH)
For unknown organism:
ceftriaxone 500mg IM single dose, plus doxycycline 100mg PO twice daily for 10-14 days
Vital:
- if >35: Ciprofloxacin 500mg bd (14 days)
- if <35 or STI Suspected:
Doxycycline 100mg bd (14 days to cover chlamydia) & ask to visit GUM clinic for contact tracing etc.
Differentiating torsion and infection
Torsion
- Pain more acute and sudden
- Pain more localised to testis
- No infective symptoms
- ve urine dip
- Lifting does not ease
Infection - Gradual onset - Pain more localised to epididymis - Possibly infective symptoms \+ve urine dip (not always) - Lifting may ease (+ve Prehn’s sign )
