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Phase 2a Sheffield Medicine > Reproductive > Flashcards

Reproductive Flashcards

1
Q

What is acute bacterial prostatitis?

A

A severe infection involving the prostate that may cause significant systemic upset.

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2
Q

What are the risk factors for acute bacterial prostatitis?

A
  • Age → Most common in men over 50 years old
  • STI
  • UTI
  • Indwelling catheter
  • Post-biopsy
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3
Q

What are the signs of acute bacterial prostatitis?

A
  • Tender, hot, swollen prostate(on digital rectal exam)
  • Palpable bladder(if urinary retention)
  • Tachycardia
  • Pyrexia
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4
Q

What are the symptoms of acute bacterial prostatitis?

A
  • Dysuria
  • Urinary frequency
  • Urinary retention
  • Hesitancy
  • Post-micturition dribbling
  • Straining
  • Perineal, rectal or pelvic pain
  • Back pain
  • Fevers
  • Myalgia
  • Malaise
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5
Q

What are the investigations of acute bacterial prostatitis?

A
  • Digital rectal exam
  • Urine dipstick
  • FBC
  • U&Es
  • CRP
  • Cultures (urine, semen, blood)
  • STI testing
  • Imaging - MRI, TRUSS (trans-rectal ultrasound scan)
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6
Q

What is the management for acute bacterial prostatitis?

A
  • Antibiotics: courses typically 14 days
    • First line:Oral ciprofloxacin or ofloxacin
    • Second line:Oral levofloxacin or co-trimoxazole
    • IV antibiotics: for patients with significant infection under microbiology guidance.
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7
Q

What are the complications of acute bacterial prostatitis?

A
  • Acute urinary retention
  • Epididymitis
  • Chronic prostatitis
  • Prostatic abscess
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8
Q

What is chronic prostatitis?

A

Chronic prostatitis is characterised by > 3 months of urogenital pain, often associated with LUTS or sexual dysfunction.

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9
Q

What are the two types of chronic prostatitis?

A
  • Chronic prostatitis/chronic pelvic pain syndrome:clinical features of chronic prostatitis in the absence of an identifiable bacterial infection.
  • Chronic bacterial prostatitis:relatively uncommon, accounting for around 10% of patients with chronic prostatitis.
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10
Q

What are the risk factors for chronic prostatitis?

A
  • Those with underlying urinary tract abnormalities are at greater risk.
  • Men with HIV are at risk of a greater breadth of infection.
  • Rarely STI’s are the infective agent.
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11
Q

What are the clinical manifestations of chronic prostatitis?

A
  • Urogenital pain
  • Urinary symptoms
    • Hesitancy
    • Dysuria
    • Frequency
  • Sexual dysfunction
    • Pain on ejaculation
    • Erectile dysfunction
    • Premature ejaculation
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12
Q

What are the investigations for chronic prostatitis?

A
  • Urine dipstick and MSU
  • Expressed prostatic secretions
  • Consider Semen MCS
  • STI screen(including blood borne viruses)
  • Consider PSA(may be elevated in prostatitis or malignancy)
  • Consider need for urological investigation to identify potential underlying structural abnormalities.
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13
Q

What is the management for chronic prostatitis/chronic pelvic pain syndrome?

A
  • Analgesia
    • Paracetamol
    • NSAIDs with PPI cover
  • Stool softeners
  • Referral to pain team specialist may be needed, particularly if neuropathic pain is considered.
  • Alpha-blockers (e.g. Tamsulosin) may be trialled if significant LUTS are present.
  • Referral to urology if symptoms are severe or persistent, or diagnosis is uncertain
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14
Q

What is the management for chronic bacterial prostatitis?

A
  • Referral to urology
  • Antibiotic course may be given dependent on the suspected organism.
    • Length of antibiotics courses vary, discussion with microbiology can help guide management.
  • Analgesia
  • Stool softeners
  • Surgical intervention may be indicated e.g. transurethral resection of the prostate (TURP)
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15
Q

Define benign prostate hyperplasia?

A

Increase in the size of the prostate without malignancy. This causes bladder outlet obstruction and lower urinary tract symptoms.

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16
Q

What are the risk factors for benign prostate hyperplasia?

A
  • Increasing age:particularly >50 years old
  • Family history
  • Ethnicity:more common in Afro-Caribbean men; black > white > Asian
  • Diabetes
  • Obesity:due to increased circulating oestrogens
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17
Q

What are the signs of benign prostate hyperplasia?

A
  • Digital rectal examination
  • Lower abdominal tenderness and palpable bladder
    • Indicates acute urinary retention
    • Perform bladder scan
    • Requires urgent catheterisation
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18
Q

What are the symptoms of benign prostate hyperplasia?

A
  • Lower urinary tract symptoms (LUTS)
    • Voiding: hesitancy, weak stream, straining and dysuria, incomplete emptying, terminal dribbling
    • Storage: urgency, frequency, nocturia (due to feeling of incomplete emptying), urgency incontinence
    • Oliguria: if complete obstruction
  • Lower abdominal pain and inability to urinate
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19
Q

What are the primary investigations for benign prostate hyperplasia?

A
  • Urinalysis
  • Prostate-specific antigen (PSA)
  • U&Es
  • International Prostate Symptom Score (I-PSS)
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20
Q

What is PSA?

A

Prostate-specific antigen (PSA):predicts prostate volume, progression and may suggest cancer if significantly raised; BPH can also raise PSA

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21
Q

What is I-PSS?

A

International Prostate Symptom Score (I-PSS):a 7-symptom questionnaire with an additional bother score to predict progression and outcome of benign prostate hyperplasia.

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22
Q

What are some complications of benign prostate hyperplasia?

A
  • Acute urinary retention
  • Urinary tract infections
  • Renal dysfunction: due to obstructive uropathy
  • Haematuria
  • Bladder stones:secondary to urinary stasis
  • Retrograde ejaculation
  • Erectile dysfunction
  • Strictures
  • Incontinence
  • TURP syndrome:
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23
Q

What is the management for a patient with benign prostate hyperplasia with non-bothersome symptoms?

A
  • Reassurance and watchful waiting
  • Conservative management: reduce caffeine and fluid intake, healthy diet regimens, exercise, medication review, bladder retraining
  • In certain circumstances a long-term catheter, with changes every 3 months, may be used.
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24
Q

What is the management for a patient with benign prostate hyperplasia with bothersome symptoms (not surgical)?

A
  • α-1 antagonists e.g. Tamsulosin. Considered first-line forsymptomatic relief
  • 5-α reductase inhibitors e.g. finasteride
  • Combination therapy: second-line management is a combination of the above
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25
Q

What are the indications for surgery for benign prostate hyperplasia?

A

RUSHES Mnemonic
- R - Recurrent or refractory urinary retention
- U - recurrent UTIs
- S - bladder Stone
- H - Haematuria
- E - Elevated creatinine
- S - Symptom deterioration despite therapy

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26
Q

What are the surgical options for benign prostate hyperplasia?

A
  • Transurethral incision of the prostate (TUIP)
  • Transurethral resection of the prostate (TURP)
  • Holmium laser enucleation of the prostate (HoLEP)
  • Transurethral electro-vaporisation of the prostate (TUVP)
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27
Q

What is prostate cancer?

A

Prostate cancers most commonly refer to prostate adenocarcinomas but other prostate cancers include transitional cell carcinoma arising from cells in the transitional zone, and small cell prostate cancer arising from neuroendocrine cells.

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28
Q

What are the risk factors for prostate cancer?

A
  • Increasing age:highest rates amongst men aged 75 to 79 years
  • Family history: 5-10% have a strong family history
  • Afro-Caribbean ethnicity
  • Being tall
  • Obesity and high-fat diet
  • Use of anabolic steroids
  • Cadmium exposure
  • BRCA1 and BRCA2
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29
Q

What are the signs of prostate cancer?

A
  • Asymmetrical, hard, nodular prostate with loss of median sulcus on digital rectal examination
  • Urinary retention
    • Presents with lower abdominal pain and tenderness, inability to urinate and a palpable bladder
  • Palpable lymphadenopathy: indicates metastatic disease
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30
Q

What are the symptoms of prostate cancer?

A
  • Frequency
  • Hesitancy
  • Terminal dribbling
  • Nocturia
  • Haematuria or haematospermia
  • Dysuria
  • Constitutional symptoms: e.g. weight loss, fatigue
  • Bone pain: e.g. lumbar back pain: suggests metastatic disease
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31
Q

What are the primary investigations for prostate cancer?

A
  • Digital rectal exam - first line
  • Prostate-specific antigen (PSA)
  • Liver profile
  • U&Es
  • Multiparametric MRI: first line for suspected localised cancer
  • TRUS was previously gold standard
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32
Q

What are some other investigations for prostate cancer?

A
  • CT abdomen and pelvis / MRI: usually performed as part of staging
  • Bone scan: if symptoms, e.g. bone pain, or PSA trends are indicative of metastasis then an isotope bone scan must be performed
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33
Q

What is the Gleason scoring system?

A

Used to grade prostate neoplasms following biopsy giving an overall score ranging from 2 - 10

  • Themost prevalenthistological pattern is graded form 1-5, with grade 5 being theleastdifferentiated
  • Thesecond most prevalenthistological pattern is graded in the same way, and the two scores are added together
    • Grade 1: Well differentiated cancer.
    • Grade 2: Moderately differentiated cancer.
    • Grade 3: Moderately differentiated cancer.
    • Grade 4: Poorly differentiated cancer.
    • Grade 5: Anaplastic (poorly differentiated) cancer.
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34
Q

What are the differential diagnoses for prostate cancer?

A
  • Benign prostatic hyperplasia
  • Chronic prostatitis
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35
Q

What are the three management options for low-intermediate risk localised prostate cancer?

A
  • Option 1:Active surveillance or observation
  • Option 2: Radical prostatectomy
  • Option 3: Radical radiotherapy or brachytherapy +/- anti-androgen therapy (flutamide, or LHRH agonists)
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36
Q

What are the four management options for high-risk localised prostate cancer?

A
  • Option 1: Radical prostatectomy
  • Option 2: Radical radiotherapy with anti-androgen therapy
  • Option 3: Radical radiotherapy with brachytherapy
  • Option 4: Docetaxel chemotherapy withanti-androgen therapy
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37
Q

What is the management for metastatic prostate cancer?

A
  • Treated with docetaxel chemotherapyandanti-androgen therapy
  • Bilateral orchidectomy(removal of testes to cause androgen deprivation) should be offered as an alternative to LHRH agonists
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38
Q

What are some cancer related complications of prostate cancer?

A
  • Urinary retention
  • Metastasis:most commonly to bone
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39
Q

What is breast cancer?

A

Breast cancer is an uncontrolled growth of epithelial cells within the breast.

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40
Q

What are the risk factors for breast cancer?

A
  • Female gender
  • Age
  • White ethnicity
  • Exposure to radiation
  • Alcohol
  • Obesity
  • Family history
  • Personal history of breast cancer
  • Genetic predispositions(e.g. BRCA 1, BRCA 2)
  • Oestrogen exposure:
    • Combined oral contraceptive(still debated, effect likely minimal if present)
    • Hormone replacement therapy
    • Early menarche and late menopause
    • Nulliparity (woman who has never given birth)
    • Increased age of first pregnancy
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41
Q

What are the clinical manifestations of breast cancer?

A
  • May be asymptomatic in the early stages
  • Breast and/or axillary lump:
    • Often irregular
    • Typically hard/firm
    • May be fixed to skin or muscle
  • Breast pain
  • Breast skin:
    • Change to normal appearance
    • Skin tethering
    • Oedema
    • Peau d’orange: thickened and dimpled skin
  • Nipples:
    • Inversion: fibrosis of lactiferous ducts and suspensory ligament causes retraction
    • Discharge, especially if bloody
    • Dilated veins
    • Paget’s disease: itching, redness, crusting and discharge from the nipple.
  • Features of metastatic spread: the bone (bone pain), liver (malaise, jaundice), lungs (shortness of breath, cough) and brain (confusion, seizures) are most commonly affected.
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42
Q

Describe the breast screening programme in England?

A
  • In England, breast cancer screening runs from the ages of 50 to 71.
  • Screening involves amammogram. The images are then reviewed by a consultant radiologist with several possible results.
  • Additional screening exists for those with family history and may involve genetic testing and imaging at a younger age.
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43
Q

What are the three possible results from a breast screen?

A
  • Satisfactory:no radiological evidence of breast cancer, approximately 96% will have a normal result
  • Abnormal:abnormality detected, further investigations needed. Around a quarter with an abnormal result will subsequently be found to have breast cancer.
  • Unclear:results or imaging unclear or inadequate. Further investigations required.
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44
Q

What is the triple assessment investigation at a breast clinic?

A
  • History and examination
  • Imaging
    • Mammogram: utilises x-rays to image breast tissue. Findings suggestive of cancer include soft tissue masses and microcalcifications.
    • USS:modality of choice in women under the age of 40. It is also used in older women, particularly when mammography and clinical findings do not align.
  • Histopathology
    • This is usually in the form of a fine-needle aspiration (FNA) or core biopsy
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45
Q

What investigations would be used for breast cancer staging and for management guiding?

A
  • Imaging:
    • CXR
    • Breast tomosynthesis
    • MRI breast
    • CT chest, abdomen and pelvis
    • CT brain
    • Contrast-enhanced liver USS
    • Bone scan
    • PET/CT
  • Receptor testing
    • Oestrogen receptor (ER) status
    • Progesterone receptor (PR) status
    • Human epidermal growth receptor (HER2) status
  • Assessment of axilla: if abnormal lymph nodes are found, they may be sampled with ultrasound-guided needle sampling
  • Genetic testing e.g. for BRCA1
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46
Q

What staging system does breast cancer use for staging?

A

TNM system.

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47
Q

What are the surgical management options for breast cancer?

A
  • Tumour resection
    • Breast conservation
    • Mastectomy
  • Lymph node assessment
  • Breast reconstruction
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48
Q

What is the management for breast cancer?

A
  • Surgery
  • Chemotherapy e.g. Trastuzumab (Herceptin)
  • Endocrine therapy
    • Tamoxifen
    • Aromatase inhibitors(e.g. anastrozole)
    • GnRH analogue(e.g. goserelin)
    • Laparoscopic oophorectomy
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49
Q

What are the differential diagnoses for breast cancer?

A
  • Other causes of breast lumps:
    • Fibroadenoma
    • Fibrocystic Breast Disease
    • Breast cysts
    • Breast abscess
    • Fat necrosis
    • Lipoma
    • Phyllodes tumour
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50
Q

What is erectile dysfunction?

A
  • Unable to develop or maintain an erection during sex.
  • Also called impotence.
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51
Q

What are the investigations for erectile dysfunction?

A
  • International index of erectile dysfunction - abnormal
  • Sexual Health Inventory for Men - abnormal
  • Fasting blood glucose - diagnosing diabetes
  • Lipid profile - abnormal in hypercholesterolaemia
  • Duplex ultrasound - evaluate blood flow, look for atherosclerosis
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52
Q

What is the management for erectile dysfunction?

A
  • First line → Treatment of underlying condition.
  • Second line → PDE5 (Sildenafil, Tadalafil, Vardenafil)
  • Third line → Intra-cavernus injection (intra-cavernous alprostadil , papaverine)
  • Fourth line → Intraurethral suppository (alprostadil urethra)
  • Fifth line → Penile prothesis
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53
Q

What is Chlamydia?

A
  • This is a common sexually transmitted infection in the UK and significant cause of infertility.
  • The causative organism is Chlamydia trachomatis
    • A gram-negative bacteria
    • It is an intracellular organism
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54
Q

What are the risk factors of Chlamydia?

A
  • Unprotected sex
  • Young, sexually active etc
  • Multiple partners
55
Q

What are the clinical manifestations of chlamydia in women?

A
  • Abnormal vaginal discharge - cloudy or yellow discharge
  • Painful urination - dysuria
  • Pelvic pain
  • Abnormal vaginal bleeding (intermenstrual or post coital)
  • Painful sex - dyspareunia
56
Q

What are the clinical manifestations of chlamydia in men?

A
  • Urethral discharge or discomfort
  • Painful urination (dysuria)
  • Epididymo-orchitis
  • Reactive arthritis
57
Q

What are the non-gender specific clinical manifestations for chlamydia?

A
  • Trachoma & Neonatal Conjunctivitis
    • Swollen eyelids
    • Purpulent discharge
    • Pain
    • Photophobia
  • C. trachomatis pneumonia
    • Rapid breathing
    • Staccato cough
      • Short, repetitive cough with deep inspiration after each cough
  • LVG
    • Ulcerating papules on genitals
    • Swollen lymph nodes in inguinal region
58
Q

What are the investigations for chlamydia infection?

A

NAAT (Nucleic acid amplification test)
- In women can be performed on vulvovaginal swab, endocervical swab or first-catch urine sample
- In men can be performed on first-catch urine sample or a urethral swab

59
Q

What is the management for chlamydia?

A
  • Anti-chlamydial antibiotics (first line)
    • Doxycycline 100mg twice for 7 days
  • Abstain from sex for seven days of treatment
  • Refer all patients to GUM
  • Test for and treat other STIs
  • Provide eduation on prevention
  • Consider safeguarding issues and sexual abuse in children and young people
60
Q

What is the management for pregnant women with chlamydia?

A
  • Doxycycline is contraindicated in pregnancy and breastfeeding
  • Alternatives are:
    • Azithromycin 1g stat then 500mg once a day for 2 days
    • Erythromycin 500mg four times daily for 7 days
    • Erythromycin 500mg twice daily for 14 days
    • Amoxicillin **500mg three times daily for 7 days
61
Q

What are the complications of chlamydia?

A
  • Pelvic inflammatory disease
  • Chronic pelvic pain
  • Infertility
  • Ectopic pregnancy
  • Epididymo-orchitis
  • Conjuctivitis
  • Reactive arthritis
  • Lymphogranuloma verenum
62
Q

What is the national STI screening programme?

A
  • This program aims to screen every sexually active person under 25 years of age for chlamydiaannuallyor when they change their sexual partner.
  • Everyone that tests positive should have a re-test three months after treatment.
  • This re-testing is to ensure they have not contracted chlamydia again, rather than to check the treatment has worked.
  • Tests are for:
    • Chlamydia
    • Gonorrhoea
    • Syphilis (blood test)
    • HIV (blood test)
63
Q

What is Gonorrhoea?

A
  • A common STI caused by Neisseria gonorrhoeae, a gram-negative diplococcus bacterium.
64
Q

What are the risk factors for Gonorrhoea infection?

A
  • Unprotected sex
  • 15-24 years old
  • Black ancestry
  • Current or prior history of STIs
  • Multiple recent sexual partners
  • Inconsistent condom use
  • Men who have sex with men
  • History of sexual abuse
65
Q

What are the clinical manifestations for Gonorrhoea?

A
  • Odourless purpulent discharge, possibly green or yellow
  • Dysuria
  • Pelvic pain (in women)
  • Testicular pain or swelling aka epididymo-orchitis (in men)
  • Rectal infection may cause anal or rectal discomfort or discharge but is often asymptomatic
  • Pharyngeal infection may cause a sore throat but is often asymptomatic
  • Prostatitis cause perineal pain, urinary symptoms and prostate tenderness on examination
  • Conjunctivitis cause erythema and a purulent discharge
66
Q

What are the investigations for Gonorrhoea?

A
  • NAAT → Will be positive for gonorrhoea.
    • NAAT does not provide any information about the specific bacteria and their antibiotic sensitivities and resistance.
  • Charcoal swab - Taken for microscopy, culture and testing antibiotic sensitivities before initiating antibiotic therapy.
    • This is especially important given the high rates of antibiotic resistance.
67
Q

What is the management for uncomplicated Gonorrhoea infections?

A

Patient should be referred to GUM clinics to coordinate testing, treatment and contact tracing
- Single dose IM Cefriaxone 1g
- Single dose Oral Ciprofloxacin 500mg
All patient should have a follow-up “test of cure” given the high antibiotic resistance.

68
Q

What is the management for complicated Gonorrhoea infections?

A
  • This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic.
  • BASHH recommend a test of cure at least:
    • 72 hours after treatment for culture
    • 7 days after treatment for RNA NAAT
    • 14 days after treatment for DNA NAAT
69
Q

What advice should be given to patients with Gonorrhoea?

A
  • Abstain from sex for seven days of treatment
  • Refer all patients to GUM
  • Test for and treat other STIs
  • Provide education on prevention
  • Consider safeguarding issues and sexual abuse in children and young people
70
Q

What are the complications of Gonorrhoea?

A
  • Pelvic inflammatory disease
  • Chronic pelvic pain
  • Infertility
  • Epididymo-orchitis (men)
  • Prostatitis (men)
  • Conjunctivitis
  • Urethral strictures
  • Disseminated gonococcal infection
  • Skin lesions
  • Fitz-Hugh-Curtis syndrome
  • Septic arthritis
  • Endocarditis
71
Q

Describe disseminated gonococcal infection?

A
  • A complication of untreated gonococcal infection
  • Where bacteria spreads to skin and joints
  • It causes
    • Various non-specificskin lesions
    • Polyarthralgia(joint aches and pains)
    • Migratory polyarthritis(arthritis that moves between joints)
    • Tenosynovitis - inflammation of synovial membrane around tendon
    • Systemic symptomssuch as fever and fatigue
72
Q

Describe gonococcal conjunctivitis?

A
  • In a neonate this means its contracted from the mother during birth
  • Neonatal conjunctivitis is called ophthalmia neonatorum
  • This is a medical emergency and is associated with sepsis, perforation of the eye and blindness
73
Q

What is Syphilis?

A
  • A sexually transmitted infection caused by the spirochaetal bacterium Treponema pallidum.
  • It infects the skin and mucous membranes of the external genitalia and mouth.
74
Q

How is Syphilis spread?

A
  • Contacted through:
    • Acquired syphilis: oral, vaginal or anal sex, , IV drug use, blood transfusions and other transplants.
    • Congenital syphilis: Vertical transmission (mother to child).
75
Q

What are the risk factors of Syphilis?

A
  • Sexual contact with an infected person
  • MSM
  • Illicit drug use
  • Commercial sex workers
  • Multiple sex partners
  • Syphilis during pregnancy
76
Q

What are the clinical manifestations of primary syphilis?

A
  • Painless genital ulcer (chancre)
  • Local lymphadenopathy
77
Q

What are the clinical manifestations of secondary syphilis?

A
  • Maculopapular rash
  • Condylomata lata(grey wart-like lesions around the genitals and anus)
  • Low-grade fever
  • Lymphadenopathy
  • Alopecia (localised hair loss)
  • Oral lesions
78
Q

What are the clinical manifestations of tertiary syphilis?

A
  • Gummatous lesions(gummasare granulomatous lesions that can affect the skin, organs and bones)
  • Aortic aneurysms
  • Neurosyphilis
    • Argyll-Robertson pupil (pupil loses the light reflex)
    • Headache
    • Altered behaviour
    • Dementia
    • Tabes dorsalis(demyelination affecting the spinal cord posterior columns)
    • Ocular syphilis(affecting the eyes)
    • Paralysis
    • Sensory impairment
79
Q

What are the investigations for syphilis?

A
  • Dark field microscopy
  • Polymerase chain reaction (PCR)
  • Antibody testing
80
Q

What is the management for syphilis?

A

All patients must be followed up by a specialist service.

  • Standard treatment → Single deep IM dose of Benzathine benzylpenicillin.
    • If patient is allergic then give Doxycycline.
  • Alternative regimes and types of penicillin are used in different scenarios, for example, late syphilis and neurosyphilis. Ceftriaxone, amoxicillin and doxycycline are alternatives.
81
Q

What are some complications for syphilis?

A

Jarisch-Herxheimer reaction for penicillin use

82
Q

Define varicocele?

A

A varicocele refers to dilated testicular veins within the pampiniform plexus. The vast majority (around 90%) occur on the left side.

83
Q

What are the signs of varicocele?

A
  • Palpable veins (described as bag of worms)
  • Scrotum may hang lower on side of varicocele
  • Signs of testicular atrophy may be seen on the affected side.
84
Q

What are the symptoms of varicocele?

A
  • Painless testicular swelling
    • May reduce on lying and be exacerbated by a Valsalva manoeuvre (slow breathing)
  • Some patients develop symptoms: discomfort, pain or a dragging sensation.
85
Q

What are thee investigations for varicocele?

A
  • Testicular examination: demonstrates dilated veins (bag of worms)
    • Examination is conducted both standing and lying.
    • The size of each testicle should be evaluated.
  • Doppler USS may be used in cases of diagnostic uncertainty and to confirm diagnosis.
  • Fertility assessments may be completed. Semen analysis can be sent alongside FSH and testosterone levels.
86
Q

Describe the grading of a varicocele?

A
  • Sub-clinical:No clinical abnormality, only detected by Doppler ultrasound.
  • Grade I (small):Only clinically palpable with Valsalva manoeuvre.
  • Grade II (moderate):Palpable without Valsalva manoeuvre.
  • Grade III (large):Varicocele is visible through the scrotal skin, easily palpable.
87
Q

What are the surgical management options for a varicocele?

A
  • Inguinal / subinguinal approach
  • Retroperitoneal high ligation
  • Microsurgical inguinal
  • Laparoscopy
88
Q

What are the endovascular management options for a varicocele?

A
  • Antegrade sclerotherapy
  • Retrograde sclerotherapy
  • Retrograde embolisation
89
Q

What is the differential diagnoses for a varicocele?

A
  • Testicular mass
  • Hydrocele
  • Inguinal hernia
90
Q

What are the complications of a varicocele?

A
  • Testicular atrophy
  • Infertility/ subfertility
91
Q

Describe the thought pathway for diagnosing scrotal lumps?

A

All testicular lumps = cancer until proven otherwise.

Acute, tender enlargement of testis = testicular torsion until proven otherwise.

  1. Can you get above it?
  2. Is it separate from the testis?
  3. Cystic or solid?
    - Cannot get above = inguinoscrotal hernia, hydrocele extending proximally
    - Separate and cystic = epididymal cyst
    - Separate and solid = epididymitis, varicocele
    - Testicular and cystic = hydrocele
    - Testicular and solid = tumour, haematocele, granuloma, orchitis, gumma (non cancerous growth)
92
Q

What is testicular torsion?

A
  • Testicular torsion is a urological emergency caused by twisting of the testicle on its spermatic cord, leading to ischaemia and eventually necrosis.
  • Germ cells are most susceptible to ischaemia.
  • “6 hour window” after onset before damage from ischaemia is irreversible.
93
Q

What are the risk factors for testicular torsion?

A
  • Young age
  • Bell clapper deformity:high riding testicle with a horizontal lie
  • Cryptorchidism:undescended testis increase the risk of torsion and would usually present in the first few months of life
  • Trauma:trauma-induced torsion accounts for less than 10% of cases
94
Q

What are the signs of testicular torsion?

A
  • Swollen, high-riding and tender testicle: skin may be erythematous
  • Abnormal lie
    • Horizontal lie
    • Rotated so that epididymis is not in normal posterior position
    • Elevated (retracted) testicle
  • Prehn’s negative:
    • Pain is not relieved on lifting the ipsilateral testicle, unlike in epididymitis
  • Absent cremasteric reflex
    • Swipe the superior and inner part of the thigh
    • A normal reflex contracts the cremaster muscle, pulling up the ipsilateral testis
    • Reflex almost always absent
95
Q

What symptoms of testicular torsion?

A
  • Usually unilateral, sudden onset and excruciatingly painful
  • Often triggered by activity
  • Pain may be severe, intermittent and self-limiting; intermittent pain does not rule out torsion
  • Nausea and vomiting secondary to pain is common
  • Lower abdominal pain: referred pain
96
Q

What is the first line investigation for testicular torsion?

A
  • Imaging should not be considered if testicular torsion is suspected as it will delay surgery.
  • Surgical exploration: should be performed immediately if there is high clinical suspicion as it allows definitive diagnosis and management. Should be performed within 6 hours to prevent irreversible damage (90% salvageable at 6 hours and 10% salvageable at ≥24 hours)
97
Q

What are the other investigations for testicular torsion?

A
  • Testicular ultrasound: operator-dependent; ‘whirl-pool’ sign suggests torsion, as does decreased blood flow in the affected testicle on colour doppler
  • Urinalysis:an abnormal result such as the presence of leukocytes and nitrites may suggest an alternative diagnosis, e.g. epididymo-orchitis
98
Q

What are the differential diagnoses of testicular torsion?

A
  • Epididymo-orchitis/ epididymitis
  • Torsion of the Hydatid of Morgagni (embryonic remnant of the Mullerian duct)
  • Hydrocele
  • Varicocele
  • Testicular cancer
99
Q

What is the management for viable testicles during testicular torsion?

A

Bilateral orchiopexy: the affected testicle is untwisted and fixed to the scrotal sac. The contralateral testicle should always be fixed to prevent contralateral torsion

100
Q

What is the management for non-viable testicles during testicular torsion?

A

Ipsilateral orchiectomy and contralateral orchiopexy: removal of the affected testis and fixation of the contralateral testis to the scrotal sac to prevent contralateral torsion

101
Q

What is the management for testicular torsion when there is a surgical delay?

A

Manual de-torsion: a temporary measure that should only be performed if surgery is not available within 6 hours. Surgical exploration must be subsequently performed to ensure the viability of the testis

102
Q

What are the complications of testicular torsion?

A
  • Recurrent torsion
  • Infertility/ subfertility: torsion for 10-12 hours results in ischaemia and irreversible damage. Orchiectomy results in decreased spermatogenesis
  • Pubertal delay:may occur, particularly if bilateral orchiectomy is performed; hormone replacement may be required
103
Q

What is Epididymo-Orchitis?

A
  • Inflammation of the epididymis (coiled tube that stores sperm and transports it from the testes) is referred to as epididymitis, whilst orchitis is inflammation of the testicle.
  • The two can co-exist and is referred to as epididymo-orchitis.
104
Q

What are the risk factors for Epididymo-Orchitis?

A
  • STI-related:young, multiple partners, unprotected sex
  • Enteric-related:elderly, bladder outflow obstruction, structural/functional abnormality of urinary tract, instrumentation of urinary tract
  • Tuberculosis: can cause epididymo-orchitis
  • Mumps
105
Q

What are the signs of Epididymo-Orchitis?

A
  • Tenderness and palpable swelling of the epididymis and testicles
  • Prehn’s sign positive
    • Pain relief with lifting the affected testicle
    • Prehn’s sign is negative in testicular torsion
  • Cremasteric reflex preserved (unlike torsion)
106
Q

What are the symptoms of Epididymo-Orchitis?

A
  • Unilateral tender, red, and swollen testicle
    • Pain develops over a few days
  • Lower urinary tract symptoms e.g. dysuria
  • Urethral discharge: may and or may not be present
  • Urethritis: may or may not be present
  • Pyrexia may or may not be present
107
Q

What are the primary investigations for Epididymo-Orchitis?

A
  • Urinalysis:first void sample is most useful and should be sent for microscopy and culture.
  • Nucleic Acid Amplification Test (NAAT):first void urine sample for NAAT to detect the DNA/RNA of the causative organism
  • Swab of urethral secretions: less sensitive than NAAT**but must also be performed in symptomatic men
108
Q

What are the other investigations for Epididymo-Orchitis?

A
  • STD screening
  • Testicular ultrasound: if the diagnosis is uncertain
  • Surgical exploration: if torsion cannot be confidently excluded clinically and ultrasound is not available expediently
109
Q

What is the differential diagnoses of Epididymo-Orchitis?

A

Testicular torsion

110
Q

What is the management for Epididymo-Orchitis?

A
  • First-line for STI:
    • Empirical: ceftriaxone and doxycycline
    • Additional management: no sex until review and partner notification
    • Test of cure:only done in cases where gonorrhoea is confirmed
  • First-line for enteric organisms:
    • Empirical:fluoroquinolone e.g. ofloxacin or ciprofloxacin
  • Analgesia
  • Scrotal support, if needed
  • Drainage, if abscess
  • Partner notification: for patients with a confirmed STI causing epididymo-orchitis.
111
Q

What are some complications of Epididymo-Orchitis?

A
  • Musculoskeletal: reactive arthritis secondary to chlamydia or gonorrhoea
  • Infective: disseminated infection secondary to gonorrhoea
  • Reproductive: male subfertility or infertility
  • Urological:epidydimal obstruction and scarring secondary to poorly treated infection
112
Q

What is testicular cancer?

A
  • Testicular cancer is the most common malignancy in young males and usually presents with a firm, painless testicular lump.
  • Testicular cancer can be divided into germ cell tumours, which are by far the most common comprising 95% of cases, non-germ cell tumours (sex-cord stromal tumours), and lymphomas.
113
Q

What are the risk factors for testicular cancer?

A
  • Young males:seminoma > 35 years; non-seminoma < 35 years
  • Caucasian
  • Family history
  • Infertility: 3-fold increased risk
  • Cryptorchidism:highest risk in abdominal and bilateral undescended testes
  • Intersex conditions: e.g. Klinefelter’s syndrome (extra X chromosome = small undeveloped testicles)
  • In-utero exposure to pesticides or synthetic sex hormones
  • Mumps orchitis: pain and swelling in testicles after mumps
  • Testicular atrophy:often following trauma
114
Q

What are the signs of testicular cancer?

A
  • Firm non-tender testicular mass
    • Does not transilluminate
    • Hydrocele (swelling in scrotum) may be present
  • Supraclavicular lymphadenopathy
115
Q

What are the symptoms of testicular cancer?

A
  • Painless testicular lump
  • Sometimes sharp or dull testicular pain and lower abdominal pain
  • Symptoms related to raised β-hCG
    • Hyperthyroidism occurs as the alpha subunit of β-hCG mimics TSH
    • Gynaecomastia
    • Loss of libido
    • Erectile dysfunction
    • Testicle atrophy
  • Bone pain: indicates skeletal metastasis
  • Breathlessness, cough or haemoptysis: indicates lung metastasis
  • Back pain: indicative of lymph node metastasis
116
Q

What are the investigations for testicular cancer?

A
  • Ultrasound testicular doppler:first-line and diagnostic in over 90% of cases
  • Tumour markers:β-hCG, AFP, and LDH must be measured prior to surgery. LDH is raised non specifically in most testicular cancers
  • CT Chest, abdomen, pelvis: performed as part of staging to assess for metastatic disease
  • NOTE: fine-needle aspiration or percutaneous needle biopsy must not be carried out due to the risk of introducing a new pathway by which the cancer can spread*
117
Q

What are the differential diagnoses for testicular cancer?

A
  • Testicular torsion
  • Hydrocele
  • Epidydimal cyst
118
Q

What is the management for localised seminoma?

A
  • Radical orchiectomy
  • Post-orchiectomy active surveillance: for patients with low-risk disease
  • Post-orchiectomy radiotherapy or chemotherapy: radiotherapy is offered in locally-invasive disease, however, carboplatin (chemo) can be used as an alternative
119
Q

What is the management for non-localised seminoma?

A
  • Radical orchiectomy:some patients also undergo retroperitoneal lymph node dissection
  • Post-orchiectomy active surveillance: for patients with low-risk disease
  • Post-orchiectomy combination chemotherapy: for patients with high-risk disease
120
Q

What is the management for advanced or metastatic testicular cancer?

A
  • Radical orchiectomy
  • Seminoma:adjuvant combination chemotherapy or radiotherapy
  • Non-seminoma:combination chemotherapy
121
Q

What are the complications of testicular cancer?

A
  • Metastasis:lung, liver, bones, brain, lymph nodes
  • Treatment-related:
    • Infertilitysecondary to orchiectomy/chemotherapy/radiotherapy
    • Secondary malignancydue to radiotherapy
    • Pulmonary or renal toxicitysecondary to chemotherapy
122
Q

What is a hydrocele?

A

Hydrocele refers to a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis (membrane covering the testes).

123
Q

What are the clinical manifestations of a hydrocele?

A
  • Scrotal swelling (in front and below testicle)
    • Smooth
    • Non-reducible
    • Demonstrating transillumination with pen-torch
    • Non-tender
    • Soft and fluctuant (communicating hydrocele)
    • Stays one size (non-communicating hydrocele)
  • Communicating hydroceles tend to change size and increase when standing for prolonged periods
124
Q

What are the investigations for a hydrocele?

A

Testicular ultrasound.

125
Q

What are the differential diagnoses for a hydrocele?

A
  • Partially descended testes
  • Inguinal hernia
  • Testicular torsion
  • Varicocele
  • Epidydimal cyst
  • Haematoma
  • Tumours (rare)
126
Q

What is the management for a hydrocele in infants?

A
  • May resolve within first year of life
  • Patients should have ongoing observation to ensure resolution occurs and to identify the development of an inguinal hernia
  • If surgery is indicated, it is an open repair with high ligation of patent processus vaginalis (for communicating hydroceles)
127
Q

What is the management for a hydrocele in adults?

A
  • Non-communicating hydroceles may have spontaneous repair.
    • Scrotal support may help adults with symptoms of discomfort.
  • Late onset communicating hydrocele less likely to resolve
    • Aspiration of a hydrocele is simple and may give initial relief
    • Surgical options include:
      • Lord’s procedure:this involves plication (folding) of the sac.
      • Jaboulay procedure:the sac is opened drained, partially excised, everted and sutured behind the testicle.
128
Q

What is an epidydimal cyst?

A

Smooth, extra-testicular, spherical sac of fluid in the head of the epididymis (top of testicle). They are usually harmless.

129
Q

What are the risk factors for epidydimal cysts?

A
  • Not uncommon overall.
  • Usually develop in adulthood.
  • Rare in children.
130
Q

What are the clinical manifestations of an epidydimal cyst?

A

Signs
- Palpable lump (often multiple and bilateral)
- Well defined and will transluminate since fluid-filled
Symptoms
Can cause dragging and soreness
- May be pain if cysts are large

131
Q

What is the investigation for an epidydimal cyst?

A

Scrotal ultrasound

132
Q

What are the differential diagnoses for an epidydimal cyst?

A
  • Hydrocele
  • Varicocele
133
Q

What is the management for an epidydimal cyst?

A
  • Usually not necessary
  • Removed, if symptomatic

Phase 2a Sheffield Medicine (10 decks)

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