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Yr 4 - Paediatrics > Urology: Undescended Testes, Hydrocele, Hypospadias, Torsion, Epididymitis & Orchitis > Flashcards

Urology: Undescended Testes, Hydrocele, Hypospadias, Torsion, Epididymitis & Orchitis Flashcards

1
Q

What is cryptorchidism?

A

Failure of testicular descent into the scrotum.

This is a surgical condition that can broadly be defined in 3 groups:

1) True undescended testis

2) Ectopic testis

3) Ascending testis

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2
Q

What is a true undescended testis?

A

Where testis is absent from the scrotum but lies along the line of testicular descent

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3
Q

What is an ectopic testis?

A

Where the testis is found away from the normal path of decent

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4
Q

What is an ascending testis?

A

Where a testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum.

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5
Q

How do the testes normally descend?

A

Under normal embryological development the testis descends from the abdomen to the scrotum, pulled by the gubernaculum, within the processes vaginalis.

They have normally reached the scrotum prior to birth.

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6
Q

What % of cases of cryptochidism are bilateral?

A

25%

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7
Q

What are some complications of undescended testis?

A

1) infertility

2) testicular torsion

3) testicular cancer

4) psychological

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8
Q

How do undescended testis affect fertility?

A

As testis are 2-3⁰ C warmer if intra-abdominal, this can effect spermatogenesis.

Although fertility in unilateral undescended testis is around 90%, this has been reported to drop to around 53% if bilateral.

Risk of infertility increases with delayed correction.

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9
Q

How does undescended testis affect testicular cancer risk?

A

2-3 times more common with a history of undescended testis (2-3%).

This risk double if correction is undertaken after puberty.

Orchidopexy also allows for self-examination for testicular abnormalities by the patient when they are older.

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10
Q

Risk factors for cryptochidism?

A
  • prematurity
  • low birth weight
  • having other abnormalities of genitalia (i.e. hypospadias)
  • having a first degree relative with cryptorchidism
  • maternal smoking during pregnancy
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11
Q

With unilateral undescended testis, what is the management?

A

1) Watch and wait to see if they descend on their own by 6 months

2) Consider referral from around 3 months of age

3) Baby should ideally see a urological surgeon before 6 months of age

4) Orchidopexy –> majority of procedures are performed at around 1 year of age

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12
Q

With bilateral undescended testes, what is the management?

A

Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation.

E.g. This may be a presentation of congenital adrenal hyperplasia (CAH) and are therefore at risk of salt-losing crisis, requiring high dose sodium chloride therapy and careful glucose monitoring followed by steroid replacement.

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13
Q

What must be excluded in cases of bilateral undescended testes?

A

Hormonal causes such as androgen insensitivity syndrome or disorder of sex development must be excluded.

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14
Q

What is orchidopexy?

A

Surgical correction of undescended testes

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15
Q

When should orchidopexy be carried out for undescended testis?

A

Between 6-12 months old

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16
Q

What are retractile testicles?

A

A normal variant in boys that have not reached puberty.

The testes move out of the scrotum and into the inguinal canal when it is cold or the cremasteric reflex is activated.

This usually resolves as they go through puberty and the testes settle in the scrotum.

Occasionally they may fully retract or fail to descend and require surgical correction with orchidopexy.

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17
Q

What is hypospadias?

A

A congenital abnormality of the penis, where the urethral meatus (the opening of the urethra) is abnormally displaced to the ventral side (underside) of the penis, towards the scrotum.

This might be:
- further towards the bottom of the glans (in 90% of cases)
- halfway down the shaft
- even at the base of the shaft

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18
Q

Pathophysiology of hypospasdias?

A

occurs due to arrest of penile development, leading to hypoplasia of the ventral tissue of the penis.

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19
Q

What is epispadias?

A

Where the meatus is displaced to the dorsal side (top side) of the penis.

Usually, the foreskin is abnormally formed to match the position of the meatus.

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20
Q

How is hypospadias usually diagnosed?

A

1) On examination of the newborn

2) If missed, parents may present describing abnormal urinary flow

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21
Q

What are the 3 key features of hypospadias (although not all 3 are required for the condition)?

A

1) Ventral opening of the urethral meatus

2) Ventral curvature of the penis or “Chordee”

3) Dorsal hooded foreskin

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22
Q

What is ‘chordee’?

A

Congenital penile curvature - causes the penis to bend or twist, especially while it is erect .

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23
Q

Management of hypospadias?

A

1) refer to specialist

2) corrective surgery (urethroplasty): typically performed when the child is around 1-years-old

Note - in boys with very distal disease, no treatment may be needed.

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24
Q

What is essential prior to hypospadias surgery?

A

It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure

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25
Q

What is the mainstay of treatment of hypospadias?

A

Urethroplasty

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26
Q

What are some complications of hypospadias?

A

1) Difficulty directing urination

2) Cosmetic and psychological concerns

3) Sexual dysfunction

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27
Q

What is a hydrocele?

A

A collection of fluid within the tunica vaginalis that surrounds the testes.

This results in a scrotal swelling.

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28
Q

What is the tunica vaginalis?

A

A sealed pouch of membrane that surrounds the testes.

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29
Q

What can hydroceles be divided into?

A

Communicating & non-communicating.

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30
Q

What are non-communicating (i.e. simple) hydroceles caused by?

A

Caused by excessive fluid production within the tunica vaginalis.

Usually this fluid gets reabsorbed over time and the hydrocele disappears.

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31
Q

What is a communicating hydrocele?

A

Where the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway called the processus vaginalis.

This allows peritoneal fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size.

If the connection is large enough, an inguinal hernia may occur due to the protrusion of intra-abdominal contents.

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32
Q

Most paediatric hydroceles, seen in neonates and infants, are congenital.

What may hydroceles presenting in older patients be 2ary to?

A

1) Testicular tumours

2) Testicular torsion

3) Trauma

4) Infection e.g. epididymo-orchitis

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33
Q

Clinical features of a hydrocele?

A

1) Soft, non-tender swelling of the hemi-scrotum, usually anterior to and below the testicle

2) The swelling is confined to the scrotum, you can get ‘above’ the mass on examination

3) Transilluminates with a pen torch

4) The testis may be difficult to palpate if the hydrocele is large

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34
Q

describe the scrotal mass on examination in a hydrocele

A

Non-tender, smooth & transilluminates.

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35
Q

What are the key differentials of a scrotal or inguinal swelling in a neonate?

A

1) Hydrocele
2) Partially descended testes
3) Inguinal hernia
4) Testicular torsion
5) Haematoma
6) Tumours (rare)

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36
Q

1st line investigation for confirming diagnosis of a hydrocele and excluding other causes?

A

US (especially in older patients to exclude any underlying cause such as a tumour).

However, diagnosis may be clinical.

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37
Q

Management of infantile hydroceles?

A

1) Reassure - usually resolve by age of 1-2 years

2) If not, surgery

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38
Q

What does surgery invove in management of hydroceles?

A

Surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis).

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39
Q

What is balanitis?

A

Inflammation of the glans penis.

This sometimes extends to the underside of the foreskin (balanoposthitis).

40
Q

Causes of balanitis?

A

1) infective (both bacterial and candidal)

2) autoimmune

41
Q

What is a key part of the treatment of balanitis?

A

Simple hygiene - improper washing under the foreskin and the presence of a tight foreskin can make balanitis worse

42
Q

Clinical features of balanitis?

A
  • itching
  • discharge
  • look for presence of other systemic conditions affecting skin e.g. eczema, psoriasis
43
Q

Investigations in balantitis?

A

1) majority are diagnosed clinically based on the history and physical appearance of the glans penis.

2) in the cases of suspected infective causes can take swab –> may demonstrate bacteria or Candida albicans.

44
Q

What is a posterior urethral valve?

A

Where there is tissue at the proximal end of the urethra (closest to the bladder) that causes obstruction of urine output.

45
Q

Who does a posterior urethral valve occur in?

A

Newborn boys

46
Q

What does a posterior urethral valve lead to?

A

1) Obstruction of outflow of urine creates a back pressure into the bladder, ureters and up to the kidneys –> hydronephrosis.

2) A restriction in the outflow of urine prevents the bladder from fully emptying, leading to a reservoir of urine –> increases UTI risk.

47
Q

Presentation of MILD posterior urethral valve?

A

1) Difficulty urinating

2) Weak urinary stream

3) Chronic urinary retention

4) Palpable bladder

5) Recurrent UTIs

6) Impaired kidney function

48
Q

How can SEVERE posterior urethral valve present?

A

1) bilateral hydronephrosis in the developing fetus

2) oligohydramnios –> this leads to underdeveloped fetal lungs (pulmonary hypoplasia) with respiratory failure shortly after birth

49
Q

how can severe cases of posterior urethral valve be picked up antenatally?

A

on antenatal scans as oligohydramnios and hydronephrosis.

50
Q

Investigations in posterior urethral valve presenting after birth e.g. young boys presenting with UTIs?

A

1) Abdo US

2) Micturating cystourethrogram (MCUG)

3) Cystoscopy

51
Q

What may an abdo US show in posterior urethral valve?

A

Enlarged, thickened bladder and bilateral hydronephrosis.

52
Q

How is an MCUG useful in posterior urethral valve?

A

shows the location of the extra urethral tissue and reflux of urine back into the bladder

53
Q

What does cytoscopy involve in posterior urethral valve?

A

Cystoscopy involves a camera inserted into the urethra to get a detailed view of the extra tissue. Cystoscopy can be used to ablate or remove the extra tissue.

54
Q

Management of posterior urethral valve?

A

1) Mild cases may simply be observed and monitored.

2) A temporary urinary catheter can be inserted to bypass the valve whilst awaiting definitive management.

3) Definitive –> ablation or removal of the extra urethral tissue, usually during cystoscopy.

55
Q

What is definitive management of posterior urethral valve?

A

ablation or removal of the extra urethral tissue, usually during cystoscopy.

56
Q

What is epididymitis?

A

Inflammation of the epididmyis

57
Q

What is orchitis?

A

Inflammation of the testicle

58
Q

What is epididymo-orchitis?

A

Usually the result of infection in the epididmyis and testicle on one side.

59
Q

What is the most common cause of scrotal pain in adults?

A

Epididymitis

60
Q

What is the epididymis?

A

Found at the back of each testicle.

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.

61
Q

What are the 2 main functions of the epididymis?

A

1) Store sperm for maturation

2) Transport sperm to vas deferens

62
Q

What does the epididymis drain into?

A

Vas deferens

63
Q

What are the 4 most common organisms causing epididymo-orchitis?

A

1) E. coli

2) Chlamydia trachomatis

3) Neisseria gonorrhoeae

4) Mumps

64
Q

What is the most common cause of epididymo-orchitis in men <35 y/o?

A

Most likely due to a sexually transmitted pathogen:

  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
65
Q

What is the most common cause of epididymo-orchitis in men >35 y/o?

A

Infection is most likely due to a non-sexually transmitted gram-negative enteric organism causing UTIs:

  • E. coli
  • Pseudomonas spp
66
Q

What condition should you consider in patients with parotid gland swelling and orchitis?

A

Mumps

67
Q

How does mumps affect the testicles?

A

Mumps tends only to affect the testicle, sparing the epididymis.

68
Q

What other organ can mumps affect?

A

Pancreas - causing pancreatitis

69
Q

Presentation of epididymo-orchitis?

A

Typically gradual onset, over minutes to hours.

Unilateral:

  • testicular pain (may radiate to groin)
  • swelling of testicle and epididymis
  • dragging or heavy sensation
  • tenderness on palpation, particularly over epididymis
  • urethral discharge (think chlamydia or gonorrhoea)
  • systemic symptoms e.g. fever, potentially sepsis
  • parotid gland swelling (think mumps)
70
Q

What is the key differential for epididymo-orchitis?

A

Testicular torsion (emergency!)

If there is any doubt, treat it as testicular torsion until proven otherwise.

71
Q

Potential examination findings in epididymo-orchitis?

A
  • enlarged, erythematous scrotum
  • tenderness to palpation on the affected side
  • in the early stages, the epididymis may be tender and thickened
  • in later stages, the entire hemi-scrotum may be oedematous
  • may be associated urethral discharge, 2ary hydrocele, and pyrexia
72
Q

What can guide investigations in epididymo-orchitis?

A

Typically guided by age of patient:
- younger adults –> assess for STIs
- older adults with a low-risk sexual history –> send MSU for microscopy and culture

73
Q

What 3 features makes an STI organism more likely as a cause of epididymo-orchitis?

A

1) Age <35

2) Increased number of sexual partners in the last 12 months

3) Discharge from the urethra

74
Q

What investigations may be useful in epididymo-orchitis?

A
  • 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 swab 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
75
Q

Management of epididymo-orchitis?

A

If acutely very unwell or septic –> admit for IV Abx

If at risk of STI –> refer to GUM

Abx (dependent on which organism is most likely)

76
Q

Give 3 examples of quinolone Abx

A

1) ciprofloxacin
2) levofloxacin
3) ofloxacin

77
Q

When are quinolones typically used?

A

UTIs, pyelonephritis, epididymo-orchitis and prostatitis.

As give excellent gram-negative cover.

78
Q

What are the 2 critical side effects of quinolones (e.g. ciprofloxacin)?

A

1) Tendon damage and tendon rupture, notably in the Achilles tendon

2) Lower seizure threshold (caution in patients with epilepsy)

79
Q

Complications of epididymo-orchitis?

A

Chronic pain
Chronic epididymitis
Testicular atrophy
Sub-fertility or infertility
Scrotal abscess

80
Q

What is testicular torsion?

A

Twisting of the spermatic cord, resulting in testicular ischaemia and necrosis.

It is a urological emergency.

81
Q

What is the typical age that testicular torsion occurs?

A

Teenagers, but can occur at any age.

82
Q

What is testicular torsion often triggered by?

A

Acitvity e.g. playing sport –> ask what the patient was doing at the time when the pain started!

83
Q

Symptoms of testicular torsion?

A
  • Unilateral testicular pain (sudden and severe)
  • May be associated abdo pain and vomiting

Note –> Sometimes abdominal pain is the only symptom in boys, and testicular examination to exclude torsion is essential.

84
Q

Examination findings in testicular torsion?

A
  • Firm, swollen, tender testis
  • Testis is retracted (elevated) upwards
  • Abnormal testicular lie (often horizontal)
  • Rotation, so that epididymis is not in normal posterior position
  • Loss of cremasteric reflex
  • Elevation of testis does NOT ease pain
85
Q

What is a bell-clapper deformity?

A

One of the causes of testicular torsion.

The fixation between the testicle and the tunica vaginalis is absent.

This causes the testicle to hang in a horizontal position (like a bell-clapper) instead of the typical more vertical position).

86
Q

What is the testicle normally fixed posteriorly to?

A

The tunica vaginalis

87
Q

How can a bell clapper deformity cause torsion?

A

The testicle is 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.

88
Q

Management of testicular torsion?

A

Urological emergency!

1) Nil by mouth, in preparation for surgery

2) Analgesia as required

3) Urgent senior urology assessment

4) Surgical exploration of the scrotum

5) Orchiopexy

6) Orchidectomy: if the surgery is delayed or there is necrosis

89
Q

What is orchiopexy?

A

Correcting the position of the testicles and fixing them in place

90
Q

What is orcidectomy?

A

removing the testicle

91
Q

When is an orchidectomy indicated in torsion?

A

If the surgery is delayed or there is necrosis

92
Q

What investigation can confirm the diagnosis of torsion?

A

A scrotal US

Note - any investigation that will delay the patient going to theatre for treatment is NOT recommended.

93
Q

What will a scrotal US show in torsion?

A

Whirlpool sign (a spiral appearance to the spermatic cord and blood vessels).

94
Q

Why are BOTH testicles fixed in the management of torsion?

A

As the condition of bell clapper testis is often bilateral.

95
Q
A

Yr 4 - Paediatrics (78 decks)

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