Blackboard EMQs Renal and Urology Flashcards
A 30 year old man presents with a swelling within the left scrotum, which aches when he stands. On examination, the swelling is not tender & feels like a ‘bag of worms’.
What is the most likely diagnosis? A. Epididymal cyst B. Inguinal hernia C. Hydrocele D. Teratoma E. Torsion of the testis F. Testicular gumma G. Varicocele H. Seminoma I. Acute epididymitis J. Mumps orchitis K. Chronic epididymitis L. Scrotal haemotoma
G. Varicocele
A bag of worms is pathognomic. A varicocele is where the internal spermatic veins and pampiniform plexus that drain the testis are abnormally dilated. The cause is due to a combination of factors including increased hydrostatic pressure in the left renal vein, or incompetent/congenitally absent valves. It occurs in 15% of adolescent boys and adult men and is 90% left sided, and can be bilateral. Ultrasound can be helpful if the diagnosis is in doubt. Small varicoceles can be brought out by Valsalva, and may require some experience to diagnose. Surgical correction can reverse the impeded testicular growth in adolescents and also improve sperm parameters (40% of men who come to a male fertility clinic have a varicocele) if this is a problem. However, many can be simply reassured or observed with serial examinations. Note that a varicocele does not transilluminate unlike a hydrocele.
A 25 year old presents with pyrexia, headache & painful swelling of his face & testes.
What is the most likely diagnosis? A. Epididymal cyst B. Inguinal hernia C. Hydrocele D. Teratoma E. Torsion of the testis F. Testicular gumma G. Varicocele H. Seminoma I. Acute epididymitis J. Mumps orchitis K. Chronic epididymitis L. Scrotal haemotoma
J. Mumps orchitis
The tender face swelling indicates mumps parotitis. Epidydimo-orchitis is the most common extra-salivary complication of mumps in males and presents as pain and swelling in one or both testicles. Mumps can also cause an aseptic meningitis, oophoritis in women and uncommonly, mastitis, encephalitis and SN deafness. Constitutional symptoms of fever, malaise, headache, myalgia and anorexia are commonly seen. Those unvaccinated and international travellers are at increased risk. The mumps vaccine is incoporated as part of MMR. Mumps is caused by an RNA paramyxovirus and spread by respiratory droplets. If the diagnosis needs to be confirmed, then serological or saliva testing is possible looking for IgM. Treatment is supportive with symptom relief mainly with analgesia and antipyretics.
A 64 year old man presents with a swelling of his left testis, which is gradually increasing in size. On examination, the swelling is hard, non-tender & does not transilluminate.
What is the most likely diagnosis? A. Epididymal cyst B. Inguinal hernia C. Hydrocele D. Teratoma E. Torsion of the testis F. Testicular gumma G. Varicocele H. Seminoma I. Acute epididymitis J. Mumps orchitis K. Chronic epididymitis L. Scrotal haemotoma
H. Seminoma
Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30 and this is why the better option for this question would be a seminoma. In reality, you cannot tell from the age. Radical orchidectomy and histology is the initial treatment in most cases.
A 45 year old man presents with a painless swelling in his scrotum. His left testis cannot be felt. The swelling transilluminates.
What is the most likely diagnosis? A. Epididymal cyst B. Inguinal hernia C. Hydrocele D. Teratoma E. Torsion of the testis F. Testicular gumma G. Varicocele H. Seminoma I. Acute epididymitis J. Mumps orchitis K. Chronic epididymitis L. Scrotal haemotoma
C. Hydrocele
A hydrocele is a collection of serous fluid between the layers of the tunica vaginalis. Patients mainly present with a painless swollen scrotum (which can be on one or both sides) which feels like a water-filled balloon. Surgery is only performed if the hydrocele is problematic. As a result of the fluid, most hydroceles can be transilluminated. On examination, the hydrocele cannot be differentiated from the testicle. The mass can also increase in size with increased intra-abdominal pressure (such as coughing, crying or raising the arms) which causes peritoneal fluid to move into the scrotal sac. This causes the mass to vary in size during the day (smaller after lying down).
A 20 year old man presents with an acute onset of vomiting & pain in the lower abdomen after playing football. His abdomen is soft but he has a very tender, swollen right testis, which lies high within the scrotum.
What is the most likely diagnosis? A. Epididymal cyst B. Inguinal hernia C. Hydrocele D. Teratoma E. Torsion of the testis F. Testicular gumma G. Varicocele H. Seminoma I. Acute epididymitis J. Mumps orchitis K. Chronic epididymitis L. Scrotal haemotoma
E. Torsion of the testis
This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. Apyrexial would point away from epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.
A 40 year old man presents with a painless swelling in his scrotum which is fluctuant & transilluminable. Both testes are easily palpable.
What is the most likely diagnosis? A. Epididymal cyst B. Inguinal hernia C. Hydrocele D. Teratoma E. Torsion of the testis F. Testicular gumma G. Varicocele H. Seminoma I. Acute epididymitis J. Mumps orchitis K. Chronic epididymitis L. Scrotal haemotoma
A. Epididymal cyst
The painless cystic swelling found here on examination, which is also clearly differentiated from the testicle and transilluminates is sufficient to diagnose an epididymal cyst. These are harmless and treatment should only be considered if problematic.
A 26 year old man presents with a painless lump in his left testis of 6 weeks duration. On examination, he has no inguinal lymphadenopathy. He has an elevated serum alpha-fetoprotein.
What is the most likely diagnosis? A. Testicular tumour B. Acute tubular necrosis C. Carcinoma of the prostate D. Chronic kidney disease E. Testicular torsion F. Acute pyelonephritis G. Acute epididymo-orchitis H. Hydrocele I. Inflamed hydatid de morgani J. Carcinoma of the kidney K. Ureteric colic
A. Testicular tumour
Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30 and this is why the better option for this question would be a seminoma. In reality, you cannot tell from the age. Radical orchidectomy and histology is the initial treatment in most cases.
A 6 year old boy presents with painless haematuria & scrotal oedema of 2 days duration. His urine demonstrates granular casts.
What is the most likely diagnosis? A. Testicular tumour B. Acute tubular necrosis C. Carcinoma of the prostate D. Chronic kidney disease E. Testicular torsion F. Acute pyelonephritis G. Acute epididymo-orchitis H. Hydrocele I. Inflamed hydatid de morgani J. Carcinoma of the kidney K. Ureteric colic
B. Acute tubular necrosis
Acute tubular necrosis is due to injury to the tubular epithelial cells in the kidney which causes these cells to die or detach from the basement membrane. The injury can be ischaemic or nephrotoxic. The condition is oftenasymptomatic and detected on lab tests. Patients tend to have a history of hypertension, fluid depletion (resulting in poor renal perfusion) or exposure to nephrotoxic drugs (like radiocontrast agents, NSAIDs, amphotericin B and aminoglycosides – 10-20% of those on aminoglycosides develop ATN). Those with underlying kidney disease, DM or hypovolaemia are more likely to develop ATN. On urinalysis, the centrifuged urine may show pigmented, muddy brown granular casts which suggests ATN and this is the diagnostic point in this question. The patient may also present with oliguria/anuria and hypotension and compensatory tachycardia due to fluid depletion. The haematuria may suggest an underlying cause and the patient’s oedema may be evidence of circulatory collapse. There is no specific treatment apart from supportive care.
A 70 year old man presents with poor stream & nocturia and bone pain in his thighs. On examination he has a palpable bladder & enlarged prostate gland. His blood pressure is 170/95.
What is the most likely diagnosis? A. Testicular tumour B. Acute tubular necrosis C. Carcinoma of the prostate D. Chronic kidney disease E. Testicular torsion F. Acute pyelonephritis G. Acute epididymo-orchitis H. Hydrocele I. Inflamed hydatid de morgani J. Carcinoma of the kidney K. Ureteric colic
C. Carcinoma of the prostate
This patient clearly has symptoms of lower urinary tract outfow obstruction which could have been present for some time. His prostate is enlarged too, and he has an obstructed bladder. This could have cause either chronic or acute kidney disease. Prostate cancer often metastasizes to bone and bone metastases might be causing his bone pain. His hypertension is most likley incidental since hypertension is so common in the population. Prostate cancer is uncommon in men under 50. Management of this condition is either expectant or definitive depending on life expectancy. Key investigations are PSA and DRE and diagnosis is confirmed on a trans-rectal ultrasound-guided needle biopsy. A PSA normally ranges from 0-4 microgams/L however this varies with age and race. Prostate cancer is graded on the Gleason score (2-10), which is the sum total of two scales from 1 to 5 which is based on how differentiated the tumour’s predominant cell lines are. It is 95% of the time an adenocarcinoma as it is a malignant growth orginating from the glandular cells of the prostate.This patient will also have a bone scan with plain XRs to correlate any positive findings – which may show lytic or blastic lesions causing this patient’s pain in the thighs.
A 70 year old man presents with poor stream & nocturia for the last year. He also described poor apetite, itching and some nausea. On examination he had excorations over his skin, a palpable bladder & smoothly enlarged prostate gland. His blood pressure is 170/95.
What is the most likely diagnosis? A. Testicular tumour B. Acute tubular necrosis C. Carcinoma of the prostate D. Chronic kidney disease E. Testicular torsion F. Acute pyelonephritis G. Acute epididymo-orchitis H. Hydrocele I. Inflamed hydatid de morgani J. Carcinoma of the kidney K. Ureteric colic
D. Chronic kidney disease
This patient has symptoms of lower urinary tract outfow obstruction which have been present for some time and evidence of BPH with chronic urinary retention. His itch, nausea and poor apetite could be caused by chronic uraemia (near end stage chronic kidney disease). His hypertension is most likley incidental since hypertension is so common in the population, but could be from salt and water retention as a result of his chronic kidney disease. The most common causes of CKD are DM and hypertension. Hence, glycaemic control and optimisation of BP are key in slowing the progression of disease. CKD is a risk factor for cardiovascular disease.
A 12 year old boy presents to casualty with red, painful, swollen scrotum. His mid-stream urine is normal.
What is the most likely diagnosis? A. Testicular tumour B. Acute tubular necrosis C. Carcinoma of the prostate D. Chronic kidney disease E. Testicular torsion F. Acute pyelonephritis G. Acute epididymo-orchitis H. Hydrocele I. Inflamed hydatid de morgani J. Carcinoma of the kidney K. Ureteric colic
E. Testicular torsion
This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. Normal MSU rules against an infection (epididymo-orchitis). If there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.
A 75 year old man presents with increased micturation & backache. On examination, he has a palpable bladder & an enlarged prostate. His serum acid phosphatase & alkaline phosphatase are both elevated.
What is the most likely diagnosis? A. Testicular tumour B. Acute tubular necrosis C. Carcinoma of the prostate D. Chronic kidney disease E. Testicular torsion F. Acute pyelonephritis G. Acute epididymo-orchitis H. Hydrocele I. Inflamed hydatid de morgani J. Carcinoma of the kidney K. Ureteric colic
C. Carcinoma of the prostate
Prostate cancer often metastasizes to bone and bone metastases might be causing his back pain. The palpable bladder is due to urinary outflow obstruction. Prostate cancer is uncommon in men under 50. Management of this condition is either expectant or definitive depending on life expectancy. Key investigations are PSA and DRE and diagnosis is confirmed on a trans-rectal ultrasound-guided needle biopsy. A PSA normally ranges from 0-4 microgams/L however this varies with age and race. Prostate cancer is graded on the Gleason score (2-10), which is the sum total of two scales from 1 to 5 which is based on how differentiated the tumour’s predominant cell lines are. It is 95% of the time an adenocarcinoma as it is a malignant growth orginating from the glandular cells of the prostate. The raised enzyme profile is also suggestive here.
A 25 year old man presents with a 6 month history of painless enlargement of the left hemi-scrotum. The swelling is fluctuant, translucent, confined to the scrotum, & the testis cannot be felt separately.
What is the most likely diagnosis? A. Tuberculosis of testicle B. Varicocele C. Undescended testicle D. Squamous cell carcinoma E. Hernia F. Hydrocele G. Testicular torsion H. Cardiac failure I. Testicular malignancy J. Epididymal cyst K. Epididymo-orchitis
F. Hydrocele
A hydrocele is a collection of serous fluid between the layers of the tunica vaginalis. Patients mainly present with a painless swollen scrotum (which can be on one or both sides) which feels like a water-filled balloon. Surgery is only performed if the hydrocele is problematic. As a result of the fluid, most hydroceles can be transilluminated. On examination, the hydrocele cannot be differentiated from the testicle. The mass can also increase in size with increased intra-abdominal pressure (such as coughing, crying or raising the arms) which causes peritoneal fluid to move into the scrotal sac. This causes the mass to vary in size during the day (smaller after lying down).
A 17 year old man presents with a 6 hour history of sudden onset of severe left scrotal pains. The scrotum is red & swollen, the testis & epididymis are very tender.
What is the most likely diagnosis? A. Tuberculosis of testicle B. Varicocele C. Undescended testicle D. Squamous cell carcinoma E. Hernia F. Hydrocele G. Testicular torsion H. Cardiac failure I. Testicular malignancy J. Epididymal cyst K. Epididymo-orchitis
G. Testicular torsion
This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. The main differential is epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.
A 30 year old man presents with an intermittent swelling in the right scrotum. Examination demonstrates a soft, compressible lump in the scrotum, the upper limit of which cannot be palpated.
What is the most likely diagnosis? A. Tuberculosis of testicle B. Varicocele C. Undescended testicle D. Squamous cell carcinoma E. Hernia F. Hydrocele G. Testicular torsion H. Cardiac failure I. Testicular malignancy J. Epididymal cyst K. Epididymo-orchitis
E. Hernia
This is an inguinal hernia. It is where the abdominal contents along with its layers of peritoneum and fascia protrude through the inguinal canal. Remember that on examination, a direct hernia cannot be controlled by pressure at the midpoint of the inguinal ligament whereas an indirect hernia can be controlled by occlusive pressure in this manner. Remember also, your anatomy of the region. The hernial sac of a direct hernia lies medial to the inferior epigastric artery whereas the hernial sac of an indirect hernia lies lateral to the artery. The hernia itself can be either reducible or irreducible and may additionally be obstructed, strangulated or incarcerated.
A 23 year old man has a dull ache in the left scrotum. He has noticed a firm, 2cm, non-tender lump at the front of the testicle. He has palpable supraclavicular lymph nodes.
What is the most likely diagnosis? A. Tuberculosis of testicle B. Varicocele C. Undescended testicle D. Squamous cell carcinoma E. Hernia F. Hydrocele G. Testicular torsion H. Cardiac failure I. Testicular malignancy J. Epididymal cyst K. Epididymo-orchitis
I. Testicular malignancy
Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. The supraclavicular lymph nodes here are an extratesticular manifestation – others include bone pain from metastasis, swelling of the lower extremities due to venous occlusion and gynaecomastia. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30 and this is why the better option for this question would be a seminoma. In reality, you cannot tell from the age. Radical orchidectomy and histology is the initial treatment in most cases.
A 70 year old man presents with mild dysuria, urinary hesitancy & terminal dribbling. He also has bilateral testicular pain, swelling & tenderness of both testes & epididymis. His temperature is 37.5 degrees Celsius.
What is the most likely diagnosis? A. Tuberculosis of testicle B. Varicocele C. Undescended testicle D. Squamous cell carcinoma E. Hernia F. Hydrocele G. Testicular torsion H. Cardiac failure I. Testicular malignancy J. Epididymal cyst K. Epididymo-orchitis
K. Epididymo-orchitis
Generally speaking, younger males are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. He is mildly febrile with tenderness on-top of urinary symptoms which points towards epididymo-orchitis. A urethral swab should be sent for Gram stain and culture of secretions. A urine dipstick is also necessary combined with urine MC+S. Treatment involves bed rest, scrotal elevation, analgesia and antibiotics if indicated.
A 25 year old patient presents with 1 year history of painful scrotal swelling. On examination there is a hard smooth swelling of the right testis. It did not transilluminate. There was no cough impulse.
What is the most likely diagnosis? A. Teratoma B. Metastasis C. Torsion of testis D. Strangulated indirect inguinal hernia E. Varicocele F. Retractile testis G. Mumps orchitis H. Hydrocele I. Cryptoorchidism J. Trauma K. Epididimo-orchitis
A. Teratoma
Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30. Radical orchidectomy and histology is the initial treatment in most cases.
An 18 year old patient brought to the A&E department by his father because of sudden onset of severe painful swelling of the scrotum. There was no history of trauma. On examination – distressed young man who had difficulty in walking with exquisite tenderness of the scrotum. He was apyrexial.
What is the most likely diagnosis? A. Teratoma B. Metastasis C. Torsion of testis D. Strangulated indirect inguinal hernia E. Varicocele F. Retractile testis G. Mumps orchitis H. Hydrocele I. Cryptoorchidism J. Trauma K. Epididimo-orchitis
C. Torsion of testis
This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. Apyrexial points away from epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is fixed to the posterior wall.
A 70 year old patient with 1 year history of swelling of the scrotum which has become painful in the last 4 days. On examination the patient is afebrile with a firm tender swelling in the left side of the scrotum extending to the inguinal region. There is no cough impulse.
What is the most likely diagnosis? A. Teratoma B. Metastasis C. Torsion of testis D. Strangulated indirect inguinal hernia E. Varicocele F. Retractile testis G. Mumps orchitis H. Hydrocele I. Cryptoorchidism J. Trauma K. Epididimo-orchitis
D. Strangulated indirect inguinal hernia
This swelling has become recently painful indicating that this hernia has strangulated. Urgent surgical intervention is necessary. Inguinal hernias lie superomedial to the PT whereas femoral hernias like inferolateral to the PT.
