Male Genitourinary Conditions - Inguinal hernias, Femoral hernias, Hydrocele, Varicocele, Testicular torsion, Epididymo-orchitis, Epididymal cyst

Question 1

Inguinal hernias
-presentation
-risk factors and types
-investigations
-management

Answer 1

Groin lump - superior medial to pubic tubercle
-disappears on pressure or when patient lies down
Discomfort and ache - worse on activity
If strangulated, extremely painful

Direct - leaves through weakness in abdominal wall and superficial ring
-more common in older adult males
Indirect - through deep and superficial ring
-more common in infant males

CLINICAL DIAGNOSIS but if in doubt
-US, CT/MRI

Treat even if asymptomatic - mesh repair
-unilateral - open approach
-bilateral/recurrent - laparoscopically

Question 2

Strangulated vs incarcerated
-presentation of strangulated
-investigations
-management

Answer 2

Incarcerated - cannot be reduced, no pain but at risk of strangulation
Strangulated - blood supply cut off to intestines

Pain
Fever
Increased size of hernia
Redness
Peritonitic
Bowel obstruction signs - distention, N/V
Bowel ischemia - bloody stools

Pain, groin discomfort
Irreducible groin mass
Tender distended abdo with lack of bowel sounds
N/V
Constipation

CLINICAL DIAGNOSIS
-FBC, U&E, LFT CRP, ABG, lactate, urinedip, G&S
-US, CT/MRI of groin/abdo - to exclude other pathologies

GEN SURG REFERRAL URGENTLY
-mesh repair

Question 3

Femoral hernias
-presentation
-risk factors

Answer 3

Groin lump, mild pain
Often non reducible, no cough impulse due to narrow femoral ring

If strangulated

Less common than inguinal
More common in women especially if
-multiparous
-obese

CLINICAL DIAGNOSIS but US done to rule out other differentials

Surgical repair needed due to risk of strangulation
-laparotomy, laparoscopy

Question 4

Hydrocoele
-what is it
-presentation
-investigations
-management

Answer 4

Accumulation of fluid in tunica vaginalis
-communicating - peritoneal fluid drains down into scrotum (common in newborn males, resovle within few months)
-non communicating - excess fluid produced within tunica vaginalis

Secondary to
-epididymo-orchitis
-torsion
-testicular tumours

Soft, non tender swelling of scrotum
Can get above mass on examination
Transillumination

CLINICAL DIAGNOSIS, US if doubt or cannot palpate underlying testis

Infantile - surgically repaired if not self resolving by 1-2years
Adults - US to exclude underlying causes

Question 5

Testicular torsion
-what is it
-presentation

Answer 5

Twisting of spermatic cord => testicular ischemia and necrosis
Most common in males 10-30

Severe, sudden onset, lower abdo pain
N/V
Swollen, tender retracted tested
Cremasteric reflex lost
Elevation of testes does not ease pain

CLINICAL DIAGNOSIS

URGENT SURGICAL EXPLORATION
-fix both testes

Question 6

Epididimo-orchitis
-what is it
-presentation
-investigations
-management

Answer 6

Infection of epididymus+testes => pain and swelling
-local spread of genital tract infections
Chlamydia, Gonorrhea - sexually active young people
Ecoli - older adults

Testicular pain, swelling
May be discharge
RULE OUT TESTICULAR TORSION!

Investigations guided by age
-younger adults - STI screening
-older adults - MSU urine

If STI => urgent referral to local SH clinic
-unknown organism - ceftriaxone 500mg IM 1 dose, doxy 100mg PO BDS 14days

If enteric => empiric PO quinolone 2wks

Question 7

Varicoele
-what is it
-presentation
-investigations
-management

Answer 7

Abnormal enlargement of testicular veins

Often asymptomatic
-bag of worms
-association with subfertility

US doppler

Conservative management
Surgery if patient troubled by pain

Question 8

Epididymal cysts
-associated conditions
-presentation
-investigations
-management

Answer 8

Most common cause of scrotal swelling
-separate from body of testicle
-posterior

PKD
CF

CLINICAL DIAGNOSIS, confirmed by US

Supportive management
-surgical removal/sclerotherapy if large or symptomatic