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1

Testicular Torsion 

Age, onset, symtoms, examination

 

• Usually younger patient (<30 y)
SUDDEN onset e.g. woke from sleep
• Unilateral pain; may be nauseated/vomit; often no LUTS 

 

Examination

Testis is very tender
• Lying high in scrotum with horizontal lie 

 

If you suspect testicular torsion, the patient needs emergency scrotal exploration Do not waste time getting investigations such as ultrasound 

2

Painless scrotal lump – Not tender 

–  Testis tumour

–  Epididymal cyst

–  Hydrocele

–  Reducible inguino-scrotal hernia 

3

Haematocoele

An accumulation of the blood in the tunica vaginalis

(e.g., traumatic rupture of the testicular artery).

It therefore does not transilluminate. 

4

Varicocoele

which side mainly, palpation findings? presentation? treatment

The veins of the pampiniform plexus become dilated in the standing position.

 

Painless/Aching at END of day 

• Dull ache, at end of day
• Lt > Rt
• May be associated with reduced fertility

(esp.if bilateral)

 

examination

• “Bag of worms” above testis
NOT tender
• ? Palpable abdominal/renal mass 

 

Treatment

– Reassure

– Radiological embolisation

• Symptomatic

• Infertility (slow motility of sperm)
• If present in adolescent and growth of testis affected 

5

spermatocœle 

cyst due to 

6

hydrocœle

a painless collection of serous fluid within the tunica vaginalis.

it can grow as large as a grapefruit! 

 

Presentation

• Slow/sudden onset

• Uni/bilateral scrotal swelling

• imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis

 

Examination

•Testis not palpable separately

•Can usually ‘get above’

•Transilluminates 

 

7

why is a varicoceole almost always on the left?

Why is a right sided varicocoele potentially worrying?

 

Hint think about the venous drainage. 

The left testicular vein empties vertically into the renal vein, much higher than the right drainage.

The varicosities form when the valve system between these two veins fails and blood falls backwards under the pull of gravity.

The right testicular vein drains directly into the inferior vena cava at an oblique angle, further down. Its valves do not have to support the same weight of blood as those in the left testicular vein and are therefore much less likely to fail.

A right sided varicocoele is very uncommon and is suggestive of other, potentially more serious problems such raised IVC pressure - e.g. due to obstruction. 

8

hydrocœles in young boys often get bigger when they cough (or cry)” why?

Hydrocœles at this age are usually still connected to the peritoneal cavity by some persisting patency of the processus. The patency is limited so raised intra-abdominal pressure is required to send i.p. fluid through into the hydrocœle. 

9

Explain why trans-illumination with a small bright torch can distinguish an epididymal cyst from a spermatocœle. 

An epididymal cyst contains clear fluid and transilluminates ‘brilliantly’, while a spermatocœle contains turbid fluid that inhibits transillumination.

 

Epididymal cysts arise from unconnected segments of the efferent tubules that sprouted from the mesonephric duct hence the clear fluid content.

Spermatocœles arise similarly, but the segment is marginally connected to the rete testis and contains degenerate products of spermatogenesis.

 

There is no important clinical difference between them, other than embryological origin. 

10

list the causes of scrotal swelling? 

Testicular torsion*;

hernia,

hydrocoele,

epididymal cyst,

epididymitis,

orchitis,

spermatocoele,

varicocoele,

a testicular mass and a cyst of the cord.

A testicular torsion is the most important diagnosis, followed by testicular mass. 

11

Acute scrotal pain - Causes 

  • Testicular torsion
  • Epididymitis / Orchitis / Epididymo-orchitis

–  Urinary tract infection (UTI)

–  Sexually transmitted infection (STI)

– Mumps

  • Torsion of hydatid of Morgagni
  • Trauma
  • Ureteric calculi (rarely) 

12

what is Fournier’s Gangrene? which condition is it seen? 

which drug can increase the risk of it?

treatment?

necrotic area of scrotal skin!

SGLT2 inhibitors

epididymo-orchitis

Emergency debridement & antibiotics 

13

Epididymo-orchitis 

Age, onset, symtoms, examination, Investigations, treatment

• Age

–  20-40/50 – STI (esp Chlamydia)

–  40/50+ - UTI (esp. E. Coli)

Gradual onset

• Usually unilateral

 

Investigations

Bloods
– FBC / U&E’s / Cultures if septic

Urine
- MSU for MC&S

Radiology
– Scrotal USS if suspect abscess 

 

Examination

• May be pyrexial; can be septic
• Scrotum erythematous
• Testis/epididymis enlarged, tender
• Fluctuant areas may represent abscess

• May have reactive hydrocoele

• Rarely – necrotic area of scrotal skin (Fournier’s Gangrene) – Fournier’s

• High mortality rate (approx 50%)

 

ANTIBIOTICS

ceftriaxone 500 mg (IM) injection as a single dose, plus doxycycline 100 mg orally twice daily for 10–14 days.

 

14

Scrotal Lumps 

  • History asked qs?
  • Examination?

•Can I get ‘above it’?
– If not, it is likely to be a hernia

•Is it in the body of the testis?
– If yes, this could be a testicular tumour!

•Is it separate to the testis?
•Does it fluctuate and transilluminate? 

15

Painless but it Aches the most at the END of day 

Varicocele 

16

•Painful – Tender 

SEE it hurts

  • Strangulated inguino-scrotal hernia
  • epididymo-orchitis
  • Epididymitis

17

Testicular tumour 

History, Age, examination, investigation, risk, markers, treat?

History

•Usually painless
•Germ cell tumours (Seminoma/Teratoma) usually in men aged <45 yrs

Risk – history of undescended testis (cryptorchidism)

•Older men (Could be lymphoma)

 

examination
•Body of testis is abnormal; can ‘get above’ Refer via 2 week wait to Urology

 

•Urology will

–  Arrange urgent ultrasound of scrotum to confirm diagnosis

–  Check testis tumour markers (aFP, hCG, LDH)

 

Treatment

– Inguinal orchidectomy *not via scrotum!*

 

18

Epididymal cyst 

presentation, examination 

•Usually painless

 

examination

•Separate from testis

•Can‘get above’ mass

•Transilluminates 

19

Urinary retention - causes 

• Prostatic enlargement
– Benign prostatic hyperplasia (BPH)

– Cancer

• Phimosis/urethral stricture/meatal stenosis

• Constipation
• UTI
• Drugs

– Anticholinergic actions

• Over-distension
– e.g. Too much fluids at party

• Following surgery

• Neurological 

20

Urinary Retention – Types and Treatment Strategies 

 

older men with noctural enuresis have ________& _______ until proven otherwise

chronic rentention and overflow incontinence

21

Male LUTS 

from history what should u determine?

if LUTS r voiding or storage

Voiding (suggestive of bladder outflow obstruction)

  • Hesitancy
  • Poor flow
  • Post micturition dribbling

– Storage

  • Frequency
  • Urgency
  • Nocturia 

22

causes (other than the prostate) that could be causing storage LUTS 

Irritative > bladder infection, inflammation, bladder stone, bladder cancer

Overactive bladder 

  • idiopathic 
  • Neuropathic> CVA, Parkinsons, MS

Low compliance of bladder (scarring)

  • after TB/shistosomiasis/pelvic radiotherpay

Polyuria

  • Global (uncontrolled diabetes)
  • Nocturnal (venous stasis, sleep apnoea)

23

what is voiding symptoms suggestive of?

Bladder Outflow Obstruction (BOO)

24