Men’s Urology

Question 1

Pathway of sperm

Answer 1

• sperm develop in the Sertoli cells of the seminiferous tubules of the testicles
• sperm ‘learn how to swim’ in the epididymis
• exit in the vas deferens of the spermatic cord
• spermatic cord enters the body via the inguinal canal + splits into the vas and the blood supply
• vas deferens meets the seminal vesicle > ejaculatory duct
• pass through the prostate gland
• prostatic urethra > membranous urethra > bulbous urethra > penile urethra

Question 2

What is epididymitis?

Answer 2

Inflammation of the epididymis

Question 3

What is orchitis?

Answer 3

Inflammation of the testicle

Question 4

What is epididymo-orchitis?

Answer 4

Inflammation of epididymis + testicle due to infection

Question 5

Causes of epididymo-orchitis

Answer 5

• E. coli - older patients
• chlamydia trachomatis - younger sexually active
• neisseria gonorrhoea - younger sexually active
• mumps

Question 6

Presentation of epididymo-orchitis

Answer 6

• gradual onset over minutes to hours
• unilateral
• testicular pain
• dragging or heavy sensation
• swelling of testicle
• tenderness
• urethral discharge (think STI cause)
• systemic symptoms
• parotid swelling (if due to mumps)

Question 7

Investigations + diagnosis of epididymo-orchitis

Answer 7

• key to distinguish whether the cause is enteric organism or STI organism
• urine microscopy, culture + sensitivity
• chlamydia + gonorrhoea NAAT testing on first pass urine
• charcoal swab > gonorrhoea C+S
• saliva swab > mumps PCR
• serum antibodies - for mumps
• USS to ass torsion or tumours

Question 8

What features make STI organism more likely to be the cause of epididymo-orchitis?

Answer 8

• age <35
• increased number of sexual partners in last 12 months
• urethral discharge

Question 9

Management of epididymo-orchitis

Answer 9

• referral to GUM if risk of STI
• if due to E. coli: ofloxacin, levofloxacin or co-amoxicv for 2 weeks
• if due to STI: IM ceftriaxone single dose + doxycyline for 2 weeks
• analgesia
• supportive underwear
• reduce physical activity
• abstain from intercourse

Question 10

Antibiotic of choice for epididymo-orchitis due to e.coli

Answer 10

Quinolones
e.g. ofloxacin, Ciprofloxacin

Question 11

Two critical side effects of quinolones

Answer 11

• Tendon damage + tendon rupture (esp Achilles tendon)
• lower seizure threshold

Question 12

Complications of epididymo-orchitis

Answer 12

• chronic pain
• chronic epididymitis
• testicular atrophy
• sub-fertility or infertility
• scrotal abscess

Question 13

Most important differential to epididymo-orchitis

Answer 13

Testicular torsion

Question 14

What is testicular torsion?

Answer 14

Twisting of the spermatic cord with rotation of the testicles

Question 15

History of testicular torsion

Answer 15

• often teenage boy
• sudden onset
• unilateral pain
• N+V
• no urinary tract symptoms

Question 16

Examination of testicular torsion

Answer 16

• firm swollen testicle
• elevated testicle
• absent cremasteric reflex
• abnormal testicular lie - often horizontal
• rotation

Question 17

What is bell clapper deformity>

Answer 17

• The normal fixation between tunica vaginalis + testicle is absent
• testicle hangs in horizontal position
• able to rotate more easily > testicular torsion

Question 18

Management of testicular torsion

Answer 18

• NMB
• analgesia
• urgent senior urology assessment
• surgical exploration of scrotum
• bilateral orchiopexy
• orchidectomy

Question 19

What is orchiopexy?

Answer 19

Correcting the position of the testicles + fixing them in place

Question 20

When is an orchidectomy needed in testicular torsion?

Answer 20

If surgery is delayed or there is necrosis

Question 21

Imaging of choice for testicular torsion

Answer 21

Scrotal USS

Question 22

Findings of scrotal USS in testicular torsion

Answer 22

Whirlpool sign

Question 23

What is a hydrocoele?

Answer 23

Accumulation of fluid within the tunica vaginalis

Question 24

Features of hydrocoele

Answer 24

• soft non tender swelling of scrotum
• can get above mass on examination
• transilluminate
• irreducible

Question 25

Types of hydrocele + causes

Answer 25

- **communicating**: caused by patency of processus vaginalis allowing peritoneal fluid to drain down into scrotum - common in newborn males + resolve within first few months - **non-communicating**: caused by excessive fluid production within tunica vaginalis

Question 26

Causes of hydrocoele

Answer 26

- idiopathic - or secondary to: - testicular cancer - testicular torsion - epididymo-orchitis - trauma

Question 27

Management of hydrocoele

Answer 27

- exclude serious causes - scrotal USS - conservatively mostly - infantile hydrocles repaired if not resolves by 1-2 years old - surgery or aspiration if large or symptomatic cases

Question 28

Causes of scrotal or testicular lumps

Answer 28

- hydrocoele - varicocele - epididymal cyst - testicular cancer - epididymo-orchitis - inguinal hernia - testicular torsion

Question 29

What is a Varicocele?

Answer 29

Occurs where the veins of the pampiniform plexus become swollen Most commonly on left side

Question 30

Presentation of Varicocele

Answer 30

- dragging sensation - dullache at end of day - worse on standing - sub-fertility or infertility

Question 31

Examination findings of Varicocele

Answer 31

- scrotal mass that feels like bag of worms - more prominent on standing - disappears when lying down - asymmetry in testicular size

Question 32

What does a Varicocele that does not disappear when lying down raise concerns about?

Answer 32

Retroperitoneal tumours obstructing the drainage of the renal vein

Question 33

Investigations of Varicocele

Answer 33

- USS Doppler - semen analysis if fertility concerns - hormone tests if concerns about function

Question 34

Management of Varicocele

Answer 34

- conservatively mainly - surgical or Endovascular embolisation if pain, testicular atrophy or infertility

Question 35

Venous drainage of the testicles

Answer 35

- pampiniform plexus into the testicular vein - right testicular vein > IVC directly - left testicular vein > left renal vein > IVC

Question 36

What are epididymal cysts?`

Answer 36

Fluid filled sac at head of epididymis

Question 37

What is a spermatocele?

Answer 37

Epididymal cyst that contains sperm

Question 38

Presentation of epididymal cyst

Answer 38

- mostly asymptomatic - lump - incidental USS findings

Question 39

Examination findings of epididymal cyst

Answer 39

- soft round lump - at top of testicle - separate from testicle - transilluminates

Question 40

Management of epididymal cysts

Answer 40

- Harmless + non associated with infertility or cancer - excision if symptomatic

Question 41

New scrotal swelling + recent mumps = ? New scrotal swelling + previous mumps = ?

Answer 41

- New scrotal swelling + recent mumps = orchitis/epididymo-orchitis - New scrotal swelling + previous mumps = unlikely to be mumps orchitis - mumps gives body permanent immunity after intial infection

Question 42

What is Prehn’s sign? What is it seen in

Answer 42

Elevation of the testis eases the pain of epididymitis

Question 43

Risk factors of testicaulr torsion

Answer 43

- bellclapper deformity - previous torsion - family history - trauma - undescended testes

Question 44

Cause of bilateral epididymo-orchitis

Answer 44

Mumps