Week 18 - testicular cancer, testicular torsion, urinary tract calculi, UTI

Question 1

where do testicular cancers arise from

Answer 1

the germ cells in the testes

Question 2

what are germ cells and what do they produce

Answer 2

are cells that produce gametes (sperm in males)

Question 3

what is the highest incidence of age in testicular cancer

Answer 3

Testicular cancer is more common in younger men, with the highest incidence between 15 and 35 years.

Question 4

what are the two types of testicular cancer

Answer 4

Seminomas

Non-seminomas (mostly teratomas)

Question 5

what are the risk factors for testicular cancer

Answer 5

Undescended testes
Male infertility
Family history
Increased height

Question 6

what is the typical presentation of testicular cancer

Answer 6

painless lump on the testicle and can occasionally present with testicular pain

Question 7

what are the characteristics of the lump

Answer 7

Non-tender (or even reduced sensation)
Arising from testicle
Hard
Irregular
Not fluctuant
No transillumination

Question 8

what can rarely be a presentation of testicular cancer, particularly in a rare type of tumour called a Leydig cell tumour

Answer 8

gynaecomastia can be a presentation

about 2% of patients presenting with gynacomastia have a testicular tumour

Question 9

what is the usual initial investigation to confirm the diagnosis of testicular cancer

Answer 9

scrotal ultrasound

Question 10

what are the 3 tumour markers for testicular cancer

Answer 10

Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas)

Beta-hCG – may be raised in both teratomas and seminomas

Lactate dehydrogenase (LDH) is a very non-specific tumour marker

Question 11

what is the staging system used for testicular cancer

Answer 11

the Royal Marsden Staging System

Question 12

what are the stages of the RMSS for testicular cancer

Answer 12

Stage 1 – isolated to the testicle
Stage 2 – spread to the retroperitoneal lymph nodes
Stage 3 – spread to the lymph nodes above the diaphragm
Stage 4 – metastasised to other organs

Question 13

where are the 4 most common places testicular cancer metastasises to

Answer 13

lymphatics
lungs
liver
brain

Question 14

what are the four things that treatment can involve for testicular cancer

Answer 14

Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted

Chemotherapy

Radiotherapy

Sperm banking to save sperm for future use, as treatment may cause infertility

Question 15

what are the side effects of testicular cancer treatment

Answer 15

Infertility
Hypogonadism (testosterone replacement may be required)
Peripheral neuropathy
Hearing loss
Lasting kidney, liver or heart damage
Increased risk of cancer in the future

Question 16

what is the prognosis for testicular caner

Answer 16

early testicular cancer prognosis is good, with a greater than 90% cure rate

Question 17

is metastatic testicular cancer curable

Answer 17

yes often

Question 18

what kind of testicular cancers have better prognosis

Answer 18

Seminomas have a slightly better prognosis than non-seminomas.

Question 19

what does testicular torsion refer to

Answer 19

the twisting of the spermatic cord, with rotation of the testicle.

Question 20

what is testicular torsion often triggered by

Answer 20

an activity, such as playing sports

Question 21

how does testicular torsion present

Answer 21

with an acute rapid onset of unilateral testicular pain, and may be associated with abdominal pain and vomiting

Question 22

what are the examination findings in testicular torsion

Answer 22

Firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position

Question 23

what is Bell-Clapper deformity

Answer 23

one of the causes of testicular torsion

Normally, the testicle is fixed posteriorly to the tunica vaginalis. A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position. It is also 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.

Question 24

what is the management of testicular torsion

Answer 24

Testicular torsion is a urological emergency, and there is an urgent requirement for treatment. Any delay in treatment will prolong the ischaemia and reduce the chances of saving the testicle.

The management of testicular torsion involves:
Nil by mouth, in preparation for surgery
Analgesia as required
Urgent senior urology assessment
Surgical exploration of the scrotum
Orchiopexy (correcting the position of the testicles and fixing them in place)
Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis

Question 25

what confirms diagnosis of testicular torsion

Answer 25

a scrotal ultrasound confirms the diagnosis. however, any investigation that will delay the patient going to theatre is not recommened.

Question 26

what will an ultrasound show in testicular torsion

Answer 26

Ultrasound can show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels.

Question 27

what is a hydrocele

Answer 27

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

Question 28

what is the tunica vaginalis

Answer 28

The tunica vaginalis is a sealed pouch of membrane that surrounds the testes. Originally the tunica vaginalis is part of the peritoneal membrane, but during development of the fetus it becomes separated from the peritoneal membrane and remains in the scrotum, partially covering each testicle.

Question 29

what is a simple hydrocele

Answer 29

Simple hydroceles are common in newborn males. They occurs where fluid is trapped in the tunica vaginalis. Usually this fluid gets reabsorbed over time and the hydrocele disappears.

Question 30

what is a communicating hydrocele

Answer 30

Communicating hydroceles occur where the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway called the processus vaginalis. This allows fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size.

Question 31

what is found on examination of a testicular hydrocele

Answer 31

cause a soft, smooth, non-tender swelling around one of the testes. the swelling will be in front of and below the tesicule. simple hydroceles remain one size, whereas communicating hydroceles can fluctuate in size depending on the volume of fluid from the peritoneal cavity

Question 32

what are the key features to remember when examining a hydrocele

Answer 32

they transilluminate with light. To transilluminate the hydrocele, hold a pen torch flat against the skin and watch as the whole thing lights up like a bulb.

Question 33

how is a communicating hydrocele managed

Answer 33

Communicating hydroceles can be treated with a surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis).

Question 34

what do lower urinary tract infections involve (UTI's)

Answer 34

involve infection in the bladder, causing cystitis

Question 35

what is cystitis

Answer 35

inflammation of the bladder

Question 36

what is pyelonephritis

Answer 36

refers to inflammation of the kidney resulting from bacterial infection the inflammation affects the kidney tissue (parenchyma) and the renal pelvis (where the ureter joins the kidney)

Question 37

why are UTI's more common in women

Answer 37

Urinary tract infections are far more common in women, where the urethra is much shorter, making it easier for bacteria to get into the bladder.

Question 38

what is the primary source of bacteria for UTI's

Answer 38

faeces. normal intestinal bacteria such as E.coli can easily journey to the urethral opening from the anus.

Question 39

how do lower urinary tract infections present

Answer 39

Dysuria (pain, stinging or burning when passing urine) Suprapubic pain or discomfort Frequency Urgency Incontinence Haematuria Cloudy or foul-smelling urine Confusion is commonly the only symptom in older and frail patients

Question 40

what are the triad of symptoms also present in pyelonephritis

Answer 40

fever loin or back pain (bilateral or unilateral) nausea or vomiting

Question 41

what is seen on a urine dipstick that suggests bacteria in the urine

Answer 41

nitrates on a dipstick test suggest bacterial in the urine

Question 42

why do nitrates on a dipstick test suggest bacterial in the urine

Answer 42

Gram-negative bacteria (e.g., E. coli) break down nitrates (a normal waste product in urine) into nitrites.

Question 43

what is sent for microscopy in relation to UTI's and why

Answer 43

A midstream urine (MSU) sample sent for microscopy, culture and sensitivity testing will determine the infective organism and the antibiotics that will be effective in treatment. Not all patients with an uncomplicated UTI require an MSU. An MSU is important in: Pregnant patients Patients with recurrent UTIs Atypical symptoms When symptoms do not improve with antibiotics

Question 44

what is the most common cause of UTI's

Answer 44

E.coli which are gram-negative. anaerobic, rod-shaped bacteria they are part of the lower intestinal microbiome and can easily spread from faeces to bladder

Question 45

what are the two initial antibiotics given in UTI's

Answer 45

Nitrofurantoin (avoided in patients with an eGFR <45) Trimethoprim (often associated with high rates of bacterial resistance)

Question 46

what are the 3 typical durations of antibiotics for UTI's

Answer 46

3 days of antibiotics for simple lower urinary tract infections in women 5-10 days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function 7 days of antibiotics for men, pregnant women or catheter-related UTIs

Question 47

how is pylenephritis treated in the community according to the NICE guidlines

Answer 47

NICE guidelines (2018) recommend the following first-line antibiotics for 7-10 days when treating pyelonephritis in the community: Cefalexin Co-amoxiclav (if culture results are available) Trimethoprim (if culture results are available) Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)

Question 48

what can UTI's in pregnancy increase the risk of

Answer 48

Urinary tract infections in pregnancy increase the risk of pyelonephritis, premature rupture of membranes and pre-term labour.

Question 49

what is the management of UTI's in pregnancy

Answer 49

Urinary tract infection in pregnancy requires 7 days of antibiotics. All women should have an MSU for microscopy, culture and sensitivity testing. The antibiotic options are: Nitrofurantoin (avoided in the third trimester) Amoxicillin (only after sensitivities are known) Cefalexin (the typical choice)

Question 50

why should nitrofurantoin be avoided in the third trimester

Answer 50

because there is a risk of neonatal haemolysis

Question 51

why should trimethoprim be avoided in the first trimester

Answer 51

as it works as a folate antagonist. Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.