What is testicular torsion?
surgical emergency and describes the twisting of the spermatic cord and its contents
What is the most common age group for testicular torsion?
between the ages of 10-30 (peak in 13-15)
How would someone with testicular torsion present?
- severe sudden onset pain in scrotum
- referred to lower abdo
- N&V
- unable to walk or sit, fidgeting
How would testicular torsion appear on examination?
- swollen, tender testis retracted upwards
- long axis orientated transversely due to shortening of spermatic cord
- erythema
- loss of cremasteric reflex
- Prehn’s sign - elevation of testis does not ease pain
What is the management for testicular torsion?
urgent surgical exploration - within 6 hours
- incision made in midline of testes, untwist cord and see if colour returns (will appear blue/black)
- soak in warm saline and hyper-oxygenate the patient for 5-10 mins
- 3 point fixation of testicle - albuginea to dartos
list some ddx for testicular torsion
- epididymo-orchitis
- tumour
- trauma
- acute hydrocele
what is epidiymitis and in what populations does it present?
inflammation of the epididymis
young (<35) due to STIs - chlamydia and gonorrhoea
older (>35) due to gram -ve bacteria (e.coli and pseudomonas) - associated with UTIs and BPH
How does epidiymitis present?
acute onset scrotal pain - tenderness and swelling of posterior testicle
fever
chills
myalgia or muscle pain
What is epidiymo-orchitis and how does it present?
epidiymitis that has spread to the testicle
acute onset scrotal pain
fever
N&V
what are the specific exam findings for epidiymo-orchitis?
testicular swelling and tenderness
positive phrehn sign - pain relived when elevating testicle
intact cremasteric reflex
what is cryptorchidism?
congenital undescended testis is one that has failed to reach the bottom of the scrotum (can affect one or both)
usually occurs in premature babies
testis usually gets stuck in the inguinal canal
what is the treatment for cryptorchidism?
if not descended by 2 years - orchidopexy
usually not required as testes will complete descent by 6 months
what is variocele?
abnormal enlargement of the testicular veins
dilatation of the pampinifrom plexus due to increased venous pressure
they are usually asymptomatic but may be important as they are associated with infertility
which side of the testes does varicocele more commonly effect?
left testis
left testicular vein drains into left renal vein forming perpendicular angle before draining into IVC = increases resistance to blood flow
unlikely to occur on right as the right testicular vein drains directly into the IVC therefore shorter route and less resistance
if a patient presents with right sided varicocele what should we suspect?
retroperitoneal tumour - renal cell carcinoma
how does varicocele present?
soft scrotal mass feeling of pressure or dull achy scrotal pain feels like a bag of worms mass distends/gets bigger when cough does not transilluminate
what is the treatment for varicocele?
conservative
surgical ligation or embolisation of dilated pampiniform plexus
what is hydrocele and what are the 2 types?
accumulation of fluid within the tunica vaginalis - between the visceral and parietal layer
congenital = communicating
- failure of processus vaginalis to close up, allows peritoneal fluid to drain into scrotum
- usually resolves within 1st few months of life
acquired = non-communicating
- due to underlying condition - excessive fluid production within tunica vaginalis
- trauma
- infections - roundworm
how does a hydrocele present on examination?
soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
how to confirm the diagnosis of hydrocele?
US
management of hydrocele?
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
in adults conservative - resolve on their own
what are neohrolithiasis and why do they form?
renal stones
form due to solute in the urine precipitating out and crystallising
what are the 6 different types of renal stones and which is the most common?
- calcium oxalate (most common)
- calcium phosphate
- uric acid
- struvite (Mg, ammonia, P)
- cysteine
- xanthine
what are the 3 most common places for renal stones to get stuck?
- uretero-pelvic junction
- vesico-ureteric junction
- location where ureters cross sacroiliac joint
