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Acute Conditions in Urology & Scrotal Swellings

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Acute Conditions in Urology & Scrotal Swellings Done by: Khadija S. El-Hammasi Supervised by: Dr. Yhaya Elshebiny Acute Conditions in Urology Acute Urological ... – PowerPoint PPT presentation

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Title: Acute Conditions in Urology & Scrotal Swellings


1
Acute Conditions in Urology Scrotal Swellings
  • Done by Khadija S. El-Hammasi
  • Supervised by Dr. Yhaya Elshebiny

2
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3
Acute Conditions in Urology
  • Acute Urological conditions
  • Urolithiasis (Calculus Disease)
  • Trauma of Genitourinary system
  • Infection of Genitourinary system
  • Testicular torsion
  • Priapism
  • Phimosis Paraphimosis

4
Urolithiasis (Calculus Disease)
  • -Incidence 1 of the population.
  • Causes of calculi formation
  • 1.Primary (idiopathic)
  • 2.Secondary due to stasis ? Infection
  • ?
    Metabolic disorders (cystinuria)
  • -Types of the calculi
  • 1.Calcium oxalate (75)
  • 2. Phosphate (15)
  • 3. Urate (5)
  • 4.Cystine (2)
  • 5. Xanthine pyruvate (rare)

5
- Factors predispose to the development of renal
stones? 1.Recent reduction in fluid intake
2. Increased exercise with dehydration
3.Medications that cause hyperuricemia (high uric
acid) 4.History of gout
  • Symptoms
  • Asymptomatic
  • Renal colic is what brings pts to the ER
  • a collection of symptoms that occur as the
    stone is in transit from the kidney to the
    bladder. This may result in partial or complete
    urinary obstruction.
  • These symptoms include
  • Sudden onset of severe colicky pain that
    originates in the flank and may radiate to the
    lower abdomen, groin or testes (labia) depending
    on the site

6
Cont
  • The pain may be associated with nausea and
    vomiting
  • Symptoms of irritative bladder such as increased
    frequency and urgency ?the stone is in the distal
    ureter
  • Symptoms of UTI
  • Hematuria
  • O/E
  • Pt is rolling on bed or pacing
  • Vitals important to take T. it defines your
    management.
  • T is high ?obstructive pyelonephritis ? PCN or
    DJ stent
  • Tenderness overlying the stone

7
  • Investigations
  • CBC ? WBCgt 15,000/cm²
  • RFT electrolytes. Impaired RFT is a
    contraindication for IVU
  • Urine analysis microscopy.
  • KUB 90 of stones are radio-opaque. (urate
    cystien stones are radiolucent)
  • U/S
  • Emergency IVU to detect site of obstruction.
  • CT scan
  • MRU (in case of pregnant women)
  • Radio nuclear study ? To confirm diagnosis
  • ? To
    evaluate kidney function

8
Nephrolithiasis Renal Calculi
  • Only The Radioopaque (i.e. White) calculi are seen

9
Ureteric and Bladder Calculi
  • Only The Radioopaque (i.e. White) calculi are seen

10
Intravenous Urography IVUNORMAL
  • Minor calyx
  • Major calyx
  • Ureter
  • Bladder

11
IVU Ureteric calculus with minor obstructive
changes
12
  • Treatment For acute symptoms (renal colic)
  • Conservative management
  • relive pain e.g. pethidine / NSAID
  • admit to hospital ? if persistent colic
  • ? fever
  • ? Renal failure
  • Antispasmodics e.g. desmopressin to inhibit
    uretric peristalsis? relief the renal colic
  • bed rest, IV fluid
  • collect urine to retrieve calculus for analysis
  • check radiograph to asses progress of stones.
  • Broad spectrum antibiotic after urine sample is
    obtained. (in case of infection)

13
Cont
  • Further management depends on
  • Response to analgesia
  • Size of the stone
  • lt4mm will pass spontaneously.(50 of stone 4-6
    mm will pass spontaneously)
  • Stone gt6mm requires removal.
  • Presence of infection/obstruction ?decompression
  • Percutaneous nephrostomy (PCN)
  • DJ stent

14
  • Stone management
  • ESWL
  • -Kidney ? stones 0.5 2.5 cm /- DJ
    stint.
  • -Ureter ? stones 0.5 2.5 cm /- DJ
    stint for stones located in the upper middle
    part of the ureter (possible lower).
  • Percutaneous nephrolithotomy
  • Uretric stone
  • Bladder ? resectoscope sheath, broken up with
    forceps and washed out
  • Open surgery
  • Ureterolithotomy( stone gt5mm, or in the ureter)
  • Pyelolithiotomy
  • Nephrolithotomy (stones pushed into the renal
    pelvis)

15
Trauma of Genitourinary system
  • Upper tract (kidney ureter)
  • Lower tract (bladder, urethra, scrotum).

16
Kidney Trauma
  • Most common injuries of urinary system.
  • Most injuries occur from car accident or sport
  • gt50 occur in males lt30 yrs
  • FM is 14
  • Pts with renal abnormalities are more prone to
    renal injuries
  • Causes
  • Blunt trauma directly to abdomen, flank or
    back.(80-85)
  • Penetrating injuries gunshot knife wounds

17
Classification and Management of Renal Injuries

18
Types of Renal Injuries
19
  • History
  • H/O trauma
  • Pain localized to flank or abdomen.
  • Hematuria.
  • Abdominal distention nausea
    vomiting(retroperitoneal bleeding)
  • O/E
  • Vitals low BP rapid pulse ?Shock
  • Bruising over the ribs posteriorly, evidence of
    penetrating injury
  • Lower rib fractures.
  • Diffuse abdominal tenderness and guarding.
  • Mass (represent retroperitoneal hematoma or
    urinary extravasations).
  • Exclude pneumothorax or bleeding into the chest
    and peritoneum

20
  • Who to investigate?
  • Penetrating injury to the flanks
  • Rapid deceleration injury?renal vascular injury
  • Blunt injury associated with hematuria,
    tenderness, rib fracture
  • Investigations
  • CBC ? dropping Hb? bleeding
  • Cross matching
  • Urine analysis
  • RFT ? IVU is needed
  • X-ray.
  • U/S
  • CT ? the gold standard (adequately stage 85 of
    renal injuries).
  • Excretory urograph (IVU)? in case of emergency
  • Arteriography detect arterial thrombosis
    avulsion of renal pedicle.

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Arteriogram following blunt abdominal trauma
shows acute renal artery thrombosis of left
kidney.
23
Contrast Enhanced CTRenal Laceration
Small perirenal hematoma
Renal laceration
24
  • managenent
  • Patient is not stable
  • Emergency measure
  • Treat shock hemorrhage.
  • Complete resuscitation evaluation of associated
    injuries.
  • Surgery
  • Indications Shock, persistent hematuria.
  • Can vary from Simple suture of laceration to
    partial or total nephrectomy.
  • Patient is stable
  • Keep under observation
  • Investigate treat accordingly (table)

25
Ureteric trauma
  • rare
  • Causes
  • 1. Large pelvic mass that displace the
    ureter laterally.
  • 2.Surgical procedure e.g. Gynecological
    procedure in
  • female (hysterectomy) Endoscopic
    manipulation of
  • ureteral calculus.
  • 3.Stap wound
  • Symptoms
  • Fever (post operatively)
  • Flank lower abdominal pain
  • Nausea vomiting.
  • Anuria ( post operative bilateral ureteral
    injury).

26
  • Signs
  • ?Signs of acute peritonitis may be present due to
    urinary extravasations into the peritoneal
    cavity.
  • Investigations
  • ?Catheterization microscopic heamaturia
  • ?Excretory urography (IVU) delayed excretion of
    contrast due to hydronephrosis.
  • ?U/S detect hydroureter or urinary
    extravasation.
  • ?CT scan
  • Treatment
  • ?Immediate re-exploration repair.
  • ?Stinting.

27
Stab wound of right ureter shows extravasation
on intravenous urogram.
28
Anuria
  • Absence of urinary output
  • Causes
  • Underperfusion of the kidneys e.g. shock or
    dehydration
  • Sepsis
  • Bilateral ureteric obsruction
  • Tumors of the pelvis or retro peritoneum ?
    chronic
  • Retroperitonial obstruction ? progressive
  • Bilateral stones causing obstruction ? acute

29
Cont
  • Management
  • History, examination
  • KUB
  • U/S
  • IVU
  • CT
  • Observation
  • PCN
  • DJ stenting
  • Treat the undelyig cause

30
Bladder Trauma
  • Mostly due to external force like urological
    procedure (bladder tumor)? iatrogenic
  • 90 associated with pelvic fracture
  • Penetrating injury
  • Indirect trauma to the lower abdomen with
    distended kidney
  • Trauma to the bladder may lead to intra or
    extraperitonial extravasation

31
  • History
  • H/O lower abdominal trauma.
  • H/O alcohol consumption followed by lower
    abdominal trauma
  • Patient unable to urinate
  • Gross hematuria (with spontaneous voiding)
  • Usually pelvic or lower abdominal pain.
  • O/E
  • Signs of shock.
  • Lower abdominal suprapubic tenderness
  • Palpable mass (in case of pelvic hematoma).
  • Investigations
  • X-ray for pelvic fracture.
  • IVU to detect any ureteric or kidney injuries or
    bladder leak.
  • CT scan
  • Cystography detect extraperitoneal extravasation
    of blood urine. This is the procedure of choice
    to R/O bladder injury

32
Contrast Enhanced CT Traumatic Urinary Bladder
Injury
Rupture of bladder with extravasation of urine
intothe peritoneal cavity
Cystogram demonstrating extravastion
33
  • Treatment
  • Emergency measure treat shock hemorrhage
  • Conservative catheter drainage
  • The majority of cases will require surgical
    intervention
  • Intraperitoneal extravasation
  • Laparoscopy or laparotomy (lower midline
    abdominal incision.)
  • Suction of urine and irrigation
  • Repair
  • Urethral and Suprapubic catheters are inserted to
    ensure complete urinary drainage control of
    bleeding.
  • 1-2 weeks later a cystogram is done
  • Extraperitoneal extravasation
  • Repair the tear
  • SPC and urethral cath
  • Drainage Cath in the retropubic space. Left for
    10- 14 days

34
Acute Urinary Retention
  • Inability to empty the bladder
  • 10 of pt with BPH present with acute urinary
    retention
  • Causes
  • In males the most common cause is prostatic
    obstruction that may be precipitated by alcohol,
    anticholinergic drugs, constipation, infection,
    anaesthetics
  • Urethral stricture
  • Bladder tumor, stone or any other cause of
    bladder outlet obstruction
  • In a female, a gravid uterus may lead to
    retention

35
  • History
  • Inability to pass urine for several hours
  • Severe suprapubic pain
  • Abdominal distension
  • /- H/O BPH
  • D/H anticholinergics, alcohol
  • H/O UTI, constipation
  • O/E
  • Pt unable to stay still
  • Bladder may be palpable
  • PR enlarged prostate that is pushed down ?size
    may be exaggerated
  • Refluxes of lower limb and perianal sensation?
    R/O prolapsed lumber disc

36
  • Investigations
  • CBC ?WBC (UTI, prostatitis)
  • MSU ?UTI
  • PSA? Ca or prostatitis
  • U/S? bladder and prostate
  • X-ray
  • IVU ? filling defect
  • Treatment
  • Aim is to relieve the pain
  • Analgesia, short course of alpha adrenergic
    blocker
  • Catheterization urethral or SPC
  • After 4-7 days, trail to void at the hospital
  • Treat the underlying condition
  • BPH
  • Voiding? medication
  • Unable to void? TURP

37
Urethral Injury
  • The most common cause is iatrogenic (catheter,
    cystoscopy)
  • 30 pelvic fractures are associated with urethral
    injuries
  • Not a common injury. More in in males. Rare in
    females
  • If a urethral injury is suspected, DO NOT insert
    a urethral cath
  • Retrograde urethrogram is the investigation of
    choice. It delineates the severity of the injury
  • If there is extravasation, SPC is inserted for
    3weeks. A cystourethrogram is then done to ensure
    resolution

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Scrotal trauma
  • This is usually occurs in sport injuries or
    violence.
  • Trauma maybe result in bleeding into the layer of
    tunica vaginalis resulting in hematocele.
  • Symptoms signs
  • -Sever pain
  • -Scrotal swelling /- ruptured
    testis
  • -Bruising
  • -Tender enlarged testis.
  • Investigation
  • -U.S.
  • - CT scan
  • Treatment
  • -Bed rest.
  • -Surgical exploration may be require to
    evacuate hematocele repair a split in the
    tunica albuginea.

40
Genitourinary Infection
  • Include
  • -Pyelonephritis
  • -Cystitis
  • -Prostatitis
  • -Epedidemo-orchitis
  • Risk Factors
  • -Vesicoureteric reflux
  • -Obstruction
  • -Neurogenic bladder
  • -Pregnancy
  • -DM

41
Pyelonephritis
  • -Bacterial infection of one or both kidneys.
  • -Most common organism is E-coli.
  • -Symptoms
  • 1.Loin pain
  • 2.Dysuria Frequency
  • 3.Fever rigors
  • -Lab findings
  • 1.Leukocytosis
  • 2.pyuria, bacteruria microscopic
  • Hematouria
  • 3.gt100,000 colonies/ml in urine culture

42
CT  
Right kidney is markedly enlarged andhas a
wedge-shaped area of low attenuation
43
  • Radiological findings
  • -IVU ? renal enlargement
  • -U/S ? dilated collecting system from
    obstruction, presence of urinary stones or renal
    abscess
  • - CT scan
  • Tx
  • -I.V Abx /- nephrostomy

44
Cystitis
  • -Common organism is E-coli.
  • -Bladder infection
  • -Symptoms
  • 1.Irritative Sx (Dysuria, frequency urgency)
  • 2. Hematuria
  • 3. Suprapubic pain tenderness
  • -Lab findings
  • 1.Pyuria, bacteruria hematuria
  • -Radiological investigation is limited to cases
    where renal infection is suspected
  • -Tx ? Abx

45
Prostatitis
  • -Commonly in young males
  • -Common organism is E-coli, Pseudomonas
  • -Sigh Symptoms
  • 1.Fever
  • 2.Low back pain, perenial pain
  • 3.Bladder irritation outflow obstruction
  • 4.Tender, warm, large firm prostate on PR
    examination
  • -Lab findings
  • 1.Pyuria, bacteruria microscopic hematuria
  • Tx ?I.V Abx

46
ParaPhimosis
  • Paraphimosis occurs when the foreskin has been
    retracted and narrows below the glans,
    constricting the lymphatic drainage and causing
    the glans to swell.
  • If not corrected, blood flow in the penis
    becomes impeded by the increasingly constricting
    band of foreskin, which causes further swelling
    of the glans. Because lack of oxygen from the
    reduced blood flow can cause tissue death
    (necrosis)
  • paraphimosis is considered a medical emergency
    and requires immediate treatment.

47
  • Causes
  • Bacterial infection (e.g., balanoposthitis)
  • Catheterization (i.e., if the foreskin is not
    returned to its original
  • position after a urethral catheter is inserted,
    the glans may become swollen, which can initiate
    paraphimosis)
  • Poor hygiene
  • Swelling-producing injury
  • Vigorous sexual intercourse
  • Symptoms and Signs
  • Inability to urinate (urinary retention)
  • Penile pain
  • Swollen glans (the shaft of the penis is not
    swollen)
  • Redness, Black tissue on the glans (indicates
    necrosis
  • Band of retracted foreskin tissue beneath the
    glans
  • Tenderness

48
  • Diagnosis
  • Paraphimosis is diagnosed during physical
    examination.
  • Treatment
  • Injection of hyaluronidase with lidocane followed
    by gentel pressure. This usually results in
    reduction
  • Failure ? incision of he constricting band
  • Circumcision to prevent reoccurrence

49
Priapism
  • -Persistent, painful erection.
  • -Causes
  • 1.Idiopathic
  • 2. Leukemia, sickle cell dx
  • 3.Pelvic malignancy
  • 4.Pt on hemodialysis
  • -Tx
  • 1.Aspiration of blood from the corpora
    cavernosa
  • 2.Anastomosis of the great saphenous vein to
    the engorged corpora cavernosa thus establishing
    venous drainage of the corpora

50
Phimosis
  • Phimosis is the inability to retract the prepuce
    (foreskin) of penis over the shaft due to a
    narrow opening.Phimosis can be congenital or
    acquired- In acquired phimosis there is
    chronic inflammation of the tip of the penis and
    prepuce (fore skin) or there are adhesions
    between glans prepuce or due to malignancy.
    In congenital causes it is present since birth.
    Phimosis is usually caused by thickening and
    repeated inflammation of the foreskin.     

51
  • Symptoms of Phimosis ?
  •  Inability to retract foreskin.
  • Straining during urination.
  • Thin stream of urine.
  • Recurrent urinary infections.
  • Pus from penis - due to belanophosthitis. How
    can we diagnose Phimosis ?From history
    examination On Examination
  • Pin hole opening of foreskin
  • Difficulty to push back the foreskin over the
    shaft of the penis.
  • Balooning of foreskin - A bulge in the tip of
    penis as urine accumulates under the foreskin.

52
  • How can Phimosis be treated ?Circumcision
  • If untreated complications of phimosis can
    occur
  • Infected foreskin leads to infection of glans
    also.
  • Paraphimosis
  • Back pressure due to obstruction of flow of
    urine.
  • Meatal Stenosis - narrowing of penile opening.
  • Sometimes a cancerous ulcer on glans can cause
    the adhesion to take place. 

53
Epididymo-orchitis
  • This is primarily an infection of the epididymis,
    but some oedema inflammatory changes spread
    into the testis
  • There maybe an associated urinary tract
    infection.
  • Types
  • Acute
  • Under 40 years old ?chalmydia trachomatis
    gonorrhea
  • In old pt ?enterococci, E.coli
  • Chronic
  • Follow recurrent acute attacks
  • TB

54
  • Hisory
  • Sever pain (comes quickly-hrs- ,can be relieved
    by scrotal support) swelling in one side of the
    scrotum
  • Malaise, fever, sweating loss of appetite
  • Symptoms of urinary tract infection
  • O/E
  • Swelling confined to one side of the scrotum
  • Scrotal skin red shiny, four days later become
    bronze in color
  • Scrotal skin hot
  • Not-tender but the testis epididymis are very
    tender
  • Surface of epididymis smooth
  • Swelling is fluctuant (secondary hydrocele)

55
  • Investigation
  • CBC ,Leukocytosis
  • MSU
  • U/S doplar
  • Treatment
  • Bed rest
  • Analgesia
  • Scrotal support
  • Broad spectrum Ab (ciprofloxacin)
  • The swelling may take as long as 2 months to
    resolve

56
Testicular torsion
  • This is twisting of the testis with interference
    to the arterial blood supply.
  • the actual torsion is usually of the spermatic
    cord
  • Possible mechanism it is associated with
  • Imperfectly descended testis
  • High investment of tunica vaginalis with a
    horizontal lie of testis
  • Epididymis testis are separated by a mesorchium,
    twisting occurs at the mesorchium.
  • The incidence is highest between 10 20 years.

57
  • Symptoms
  • pain in the scrotum groin
  • Sever
  • Sudden onset
  • Radiating to the lower abdomen
  • Associated with vomiting
  • May follow strain, lifting, exercise, or
    masturbation
  • Signs
  • Swollen testis
  • Tender
  • Drawn up to the groin

58
  • Treatment
  • Explore testis as soon as possible (untwisting
    should be carried out within 6 hrs of symptoms).
  • Check that it is not irreversibly infarcted.
  • Fix it to the scrotal septum.
  • The other testis should be fixed at the same
    operation, since it is likely to have abnormal
    position.
  • However
  • If the testis is infarcted, it should be removed

59
Scrotal Swellings
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62
Hydrocele
  • A collection of serous fluid in the tunica
    vaginalis
  • Types
  • Congenital occurs in infants due to patent
    processus vaginalis ? peritoneal fluid can enter
    the scrotum
  • Secondary
  • develop rapidly
  • small
  • lax
  • secondary to inflammation, trauma or tumor of
    underling testes
  • younger age group(20-40)
  • Primary. (idiopathic)
  • Develop slowly
  • Large
  • Hard tense
  • No defined cause
  • Over 40s

63
  • Congenital hydrocele processus vaginalis is
    patent connects to the peritoneal cavity. In
    children lt3yrs
  • Infentile hydrocele the tunica and processus
    vaginalis are distended to the superficial
    inguinal ring. There is no conection. Occurs in
    all ages
  • Hydrocele of the cord swelling near the
    spermatic cord. D/D hernia, lipoma of the cord

64
  • Symptoms
  • Scrotal swelling
  • Pain discomfort if its secondary
  • Frequent painful micturation if secondary to
    epididymo-orchitis
  • Malaise weight loss if secondary to tumor with
    distant metastases
  • Dont affect fertility

65
  • O/E
  • often bilateral
  • Can get above it
  • Testes cannot be felt separately
  • Transilluminates
  • Fluctuant
  • Fluid thrill
  • Dull to percussion
  • Not campressible or pulsatial
  • Cant be reduced
  • Normal skin color temp
  • Not tender if primary (may be tender if
    secondary)
  • Size can be reach up to 10-20cm in diameter
  • Surface smooth

66
U/S of hydrocele
  • Done to exclude testicular tumor or epididymitits

67
Treatment
  • If congenital hydrocele persists beyond the age
    of 1year, surgical treatment is indicated. This
    involves the division and ligation of the
    processus.
  • In an adult with primary hydrocele
  • Surgery
  • Opening the tunica vaginalis longitudinally
  • Emptying hydrocele
  • Everting the sac
  • Suturing it behind the cord thus obliterating the
    potential space
  • Aspiration ? reccurance
  • In elderly patient who are not fit for surgery
  • Secondary hydrocele ? treat the underlying cause

68
Epididymal cyst
  • Fluid-filled swellings connected with the
    epididymis.
  • If cyst contains clear fluid ,it is called
    epididymal cyst .
  • However, if the fluid is grey opaque contains
    few spermatozoa, it is called spermatocele (after
    aspiration)
  • Symptoms
  • Over age of 40 years
  • Scrotal swelling (as if having a 3rd testis)
  • Painless
  • Often multiple, bilateral
  • Enlarge slowly
  • Doesnt affect fertility (maybe after surgical
    removal)

69
  • O/E
  • Frequently bilateral
  • Lies above slightly behind the testes, the cord
    is felt above it
  • Cysts are not tender
  • Elongated, measures from few millimeters to
    5-10cm diameter
  • Smooth surface
  • Testis can be felt separately
  • Can get above it
  • Fluctuant, fluid thrill, dull to percussion
  • Cant be reduced
  • Transilluminates if contains clear fluid i.e
    Epididymal cyst (spermatocele sometime depend on
    density of the fluid)

70
U/S
  • Must be done to confirm your diagnosis R/O
    testicular tumore

spermatocele
71
  • Treatment
  • None if asymptomatic
  • But if large interfere with walking
  • Aspiration may help
  • Excision for large cysts this may affect
    fertility of the testis

72
Hematocele
  • Blood in the scrotum
  • H/O trauma
  • Symptoms include severe disomfort with an
    expanding mass
  • O/E ecchmosi, swelling, may not palpate the
    testes, no transillumination
  • Main concerns are testicular rupture or atrophy
  • U/S to confirm
  • Surgical exploration and clot evacuation

73
Testicular tumors
  • Commonest malignancy in men lt 35
  • Rare in men of African ancestry and before
    puberty
  • Peaks in the early twenties
  • 90 arise from germ cells are either
    seminomas(30-40 years) or teratomas(20-30 years)
  • 10 are lymphomas, sertoli cell tumors or leydig
    cell tumors
  • One in 10 testicular tumors occurs in association
    with maldescent of the testis.
  • Prognosis is good particularly if there was no
    lymph node involvement

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75
  • Symptoms
  • Painless swelling of the testis, (sometime dull
    aching, dragging pain )(80)
  • Heaviness in the scrotum
  • Maybe history of trauma ?delays diagnosis
  • General malaise, wasting ,loss of appetite
  • Abdominal pain if lymph nodes are enlarged
  • Swelling of legs caused by lymphatic or venous
    obstruction
  • Infertility
  • Secondary hydrocele

76
  • Signs
  • can get above it
  • Testes can not be felt separately
  • Not translucent
  • Not fluctuant
  • Harder than normal testis
  • Dull to percussion ? hydrocele
  • If skin is affected, it maybe warm discolored
  • Usually not tender
  • Irregular, different sizes
  • Surface usually smooth (sometime irregular or
    nodular)
  • Examine the para-aortic supraclavicular lymph
    nodes for metastasis
  • The liver maybe enlarged there maybe sign of
    pulmonary secondaries (collapse, consolidation or
    a pleural effusion).

77
  • Investigation
  • US testis
  • CXR ? mets
  • Tumor markers AFP (yolk-sac cell), ßHCG
    (trophoblastic cells).
  • CT scan ?abdomen and chest to identify lymph
    nodes and pulmonary mets

78
  • Treatment
  • Explore testis through an inguinal incision
  • Orchidectomy
  • Further treatments depends on the type and stage

DXTdeep x-ray therapy, RPLNDretroperitoneal
lymph node dissection
79
Varicocele
  • It is a bunch of dilated tortuous veins of the
    pampiniform plexus i.e. (varicose vines in the
    spermatic cord).
  • More common on the left side
  • 25 of normal men have small symptomless
    varicoceles.
  • Causes of varicocele
  • Incompetent valve btw the renal and testicular
    veins
  • Nephrectomy
  • Lt. Renal neoplasm
  • Lymphadenopathy

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  • Symptoms
  • Varicose veins in the scrotum on standing.
    Disappear on lying down
  • Heavy or dragging sensation in scrotum
  • Aching pain
  • Bilateral varicoceles may case subfertility
  • O/E
  • The pt must be examined standing, not to miss the
    diagnosis
  • Vein often visible
  • They are also palpable fell like a bag of
    worms
  • Affected testis may be smaller more soft

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U/s PIC
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  • Treatment
  • In Asymptomatic pt ,no treatment is required
  • Scrotal support for aching discomfort
  • If symptoms fail to settle or there is evidence
    of subfertility there are two options for
    treatment
  • Embolization obliteration under radiological
    control (majority)
  • Surgery is via an inguinal approach, all
    testicular veins bar on being ligated at the deep
    inguinal ring.
  • Microsurgery is used in most cases. Has less
    recurrence rate and better success.
  • Embolization is preferred in case of recurrence

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Indirect inguinal hernia
  • A peritoneal sac protrudes through the deep
    inguinal ring, passes down the inguinal canal,
    may extend as far as the upper pole of the
    testis.
  • The defect is congenital is due to persistent
    processus vaginalis
  • Symptoms
  • Often none (scrotal swelling that can be pushed
    back by the pt.
  • Aching dragging sensation in the groin
  • Some pt relate the development to an episode of
    straining or lifting

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  • Signs
  • Cant get above it
  • There is a cough impulse
  • Reducible
  • Treatment
  • Herniotomy Herniorrhaphy (excision of the sac
    repair of the defect) in adult By
  • Lichtenstein repair (tension free mesh repair)
  • Shouldice repair

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History
  • Age?tumors (20-40). Rare before puberty
  • Torsion usually in teens and children
  • Hydrocele in an infant?communicating
  • H/o trauma
  • Pain?epididymo-orchitis, varicocele, torsion
  • Infertility
  • Constitutional symp?malignancy
  • PSH?varicocele
  • SOH? marital status extramarital relation?
    epididymo-orchitis

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investigations
  • CBC? WBC
  • MSU for culture and sensitivity
  • Tumor markers if indicated
  • U/S doplar
  • CT if indicated? tumor

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