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Testicular Examination DR AMY ROSS (FY2)Examination of male genitalia Wash hands, don PPE Introduction Confirm Name and DOB Explain what the examination will involve “I have been asked to carry out an involve examining your penis, testicles and surrounding region.” Consent and CHAPERONE Maintain dignity throughout Ask if any pain prior to commencing examination Inspection Skin changes: warts (human papillomavirus), erythema (e.g. cellulitis, fungal infection). Scars: may indicate previous surgery (e.g. vasectomy, testicular fixation). Masses: note any lumps associated with the scrotum (e.g. testicular cancer) or the perineum (e.g. abscess). Swelling:note any swelling of the scrotum (e.g. hydrocoele, oedema) and look for associated erythema (e.g. cellulitis). Bruising: may indicate local trauma. Necrotic tissue:consider Fournier’s gangrene (necrotising fasciitis of the external genitalia and/or perineum) which is often first noted on the perineum.Question 1 A 22 year old man presents with an aching pain and discomfort in his right testicle. He has felt systemically unwell for the preceding 48 hours. On examination, there is tenderness of the Right testicle. He has an exaggerated cremasteric reflex. What is the correct course of action? A Scrotal exploration via a scrotal approach B Testicular inspection via an inguinal approach C Administration of antibiotics D Fine needle aspiration cytology E Reassure and dischargeAnswer C This is likely to represent epididymo-orchitis Usually due to infection with gonorrhoea or chlamydia in this age group In addition to treatment with antibiotics – contact tracing and appropriate swabs should be performed Epididymitis ** Testicular torsion ** Epididymal cysts Hydrocele Varicocele Inguinal herniaEpididymitis Acute epididymitis is an acute inflammation of the epididymis, often involving the testis (epididymo-orchitis). Usually caused by bacterial infection. Infection spreads from the urethra or bladder. In men <35 years, gonorrhoeaor chlamydia are the usual infections. Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug. Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis. Often hx of dysuria & urethral discharge. Can be eased by elevating the testes. Twist of the spermatic cord resulting in testicular ischaemia and necrosis. Most common in males aged between 10 and 30 (peak incidence 13- 15 years Pain is usually severe and of sudden onset. Treatment is with surgical exploration. If a torted testis is Cremasteric reflex is identified, then both testis should lost and elevation of be fixed as the condition of bell the testis does not clapper testis is often bilateral. ease the pain.Cremasteric reflex Superficial reflex elicited when the inner part of the thigh is stroked. Stroking of the skin causes the cremaster muscle to contract and pull up the testicle toward the inguinal canal (ipsilateral side). Dependent on nerve roots L1 and L2. ABSENT IN TESTICULAR TORSION In children, this reflex may be overexaggerated – can lead to the mistaken diagnosis of undescended testes. Upper and lower motor neurone disorders can also cause absent reflex.Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lies above and behind testis It is usually possible to 'get above the lump' on examination Epididymal cysts can be excised using a scrotal approach Presents as a mass, usually possible to 'get above' it on Hydrocele examination. Painless, often transilluminates In younger men it should be investigated with USS to exclude tumour. In children it may occur as a result of a patent processus vaginalis. Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated. Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller Bilateral varicoceles may affect fertility Usually managed conservatively. If concerns about testicular function or fertility, then surgery or radiological management can be considered.Inguinal hernia Inguinoscrotal swelling Cannot get above it on examination Cough impulse may be present May be reducibleTesticulaumours Testicular cancer is the most common malignancy in men aged 20-30 years. 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into: Features Risk factors A painless lump is the most common ■ Cryptorchidism presenting symptom ■ Infertility Pain may also be present in a minority of men ■ Family history Other possible features include ■ Klinefelter's syndrome hydrocele, gynaecomastia ■ Mumps orchitisTumour type Key features Tumour markers Pathology Seminoma •Commonest subtype (50%) AFP usually normal Sheet like lobular patterns of cells with substantial fibrous •Average age at diagnosis = 40 HCG elevated in 10% seminomas component. •Even advanced disease associatedLactate dehydrogenase; elevated Fibrous septa contain lymphocytic with 5 year survival of 73% in 10-20% seminomas (but also in inclusions and granulomas may be many other conditions) seen. • Non seminomatous germ cell Younger age at presentation-=20FP elevated in up to 70% of cases Heterogenous texture with tumours (42%) 30 years occasional ectopic tissue such as • Teratoma βHCG elevated in up to 40% of hair • Yolk sac tumour Advanced disease carries worse cases • Choriocarcinoma prognosis (48% at 5 years) • Mixed germ cell tumours Other markers rarely helpful (10%) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy Diagnosis ■ Ultrasound is first-line ■ CT scanning of the chest/ abdomen and pelvis is used for staging ■ Tumour markers (see above) should be measured Management Orchidectomy (Inguinal approach) Chemotherapy and radiotherapy may be given depending on staging Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection. Prognosis is generally excellent: ■ 5 year survival for seminomas is around 95% if Stage I ■ 5 year survival for teratomas is around 85% if Stage IQuestion 2 A 20 year old male notices a mild painful swelling of his right scrotum. He also complains of abdominal pain. Clinically, the patient is found to have a swollen right testicle. Apart from a supraclavicular node, there is no obvious lymphadenopathy. What is the best course of action? A Orchidectomy via a scrotal approach B Trucut biopsy of the testis C FNAC of the testis D Orchidectomy via an inguinal approach E Administration of antibioticsCorrect answer D The patient is likely to have a teratomawhich has metastasized to the supraclavicular nodes. There is suspicion of spread to the para-aortic nodes due to the abdominal pain. He will need orchidectomy and combination chemotherapy. There is no role for orchidectomy via scrotal approach in malignancy.RENAL STONES Renal Stones Renal stones: also known as renal calculi, urolithiasis and nephrolithiasis. ureters.nes that form in the renal pelvis, where the urine collects before travelling down the May be asymptomatic until they irritate or get stuck in the ureters. Two key complications are: Obstruction leading to acute kidney injury Infection with obstructive pyelonephritis Types of renal stones Calcium-based stones are the most common type of kidney stone (about 80%). Having a raised serum calcium(hypercalcaemi) and a low urine outputare key risk factors for calcium collecting into a stone. Two types of calcium stones: Calcium oxalate (more common) Calcium phosphate Other types: Uric acid – not visible on x-ray Struvite – produced by bacteria, therefore, associated with infection Cystine – associated with cystinuria, an autosomal recessive disease Presentation Renal stones may be asymptomatic and never cause an issue. Renal colicis the presenting complaint in symptomatic kidney stones. May also be: - Haematuria - Nausea or vomiting - Reduced urine output Renal colic is: - Symptoms of sepsis, if infection is present Unilateral loin to groin painthat can be excruciating (“worse than childbirth”) Colicky (fluctuating in severity) as the stone moves and settles Investigations Urine dipstickusually shows haematuria in cases of kidney stones. A normal urine dipstick does not exclude stones. Bloods (FBC, U&E, CRP, Bone profile) An abdominal x-ray can show calcium-based stones, but uric acid stones will not show up (they are radiolucent). Non-contrast computer tomography(CT) of the kidneys, ureters and bladder (CT KUB) is the initial investigation of choice for diagnosing kidney stones. NICE guidelines (2019) recommend a CT within 24 hours of the presentation. kidney stones but is helpful in pregnant women and children.UB). - less effective at identifying NICE Guidelines 1.1.1 Offer urgent (within 24 hours of presentation) low-dose non-contrast CT to adults with suspected renal colic. If a woman is pregnant, offer ultrasound instead of CT. 1.1.2 Offer urgent (within 24 hours of presentation) ultrasound as first-line imaging for children and young people with suspected renal colic. 1.1.3 If there is still uncertainty about the diagnosis of renal colic after ultrasound for children and young people, consider low-dose non-contrastCT.Management not suitable)e most effective type of analgesia (IV paracetamol is an alternative when NSAIDs Watchful waitinin stones less than 5mm, 50-80% chance they will pass without any intervention. Tamsulosinan alpha-blocker) can be used to help aid the spontaneous passage of stones. Surgical interventionsSurgical interventions Extracorporeal shock wave lithotripsy (ESWL): ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass. Ureteroscopy (URS) and laser lithotripsy: A camera is inserted via the urethra, bladder and ureter, and stone is identified. Then broken up using targeted lasers, making the smaller parts easier to pass. Percutaneous nephrolithotomy (PCNL): PCNL is performed in theatres under a GA. A nephroscope is inserted via a small incision at the patient’s back. The scope is inserted through the kidney to assess the urtube may be left in place after the procedure to help drain the kidney.my **Urological Emergency ** Patients with urinary calculi alongeverand other signs or symptoms of infection need emergency urology review for drainage and intravenous antibiotics. Failure to perform rapid renal decompression can perpetuate urosepsis and result in death. Drainage can be accomplished in two ways: - Urologist can place a ureteric stent past the obstruction and achieve drainage. - Interventional Radiology can place a percutaneous nephrostomy tube. Surgical treatment (including SWL) of renal stonesin adults, children and young people Treatment for adults Treatment for children and Stone type and size (16 years and over) young people (under 16years) Renal stone less than 10mm Offer SWL Consider URS or SWL Consider URS: Consider PCNL if: •if there are •URS or SWL have failed or contraindications for SWLor •for anatomical reasons, PCNL is Consider watchful waitingfor asymptomatic •if a previous course of SWL the more favourable option renal stones in adults, children and young people if: has failed or •because of anatomical the stone is less than 5 mm or reasons, SWL is not the stone is larger than 5mm and the person indicated (or their family or carers, as appropriate) agrees Consider PCNL if SWL and to watchful waiting after an informed URS have failed to treat the discussion of the possible risks and benefits. current stone or they are not an option Renal stone 10 to 20mm Consider URS or SWL Consider URS, SWL or PCNL Consider PCNL if URS or SWL have failed Renal stone larger than Offer PCNL Consider URS, SWL or PCNL 20 mm, including staghorn Consider URS if PCNL is not stones an optionTable2 Surgical treatment (including SWL) of ureteric stonesin adults, children and young people Treatment for children and Treatment for adults young people (under Stone type and size (16 years and over) 16 years) Ureteric stone less than Offer SWL Consider URS or SWL 10 mm Consider URS if: •stone clearance is not possible within 4 weeks with SWL or •there are contraindications for SWLor •the stone is not targetable with SWL or •a previous course of SWL has failed Ureteric stone 10 to 20 mm Offer URS Consider URS or SWL Consider SWL if local facilities allow stone clearance within 4 weeks Consider PCNL for impacted proximal stones when URS has failedReducing the risk of recurrence… - Increase oral fluid intake (2.5 – 3 litres per day) - Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones) Two medications may reduce the risk of - Avoid carbonated drinks (cola drinks contain recurrence are: phosphoric acid, which promotes calcium oxalate formation) Potassium citratein patients with calcium oxalate stones and raised urinary calcium - Reduce dietary salt intake (less than 6g per day) Thiazide diuretics (e.g., indapamide) in patients - Maintain normal calcium intake (low dietary with calcium oxalate stones and raised urinary calcium might increase the risk of kidney calcium stones)QUIZ 1. What are risk factors for developing germ cell tumours? A Orchitis B Hydrocele and varicocele C Klinefelter syndrome and cryptorchidism D Hypospadius2. What area does prostate cancer spread to most frequently? A Brain B Lung C Pancreas D Lumbar Spine3. What is the best description for the area of the prostate that the carcinoma usually affects? A Posterior and peripheral region B Anterior and peripheral region C Periurethral region D Entire anterior regionProstatic cancer typically arises from the posterior lobe and on the periphery à often asymptomatic & does not compress the urethra producing no urinary symptoms at an early stage.4. Are testicular tumours usually biopsied? A YES B NONo – not biopsied à high risk of seeding the scrotum. Instead, investigations include a scrotal ultrasound and blood tests for tumour markers.5. What is hypospadias? A Opening of urethra on the ventral surface of the penis B Opening of urethra on dorsal surface of the penis C Inflammation of the testicles D Benign warty growth on genital skinThank you! Please complete feedback..