uROLOGY
CASE 57: teStiCular pain
history
A 16-year-old boy attends the emergency department complaining of sudden onset of right testicular pain. The pain woke him from his sleep and has persisted over the last 3 h. His mother says that he has vomited once. His previous medical history includes a similar event a year ago, but on that occasion the pain subsided quickly. He is asthmatic and uses a salbutamol inhaler.
examination
On examination the left hemi-scrotum feels normal but the right side is acutely swollen and tender on palpation. The testicle is elevated when compared to the other side and has an abnormal horizontal lie. The abdomen is soft and non-tender. His blood pressure is 130/84 mmHg and the pulse rate is 110/min. The cremasteric reflex is absent.
INVESTIGATIONS
urinalysis is clear.
Questions
•What is the diagnosis?
•What should you consider in the differential?
•What is the management in this case?
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100 Cases in Surgery
ANSWER 57
This boy has testicular torsion until proven otherwise. It is likely that a year ago he had an episode of intermittent torsion with spontaneous detorsion. Testicular torsion is actually torsion of the spermatic cord and not of the testis. This results in irreversible ischaemia to the testicular parenchyma, which can occur within 4–6 h of cord torsion. The presentation can vary and includes vague loin or groin pain as well as scrotal signs and symptoms. There may be a history of excessive physical activity or trauma. Testicular torsion can occur at any age but commonly has a bimodal distribution. There is a small peak in the first year of life but is more common between late childhood (post puberty) and early adulthood, i.e. 12–18 years.
Normally, the tunica vaginalis envelops the body of the testis and only part of the epididymis (which is usually fixed), and the testis is unable to twist. In cases of torsion, there is an abnormal amount of free space between the parietal and visceral layers of the tunica vaginalis, which encompasses the testis, epididymis and the cord for a variable distance. This free space allows the now hypermobile testis and epididymis to rise in the scrotum and twist. This accounts for the abnormal horizontal lie of the testis (‘bell clapper deformity’). If the presentation is delayed, an acute hydrocoele may develop making examination difficult, and the scrotum may appear erythematous. Surgical exploration is essential if torsion is considered. Testicular salvage rates are directly correlated with the number of hours after the onset of pain with a significant drop off after 6 h. Urinalysis is often negative and the diagnosis should be made clinically.
!Differential diagnoses
•torsion of the appendix testis
•torsion of the appendix epididymis
•epididymo-orchitis
•infected hydrocoele
•testicular rupture
•Strangulated inguinal hernia
•a bleed into a tumour
In torsion of the appendix testis, the tenderness is usually localized above the upper pole of the testis and may be accompanied by the ‘blue dot’ sign, which represents necrosis in the appendix. Hydrocoeles may be tender if large and will transilluminate. If a patient is suspected of having epididymo-orchitis, the urine should be screened for infection. There may also be a history of urethral discharge or urinary symptoms such as frequency or dysuria.
KEY POINTS
•if testicular torsion is suspected, surgical exploration should be carried out as soon as possible.
•testicular salvage rates decline significantly after 6 h from the onset of testicular pain.
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Urology
CASE 58: leFt loin pain
history
A 33-year-old female office worker presents to the emergency department complaining of severe left-sided abdominal pain. The pain woke her in the early hours of the morning and has persisted throughout the day. She is unable to keep still and has vomited bilious material on five occasions. She reports no diarrhoea or rectal bleeding. Previous medical history includes appendicectomy and irritable bowel syndrome. She has had a recent colonoscopy, which was normal. She takes mebeverine for irritable bowel syndrome and multivitamin tablets. She smokes 15 cigarettes per day.
examination
On examination, she has a temperature of 37°C, a blood pressure of 125/88 mmHg and pulse rate of 96/min. There is marked left loin tenderness, but the rest of the abdomen is nontender. Heart sounds are normal and the chest is clear.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
12.6 g/dl |
11.5–16.0 g/dl |
White cell count |
12.8 × 109/l |
4.0–11.0 × 109/l |
platelets |
254 × 109/l |
150–400 × 109/l |
Sodium |
141 mmol/l |
135–145 mmol/l |
potassium |
4.2 mmol/l |
3.5–5.0 mmol/l |
urea |
5.0 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
62 μmol/l |
44–80 μmol/l |
Urinalysis: |
|
|
protein: negative |
|
|
nitrites: negative |
|
|
leucocytes: +1 |
|
|
blood: +4 |
|
|
glucose: negative |
|
|
human chorionic gonadotropin: negative |
|
|
Questions
•What is the likely diagnosis?
•What investigation would you like to do to confirm your diagnosis?
•What are the indications for admitting this patient?
•What is the initial management?
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100 Cases in Surgery
ANSWER 58
The combination of left loin pain and microscopic haematuria, in the absence of abdominal peritonism, suggests a diagnosis of renal/ureteric colic. In 10–15 per cent of cases of renal colic, the dipstick will be negative for blood. The differential diagnosis includes pyelonephritis, diverticulitis, bowel obstruction, peptic ulcer disease and gynaecological conditions such as ectopic pregnancy, torted ovarian cyst or tubo-ovarian abscess. In addition to the above, on the right side, appendicitis and biliary colic should also be considered. In an older patient, it is important to exclude a ruptured abdominal aortic aneurysm.
The pain of renal colic is caused by the distension of the ureter or collecting system from an obstructing calculus. The pain may radiate from loin to groin and to the tip of the penis in males and to the labia in females (the latter being typical in males and females, respectively, of a stone at the vesico-uretric junction). Calculi may also irritate the bladder, causing urgency, frequency and strangury.
The gold standard investigation in the work-up of renal colic is a non-contrast computerized tomography (CT) KUB (kidneys, ureter, bladder) scan. This has a sensitivity of 94–100 per cent and specificity of 92–100 per cent. Advantages of CT KUB compared with more traditional tests such as intravenous urogram include the possibility to diagnose other conditions, accuracy of stone measurement, quick test and does not require administration of intravenous contrast and its potential pitfalls, e.g. allergy and chemotoxic reaction in patients with renal insufficiency. However, its use does involve a higher radiation dose.
Indications for admitting the patient include:
•Pain not controlled with simple analgesia
•Evidence of sepsis, e.g. pyrexia, raised white cell count or signs and symptoms of septic shock
•Obstructing calculi in a solitary kidney, or bilateral ureteric stones
•Deranged renal function
Renal drainage via percutaneous nephrostomy or retrograde ureteric stent insertion is required urgently in patients with sepsis and obstruction and is a urological emergency.
Figure 58.1 Ct Kub.
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Urology
The analgesic of choice is rectal diclofenac, although in some cases opiates will be required. Fluids should be given and in cases of suspected infection, antibiotics with good Gramnegative cover administered.
The CT KUB in Figure 58.1 clearly demonstrated the offending urinary calculus, which is the opacification seen in line with the ureter.
KEY POINTS
•haematuria is present in 90 per cent of cases of renal colic.
•Sepsis and obstruction of the urinary system is a urological emergency and requires urgent renal drainage.
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