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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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258 SYMPTOM SORTER
A history of travel or sexual contact with travellers is important – a number of the more
obscure causes are ‘tropical’.
Take a sexual history – syphilis is rare generally but is more common in homosexuals.
Balanitis and urethritis, arthritis and conjunctivitis form the triad of Reiter’s syndrome.
Always make a thorough general systemic enquiry.
A single, unexplained, persistent ulcer needs thorough investigation as signicant disease
(infection or malignancy) is likely.
Remember the possibility of underlying diabetes in severe or recurrent candidal balanitis.
NOTES:
https://t.me/med1917
259
SCROTAL SWELLING
The GP overview
Scrotal swellings can occur at any age. ey arise most commonly from the testicle and its
coverings, the spermatic cord and the skin. Greater awareness of testicular cancer has resulted
in increasing numbers of young men attending the GP, usually with benign lumps.
Differential diagnosis
COMMON
inguinal hernia
sebaceous cyst
hydrocoele
epididymal cyst
epididymo-orchitis (EO)
OCCASIONAL
torsion of the testis
iatrogenic sepsis: surgery and catheterisation
haematocoele
varicocoele
congestive heart failure
post-vasectomy swelling (aseptic), including haematoma, inammatory reaction to spilt
sperm
trauma: haematoma
RARE
testicular tumour (seminoma, teratoma)
ascites
inferior vena caval thrombosis
tuberculosis and syphilis (not rare abroad)
elephantiasis (lariasis)
https://t.me/med1917
260 SYMPTOM SORTER
Ready reckoner
Hernia Sebaceous cyst Hydrocoele Epididymal cyst EO
Can get above swelling No Ye s Ye s Ye s Ye s
Testicle tender No No No Possible Ye s
Swelling xed to skin No Ye s No No No
Tender groin nodes No Possible No No Possible
Transilluminates No No Ye s Possible No
Possible investigations
LI KE LY: Ultrasound.
POSSIBLE: Urinalysis, MSU.
SMALL PRINT: FBC, U&E, LFT, CXR, urethral swab, AFP and β-HCG.
Ultrasound useful to distinguish solid from cystic swelling.
Urinalysis may show signs of UTI, but may be negative in epididymo-orchitis, as may MSU.
If urethra discharging, take urethral swab for gonococcus and Chlamydia.
FBC, AFP and β-HCG essential baseline investigations if solid tumour suspected – would
be arranged by the specialist aer referral.
CXR may show cannonball metastases if carcinoma has spread.
May require further investigations such as U&E, LFT, syphilis serology if underlying
pathology (e.g. ascites, cardiac failure, syphilis) suspected.
TOP TIPS
Don’t forget that the patient’s main fear is likely to be cancer. Broach this even if the swelling
is obviously benign.
Examine the patient standing. Many lumps are easier to feel this way and some – especially
varicocoeles – may disappear on lying down.
In the older patient, with bilateral swelling, there is likely to be some underlying disease
process such as cardiac failure.
Consider arranging an ultrasound if a patient remains very anxious about an obviously cystic
swelling, or if you have any doubt yourself – a normal result will relieve both parties.
https://t.me/med1917
SCROTAL SWELLING 261
Seminoma may oen feel smooth and mimic a large normal testis. Do not rely on the absence
of clinical features of malignancy – if the patient feels there has been a change in the testis,
act on it.
It can be dicult to distinguish between hernias and hydrocoeles in babies. Hernias require
surgical attention; hydrocoeles may resolve within the rst year of life. If in doubt, refer.
Remember that a hydrocoele may be caused by an underlying malignancy; in younger
patients, always refer, while in the elderly, examine the testis carefully aer aspiration.
Le supraclavicular nodes may be involved aer tumour spread to para-aortic nodes (can be
massive). Examine the abdomen and chest if any suspicion of malignancy.
If any suspicion of torsion – admit urgently.
NOTES:
https://t.me/med1917
262
TESTICULAR PAIN
The GP overview
is is an uncommon symptom in everyday general practice. ough commonest in the young
adult, it can aect all age groups. In its acute form, it is excruciating and disabling. In the chronic
form it is usually described as a dull ache or dragging sensation. It is the former which causes the
GP the most diagnostic diculty and anxiety.
Differential diagnosis
COMMON
acute orchitis (mumps, and less commonly scarlet fever and u)
acute epididymo-orchitis (EO) (UTI and sexually transmitted infection)
torsion of the testis
epididymal cyst
referred from ureteric stone
OCCASIONAL
idiopathic chronic testicular pain (accounts for 25% of chronic cases)
varicocoele
haematocoele
hydrocoele
trauma (fractured testis)
undescended or misplaced testis
torsion of the appendix testis
post-vasectomy pain
RARE
testicular carcinoma (teratoma and seminoma)
incarcerated or strangulated inguinoscrotal hernia
syphilis
referred from spinal tumours
neuralgia testis
tuberculosis of the testis
https://t.me/med1917
TESTICULAR PAIN 263
Ready reckoner
Orchitis EO Torsion Epididymal cyst Stone
Testicle tender Ye s Ye s Ye s No No
Urethral discharge No Possible No No No
Fever Ye s Possible No No No
Testis high in scrotum No No Ye s No No
Transilluminating lump No No No Possible No
Possible investigations
LI KE LY: Urinalysis, MSU.
POSSIBLE: Urethral swab, ultrasound.
SMALL PRINT: Lumbosacral spine and abdominal X-rays, syphilis serology.
Urinalysis: Protein, blood and pus cells in EO. Blood alone with stone.
MSU: Will identify UTI.
Urethral swab for gonococcus and Chlamydia necessary if STD suspected.
Plain lumbosacral spine and abdominal X-rays are valuable to investigate referred testicular
pain (stones and spinal pathology).
Ultrasound is good at ‘seeing’ if a testicular mass arises from the body of the testis or its
coverings, and whether solid or not.
Syphilis serology: If syphilis suspected.
TOP TIPS
In an adult, relief of pain by elevating the testicle suggests epididymitis.
A negative urinalysis does not exclude epididymitis.
In mild, chronic testicular ache, examine the patient standing up, otherwise you may miss
a varicocoele.
A sudden onset of excruciating pain associated with nausea suggests torsion of testis –
especially in children and adolescents. Admit immediately.
Repeated episodes of spontaneously resolving pain may represent recurrent, self-correcting
torsion. Refer for possible orchidopexy and warn the patient to report urgently if there is
severe and persisting pain.
If non-gonococcal/chlamydial epididymitis is clinically suspected, treat immediately with a
broad-spectrum antibiotic.
If epididymitis does not settle with antibiotics, consider abscess formation – admit for IV
antibiotics or surgical drainage.
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264
VAGINAL DISCHARGE
The GP overview
Vaginal discharge is usually a symptom of the reproductive years, but can occur at any age. It
can be inuenced by the menstrual cycle, use of ‘the pill’, age, pregnancy and sexual activity.
Treatment is oen simple, but if it fails, or if there are risk factors for STDs, it is sensible to refer
to a GUM clinic.
Differential diagnosis
COMMON
excessive normal secretions
thrush
bacterial vaginosis (BV)
trichomonal vaginosis (TV)
cervicitis (gonococcus, Chlamydia, herpes)
OCCASIONAL
cervical ectropion
cervical polyp
lost tampon, ring pessary or other foreign body
IUCD
bartholinitis
salpingitis
RARE
vulvovaginal neoplasia
cervical or uterine neoplasia
sloughing intrauterine broid
pyometra
pelvic stula
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VAGINAL DISCHARGE 265
Ready reckoner
Normal Thrush BV TV Cervicitis
Intense itch No Ye s No Possible Possible
Offensive smell No No Ye s Ye s Possible
Vulval soreness No Yes No Ye s Possible
Yellow/green/grey (mucopurulent)
discharge
No No Ye s Ye s Yes
Inamed cervix No No No Ye s Yes
Possible investigations
LI KE LY: High vaginal swab (HVS).
POSSIBLE: Endocervica l swab, urethral swab, urine testing for Chlamydia, blood sugar or HbA1c.
SMALL PRINT: Other specialist investigations.
Most GPs would conne themselves to the HVS, endocervical swab and urine test. ose with
a special interest might undertake the microscopy themselves.
HVS is simple and readily detects Candida, BV and TV.
Wet saline microscopy shows clue cells in BV, motile trichomonads in TV.
Gram stain of cervical or urethral exudate shows negatively staining diplococci in up to 85%
of gonococcal infections.
Endocervical swab for ELISA is the gold standard for detecting Chlamydia.
DNA amplication testing of rst-catch urine (not MSU) specimens for Chlamydia is non-
invasive and relatively acceptable to patients.
Blood sugar or HbA1c: To detect diabetes in severe or recurrent thrush.
Specialist investigations might include D&C or hysteroscopy (for possible malignancy) and
barium enema (for pelvic stula).
TOP TIPS
It is reasonable to diagnose and treat thrush empirically in a woman with classical symptoms
who has had the problem before – many women successfully self-medicate and only attend
to obtain their treatment free, via a prescription. But if in any doubt about the diagnosis,
examine and investigate as appropriate.
It is worth investing time with the patient suering conrmed recurrent thrush – advice
supplemented by written patient information may help minimise future problems.
Make sure you have all the appropriate swabs (HVS, endocervical, urethral) to hand – you
never know when you might need them.
Excessive concern about normal secretions might mask a sexual problem or worry – enquire
discreetly about this.
https://t.me/med1917
266 SYMPTOM SORTER
Recurrent or orid thrush may be a presentation of undiagnosed diabetes mellitus. Ask
about thirst, polyuria and tiredness and check a fasting glucose if any suspicion of underlying
diabetes, or there is a positive family history of diabetes.
Vaginal discharge is an uncommon symptom before puberty. Don’t forget the possibilities
of abuse or a foreign body.
Always conduct a full pelvic examination in the post-menopausal woman with vaginal
discharge. Malignancy is one of the likeliest causes.
A orid erosion is likely to be caused by chlamydial cervicitis – take a swab and treat
appropriately.
If you suspect a sexually transmitted disease, refer to the GUM clinic for full assessment and
contact tracing. Refer urgently to the GUM clinic or duty gynaecologist if there are systemic
u-like symptoms and fever with pelvic pain and vaginal discharge.
NOTES:
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267
VULVAL IRRITATION
The GP overview
Vulval irritation encompasses soreness and itch and is a very common presentation in primary
care. Embarrassment may mean a ‘calling card’ symptom has rst to be presented. Sometimes it
is a ‘calling card’ itself, being easier to talk about than a psychosexual problem. With sensitivity,
the real issues should emerge during the consultation.
Differential diagnosis
COMMON
thrush: Candida infection
Trichomonas vaginalis
chemical: Bubble baths, detergents, ‘feminine hygiene’ douches
trauma: Insucient lubrication during intercourse
atrophic vaginitis
OCCASIONAL
ammoniacal vulvitis from incontinence
skin disorders (e.g. eczema, psoriasis, lichen planus)
infestations: readworms, pubic lice
psychosexual problems
other infections (e.g. genital warts or herpes)
RARE
diabetes (without Candida infection)
vulval dysplasia (various other terms for this include lichen sclerosus et atrophicus,
leukoplakia)
vulval carcinoma
general disorder causing pruritus (e.g. jaundice, leukaemia, chronic renal failure, lymphoma)
psychogenic (no organic or psychosexual problem)
https://t.me/med1917
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