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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3998_Библиотеки_им_академика_М_И_Перельмана
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Scrotal pain, testicular lumps 287
CASE 5.24 –
‘My son is complaining of a painful scrotum and is not able
to walk’
A1: What is the likely differential diagnosis?
Testicular torsion
Torsion of a testicular appendage
Epididymo-orchitis
Idiopathic scrotal oedema
A2: What issues in the given history support/refute a particular diagnosis?
Torsion of the testicle on the spermatic cord is common around puberty. The symptoms are sudden in
onset with pain and nausea and vomiting. There may be local redness and the testis may be lying higher
in the root of the scrotum.
A3: What additional features would you seek to support a particular
diagnosis?
A history of sharp intermittent pains that are self-limiting may be present and signify previous
intermittent torsions that have resolved.
A4: What clinical examination would you perform and why?
The testis may be horizontal or retracted up to the root of the scrotum. The testis is usually swollen and
exquisitely tender. A cremasteric reex is often absent and may be a useful indicator.
A5: What investigations would be most helpful and why?
Ultrasound and colour Doppler assessment are operator dependent and may delay prompt surgical
intervention; they are considered only if the diagnosis is doubtful.
A6: What treatment options are appropriate?
A manual de-torsion may be attempted but this must not delay an urgent exploration of the testicle.
The testis is examined for signs of ischaemia; if normal it is repositioned and xed to the tunica vaginalis
with non-absorbable, non-reactive sutures. If nonviable testis is present despite attempts to improve
vascularization and oxygenation (warm saline packs around testes, increased oxygenation of patient and
detorsion), this may result in an orchiectomy of the necrotic testis.
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288 Urology
REVISION PANEL
A painless testicular lump is often indicative of testicular tumour and regular self-examination of
testes is usually recommended as a screening tool.
Testicular tumours are treated by radical orchidectomy followed by additional treatment
depending on the grade and stage of disease.
Serum tumour markers are available to identify the tumour and for monitoring treatment if
elevated.
Advanced germ cell tumours may present with intra-abdominal lymphadenopathy or metastatic
disease. The primary tumour may often be impalpable as a ‘burned out’ primary testicular tumour
requiring an ultrasound scan to identify this.
Unilateral painful swelling of the testes may be related to epididymo-orchitis.
Voiding symptoms or indwelling foreign bodies like urethral catheter may be associated with
related epididymo-orchitis coliform infection.
Urethral discharge or history of STI may be related to a chlamydial epididymo-orchitis.
Epididymo-orchitis may result in severe pain and often scrotal abscess.
Testicular torsion is a clinical diagnosis and prompt scrotal exploration is indicated to avoid loss of
the testis.
The clinical diagnosis is based on unilateral testicular pain that is of sudden onset associated with
clinical examination of an abnormal lie of the testis that is often higher than the other testis in the
absence of any inammatory features.
Scrotal exploration within 6 to 8 hours usually leads to salvage of a viable testis.
Unilateral orchidectomy of the necrotic testes may become necessary if there has been a delayed
diagnosis.
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Erectile dysfunction/infertility 289
ERECTILE DYSFUNCTION/INFERTILITY
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What issues in the given history support/refute a particular diagnosis?
Q3: What additional features would you seek to support a particular diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
CASE 5.25 –
‘I am unable to have erections’
A 45-year-old man newly diagnosed with diabetes presents with difculty having erections for the last 6
months. He does not have adequately rigid erections and is unable to maintain them.
CASE 5.26 –
‘We have been trying for a child for 3 years’
A couple have had unprotected intercourse for 3 years and have not conceived. He had repair of an
undescended testicle as a child.
CASE 5.27 –
‘I have an ulcer on my penis’
A 78-year-old man has had a foul-smelling discharge from his foreskin for several months and on clinical
examination has a fungating mass on the end of his penis.
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290 Urology
OSCE Counselling case
OSCE COUNSELLING CASE 5.9 –
Counsel a 35-year-old patient for a
vasectomy
A 35-year-old man has requested a vasectomy; he and his partner have three children, have completed
their family and would like a permanent sterilization.
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Erectile dysfunction/infertility 291
Key concepts
Erectile dysfunction is the inability to obtain a satisfactory erection for sexual intercourse.
The male factors of infertility or subfertility are the following: men with one or both undescended
testicles regardless of the age at orchidopexy, mumps or orchitis after puberty and substance abuse.
Penile carcinoma is uncommon but occurs in elderly men. The premalignant conditions associated
with penile cancers appear as chronic, painless, red or pale patches and include leukoplakia and
erythroplasia of Queyrat.
Infections with human papilloma virus (HPV)-16, -18 and -21 are important and associated with
cervical cancer in the partner. Circumcision as a neonate may confer some protection against penile
cancer, and this may be related to the chronic irritation from the smegma and balanitis in men with
poor hygiene.
The most common cancer is a squamous carcinoma which may be preceded by carcinoma in situ of
the glans or the foreskin. Metastasis is to the inguinal lymph nodes and then to the pelvic lymph nodes.
Blood-borne metastasis to the lungs and liver is rare.
The common presentation is a hard painless lump or a malignant ulcer on the penis.
Vasectomy is a permanent form of sterilization. There are several techniques that are used. The
principle involves isolating the vas deferens, delivering it through a small skin incision and dividing a
portion of it.
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292 Urology
Answers
Clinical cases
CASE 5.25 –
‘I am unable to have erections’
A1: What is the likely differential diagnosis?
Psychogenic erectile dysfunction is the most common cause and is associated with stress, performance
anxiety and previous sexual relationship problems.
Organic erectile dysfunction may also occur as a result of disruption of nerve conduction caused by
neurological processes such as Parkinson’s disease, stroke, head trauma and nerve disruption, as in a
radical prostatectomy.
Arterial occlusive disease of the pudendal cavernous helicine arteries can reduce arterial inow to the
sinusoids. Common risk factors include hypertension, hyperlipidaemia, cigarette smoking and diabetes.
Causes are also drug induced and due to hypogonadism (pituitary or gonadal).
A2: What issues in the given history support/refute a particular diagnosis?
Diabetes is a common cause of erectile dysfunction.
A3: What additional features would you seek to support a particular
diagnosis?
Erectile dysfunction that is gradual and insidious in onset is more likely to be organic. It is often
associated with loss of spontaneous or early morning erections.
On the contrary, erectile dysfunction related to periods of stress (e.g. marital, nancial and
psychological stress) is commonly sudden in onset, and spontaneous erections are often preserved.
Drug-induced erectile dysfunction is common with centrally acting antihypertensives, antipsychotics
and antidepressants.
Chronic alcoholism and smoking are known to affect erection adversely.
A4: What clinical examination would you perform and why?
Examination of the breasts, hair distribution, testes and thyroid would be conducted to detect an
endocrine abnormality.
Femoral and foot pulses would be checked for vascular insufciency.
Genital and perineal sensation would be examined for neurological decit and penile abnormalities.
Clinical syndromes such as Klinefelter’s syndrome are associated with a typical appearance.
A5: What investigations would be most helpful and why?
Hormonal evaluation: serum prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH)
and testosterone (if evidence of low testosterone on clinical examination), thyroid hormones, liver
and renal function tests
Serum glucose: diabetes
Tests that are rarely performed:
Duplex ultrasonography: measures penile blood ow velocity
Cavernosography: identies a venous leak, but is fraught with false positives and is rarely
performed
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Erectile dysfunction/infertility 293
Nocturnal tumescence testing: to access sleep-related erection; useful in differentiating psychogenic
erectile dysfunction (where nocturnal erections are preserved) from the organic erectile dysfunction
(nocturnal erections are lost); performed using a Rigiscan device
A6: What treatment options are appropriate?
General principles include cessation of smoking, reduction of alcohol intake, consumption of a
healthy diet and participation in exercise. Remove precipitating factors such as drugs, long-distance
cycling.
If a psychological component is present, refer to a psychosexual counsellor.
Treatment depends on patient suitability and preference.
Oral medications include phospodiesterase inhibitors (sildenal, vardenal, tadalal). PDE5 inhibitors
are contraindicated if the patient is on any form of nitrate therapy (e.g. GTN spray or long-acting
nitrates).
Major side effects are headaches, ushing and dyspepsia; use caution with cardiac patients on
nitrates (associated with fatal hypotension and arrhythmia).
Sublingual apomorphine acts on the central dopaminergic receptors and induces erections. The side
effects include nausea and vomiting.
A vacuum device can be placed over the penis and a pump produces a vacuum; a constricting ring is
placed on the base of the penis to maintain the rigidity after the penis is engorged by the negative
pressure. A retained ejaculate and numbness of the penis are some of the side effects.
Intracavernosal injections: papaverine and alprostadil are used and this is one of the most effective
and reliable second-line therapies for erectile dysfunction. There is a risk of persistent erection lasting
more than 4 hours (priapism) that requires urgent decompression.
Penile prosthesis is implanted into the corpora and replaces the normal erectile tissue; the prosthesis
may be solid (rigid or semirigid) and is malleable. The most common prosthesis is the inatable device
with a reservoir and pump and inatable rods that are implanted into the corpora.
CASE 5.26 –
‘We have been trying for a child for 3 years’
A1: What is the likely differential diagnosis?
Male causes of primary infertility
Hypothalamic causes: hypogonadotrophic hypogonadism: Kallmann’s syndrome
Pituitary causes: surgery, irradiation, infarction, tumours, infections
Hormonal excess: anabolic steroids, congenital adrenal hyperplasia, excess oestrogens and
prolactinomas
Chromosomal: Klinefelter’s syndrome (XXY)
Systemic diseases: uraemia, liver failure
Testicular causes: orchitis (postpubertal), undescended testes, trauma, infections, varicocoele
Cystic brosis: associated with bilateral vasal agenesis
A2: What issues in the given history support/refute a particular diagnosis?
History of an undescended testis as a child is important.
A3: What additional features would you seek to support a particular
diagnosis?
Duration of infertility and prior pregnancies; details of sexual history and potency and use of
lubricants are important.
History of previous surgery to the vas or pelvis and infections (e.g. mumps, trauma to testis) are
important.
History of diabetes and drug history and family history of cystic brosis are important.
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294 Urology
A4: What clinical examination would you perform and why?
General examination: body hair distribution, gynaecomastia
Examination of genitalia, size of the testis, thickening of epididymis
Examination for penile abnormalities (e.g. hypospadias)
Examination for presence of a vas deferens
Examine for presence of a varicocoele
A5: What investigations would be most helpful and why?
Urine: microscopy to rule out infection and to assess for sperm (retrograde ejaculation)
Semen analysis: oligospermia/azoospermia sperm counts
Asthenospermia
Hormonal evaluation: LH, FSH, testosterone and prolactin
Testicular biopsy: in azoospermia to differentiate between obstructive and non-obstructive forms;
reported as a Johnsen’s score 0 to 10 and a score >8 would suggest that the sperm is useful for
intracytoplasmic sperm injection (ICSI)/in vitro fertilization (IVF)
In cases of obstructive azoospermia: transrectal ultrasonography to assess the fullness of the seminal
vesicles and vasography to identify the level of the block
Rare tests: postcoital tests/anti-sperm antibodies (in serum, seminal plasma), karyotyping and cystic
brosis mutation testing
A6: What treatment options are appropriate?
A combined cause is noted in 30 per cent of cases and a purely male factor for infertility is noted in 20
per cent of cases.
For post-testicular causes: after vasectomy or focal obstruction: the block is identied using a
vasography. A vasovasostomy or vasoepididymostomy is performed.
Testicular causes: varicocoele is a common cause for infertility and this is repaired either by an open
technique (ligation of spermatic veins) or by a laparoscopic technique.
Correction of the hormone abnormalities is attempted.
Investigation for a prolactinoma and appropriate management is undertaken.
CASE 5.27 –
‘I have an ulcer on my penis’
A1: What is the likely differential diagnosis?
Carcinoma of the penis
Balanitis xerotica obliterans: white patch involving prepuce and glans and also the meatus
Leukoplakia: rare condition, common in those with diabetes, white plaque involves meatus
Condyloma acuminata: viral origin – HPV
A2: What issues in the given history support/refute a particular diagnosis?
Carcinoma of the penis is more common in older patients. It may develop as an ulcer (typical shallow
erosion/excavated ulcer with rolled-out edges) or an exophytic lesion. It eventually develops into a
fungating mass and has a purulent smell.
Circumcision in the neonate is protective and it is believed that the presence of smegma and poor
hygiene are contributory.
A3: What additional features would you seek to support a particular
diagnosis?
The aetiology is linked to HPV-16 and occurs in partners with carcinoma of the cervix (thought to be
linked to HPV).
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Erectile dysfunction/infertility 295
Smoking is a known risk factor for carcinoma of the penis.
The metastatic spread of penile carcinoma is to the lymph nodes and then to the distant organs
(lungs/liver/bone).
Carcinoma in situ (Bowen’s disease, when it appears in the shaft of the penis, and erythroplasia of
Queyrat, when it appears as a red velvety lesion with ulceration on the glans penis) is a precursor for
squamous carcinoma of the penis.
A4: What clinical examination would you perform and why?
General examination is needed to assess the nutritional status, hygiene and general well-being of the
patient.
The diagnosis is made by clinical examination and in some circumstances a biopsy may be
necessary. Assess the ulcer (size, shape, base, edge, site and involvement of the shaft of the penis and
bodies of the corpora). Inguinal lymph nodes may be palpable and in 50 per cent of the cases they are
enlarged as a result of infection of the ulcer and not as a result of metastatic spread of the cancer.
A5: What investigations would be most helpful and why?
Culture swab
Biopsy of the lesion may be necessary in suspicious circumstances
Primary tumour (corporal involvement): MRI
Lymph node involvement: CT of groin, pelvis, abdomen and chest
Bone scan: distant metastases
A6: What treatment options are appropriate?
Prognosis depends on the following:
Histological classication (Broder’s grade 1 to 3 with 5-year survival rate of 80 per cent in grade 1
and of 30 per cent in grade 3)
Depth of invasion
Pattern of growth (supercial spreading, vertical growing, verrucous and multicentric)
Vascular invasion
Carcinoma in situ may be treated with penis-conserving treatment: topical chemotherapy (e.g.
5-uorouracil) or glansectomy with resurfacing.
The primary lesion of carcinoma of the penis is treated by excision. Penis-conserving surgery may
be performed for lesions involving only the glans. A tumour that involves the corpus spongiosus or
cavernosus (T2), or the urethra and prostate (T3), is treated by excision of the lesion with a margin
(partial or total penectomy).
A 4-week course of antibiotics often allows differentiation of the lymph nodes with cancer from the
ones that are enlarged as a result of infection.
If no palpable nodes are present a prophylactic lymph node dissection of supercial inguinal lymph
nodes, and if the frozen section is positive an ipsilateral deep inguinal and pelvic node dissection, is
performed in high-grade G3 tumour and high-stage T2–4 disease.
In low-grade G1–2 tumour and T1 disease with no lymph nodes a protocol for surveillance is
acceptable, but with a 2-month follow-up.
The presence of nodes after the antibiotic course would require a full dissection of ipsilateral lymph
nodes (supercial/deep inguinal/pelvic) and contralateral supercial lymph nodes.
A positive pelvic lymph node is associated with a very poor prognosis: 5-year survival rate of 10 per
cent. Chemotherapy is considered for large lymph nodal metastasis and pelvic nodal metastasis.
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296 Urology
OSCE Counselling case
OSCE COUNSELLING CASE 5.9 –
Counsel a 35-year-old patient for a
vasectomy
Vasectomy is a permanent form of sterilization and a decision needs to be made by both partners.
The contraindications for vasectomy are mainly relative: clotting abnormalities, local infections
and skin abnormalities. Appropriate counselling of couples with a pregnant partner who request a
vasectomy is necessary to take into account the risk of stillbirth or perinatal mortality.
A reversal of vasectomy is not as successful (success depends on time between vasectomy and reversal).
Microsurgical techniques have a success rate of 60 to 80 per cent, with much lower paternity rates.
Vasectomy is not foolproof. Success is conrmed by negative semen analysis in the third and fourth
months after vasectomy. Late recanalization after a negative semen analysis may occur up to 15 years
after the procedure in 1:2000.
Persistence of semen in the tract will account for positive semen analysis; a guarded clearance may be
given for patients with non-motile sperm of <10 000/mL at least 7 months after the vasectomy.
Technique may be by an open vasectomy or a ‘no-scalpel technique’ using ne sharp instruments to
puncture the skin and deliver the vas for ligature – excising a segment of vas and repositioning the ends
of the vas either with or without ligation (open-ended vasectomy).
Complications include the sperm granuloma with a painful nodule on the vas. There is post-
vasectomy testicular pain/discomfort in up to 18 per cent of patients (caused by epididymal congestion,
often treated by non-steroidal anti-inammatory drugs and rarely requiring reversal of vasectomy). Local
complications of haematoma and wound infection are <5 per cent.
REVISION PANEL
Erectile dysfunction (ED) is often related to endothelial dysfunction and often precedes other
organ failures (e.g. myocardial ischaemia or cerebral ischaemia). The history of ED should often be
sought out as this may lead to early correction of risk factors for endothelial dysfunction and may
prevent strokes or heart attacks.
Erectile dysfunction is investigated to rule out diabetes or hypogonadism or if there is a
psychological cause for this.
The treatment is often multidisciplinary and oral PDE5 inhibitors have revolutionized the treatment of ED.
PDE5 inhibitors are contraindicated in patients on nitrate therapy. Patients with high-risk cardiovascular
stratication (unstable angina, recent myocardial infarction, certain arrhythmias and uncontrolled
hypertension) should be advised to withhold sexual activity until the medical condition improves.
Infertility is one of the presentations for patients with Klinefelter’s syndrome (47XXY). This
accounts for up to 10 per cent of non-obstructive azoospermia. This was originally described as
having a triad of gynaecomastia, hypergonadotrophic hypogonadism and infertility. It is often
presented with delayed puberty in men with a tall stature, narrow shoulders and shorter torso.
Clinical examination often reveals small-volume testes.
Infertility may be dened on the basis of sperm counts with oligospermia or azoospermia (which
may be obstructive or non-obstructive).
Obstructive azoospermia is associated with a normal testicular biopsy. Non-obstructive
azoospermia is often associated with maturation arrest.
Sperm retrieval and assisted reproduction techniques are commonly used to treat infertility.
Penile growths are usually squamous cell cancers of the penis.
This is managed by biopsy and radical excision of the penile lesion.
Redness and ulceration on the penis need to be examined and biopsied to rule out underlying
malignancy.
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