Testicular Torsion

Swc.'Ik ri testis,, overlying erythema,.positive, urinalysis, nrethral discharge, urtitbriiis, prostatitis

Testej; may be elevated into the mgttmai cânal; sv.il! ¡11;;

Swc.'Ik ri testis,, overlying erythema,.positive, urinalysis, nrethral discharge, urtitbriiis, prostatitis

Pjvliiis-Stgri Treatment ■

Pain stays, the same or worsens with testicular elevation . Puiii li&TCMv with tffiliciikir iJeyfltion

Inimdwle stugwy to salvage testis; orchiopexy of .Antibiotics* "

both testes

Pjvliiis-Stgri Treatment ■

Pain stays, the same or worsens with testicular elevation . Puiii li&TCMv with tffiliciikir iJeyfltion

Inimdwle stugwy to salvage testis; orchiopexy of .Antibiotics* "

both testes

* In men '< S.0,_epididymitis is commonly due; to a sexually uausiuiticd disease (chlamydial infoctiun, gonorrhea); treat aisordljigly. In ■ roien > 50, it is commonly due tciTirinary tract infection bugs; w«at with frimtalu^wira-suHkmrtUoxi/.ok or ciprofloxacin.

* In men '< S.0,_epididymitis is commonly due; to a sexually uausiuiticd disease (chlamydial infoctiun, gonorrhea); treat aisordljigly. In ■ roien > 50, it is commonly due tciTirinary tract infection bugs; w«at with frimtalu^wira-suHkmrtUoxi/.ok or ciprofloxacin.

Testicular cancer: usually presents as a painless mass in a young man (age 20—40).The main risk factor is cryptorchidism. Roughly 90% are germ cell tumors, the most common being seminoma. Treatment generally consists of orchiectomy and radiation . If disease is widespread , use chemotherapy. Alpha-fetoprotein is a tumor marker lor yolk sac tumors, whereas human chorionic gonadotropin is a marker for choriocarcinoma. Leydig cell tumors may secrete an drogens and cause precocious puberty.

Note: Remember mumps as a cause of orchitis (painful, swollen testis, usually unilateral, in a post pubertal male). The best treatment is prophylactic (immunization). Mumps almost never causes sterility because it is usually unilateral.

Benign prostatic hypertrophy (BPH):

1. Symptoms: urinary hesitancy, interrnittency, terminal dribbling, decreased size and force of stream, sensation of incomplete emptying, nocturia, urgency, dysuria, frequency.

2. BPH may result in urinary retention, urinary tract infections, hydronephrosis, and even kidney damage or failure in severe cases.

3. Drug therapy is started when the patient becomes symptomatic. Options include alpha-one blockade (prazosin, terazosin, doxazosin) and antiandrogetis (gonadotropin releasing hormone analogs, ilutamide, finasteride).

4. Transurethral resection of the prostate (TURP) is used for more advanced cases, espe dally with repeated urinary tract infections, urinary retention, and hydronephrosis or kidney damage due to reflux. Prostatectomy also may be used but is a more complicated operation.

Note: Wit h acute urinary retention (pain, palpation of full bladder on abdominal exam, history of BPH, no urination in past 24 hours), the first step is to empty the bladder. If you cannot pass a regular Foley catheter, do a suprapubic tap. Then address the underlying cause.

Impotence: most commonly caused by vascular problems. Medications are also a common culprit (especially antihypertensives and antidepressants). Diabetes mellitus may be a vascular (increased atherosclerosis) or neurogenic cause of impotence. Remember point and shoot: parasympathetics mediate erection, sympathetics mediate ejaculation. Patients undergoing dialysis also are commonly impotent. The history often gives you a clue if the cause of impotence is psychogenic. Look for a normal pattern of nocturnal erections, selective dysfunction (a patient who has normal erections when masturbating but not with his wife), and stress, anxiety, or fear.

In patients with trauma, look for signs of urethral injury (high riding, ballottable prostate, blood at the urethral meatus, severe pelvic fracture, eccbymosis) before trying to pass a Foley catheter. If any of these signs are present, do not try to pass a Foley catheter until you have gotten a retrograde urethrogram to rule out urethral injury. Urethral injury is a contraiudica tion to a Foley catheter.

Hydrocele vs. varicocele: hydrocele represents a remnant of the processus vaginalis (remember embryology?) and transiHuminates. It generally causes no symptoms and does not require treatment. A varicocele is a dilatation of the pampiniform venous plexus ("bag of worms," usually on the left), does not transilluminate, disappears in the supine position, and may be a cause of male infertility or pain (in which case it is surgically treated).


1. Signs and symptoms include severe flank: pain, which, often radiates to the groin and is colicky in nature; hematuria; and storre on abdominal x- ray (90% of stones radiopaque).

2. 75% of stones are calcium (look for hypercalcemia and hyperparathyroidism; small bowel bypass also increases oxalate absorption and thus calcium stone formation), 15% are struvite/magnesium ammonium-phosphate stones (think of infection), 7% are uric acid stones (look for history of gout or leukemia), and 2% are cystine stones (think of cystinuria),

3. Treat stones with lots of hydration, narcotics for pain, and observation. Most stones pass by themselves. If"not, do lithotripsy, utemsc.opy with stone retrieval, or open surgery (if needed).

Cryptorchidism: arrest of descent of the testicle(s) somewhere between the renal area and the scrotum.The more premature the infant, the greater the likelihood of cryptorchidism.. Many arrested testes eventually descend on their own within the first year. After J year, surgical intervention (orchiopexy) is warranted to attempt to preserve fertility as well as facilitate future testicular exams (because of increased cancer risk). Cryptorchidism is a major risk factor for testicular cancer (40-fold increased risk), and bringing the testis into the scrotum does not alter the increased risk for testicular cancer. The higher the testicle is found (the further away from the scrotum), the higher the risk of developing testicular cancer and the lower the likelihood of retaining fertility.

Note: The right testicular/ovarian vein drains into the inferior vena cava, whereas the left ovar-ian/testicular vein drains into the left renal vein.

Renal transplant: an option for patients with end-stage renal disease, unless they have active infections or other life-threatening conditions (e.g., AIDS, malignancy). Lupus and diabetes me I lit us are not contraindications to transplant. Living, related donors are best (siblings or parents) , especially when 111. A- similar, but cadaveric kidneys are more common because of availability. Before the transplant, perform ABO and lymphocytotoxic (i ll,A) cross -matching.

a A transplanted kidney is placed in the iliac fossa (for easy biopsy access in case of prob lems as well as for technical reasons) ; usually the recipient's kidneys are left in place to reduce morbidity.

^ Unacceptable kidney donors: newborns, age over 60, history of generalized or intraabdominal sepsis, history of disease with possible renal involvement (e.g., diabetes mellitus, hypertension, lupus), and history of malignancy.


1. Hyperacute rejection: preformed cytotoxic antibodies against donor kidney (happens with ABO mismatch as well as other preformed antibodies). Classic picture: surgery is eomplete, vascular clamps are released, and the kidney quickly turns bluish-black.Treat by removing the kidney.

2. Acute rejection: T eel! mediated rejection that presents during first several months with fever, oliguria, weight gain, tenderness and enlargement of the graft, hypertension, and/or renal function lab derangement. Treat by increasing steroids or using antithymo -cyte globulin or other immunosuppressants.

3. Chronic rejection: T-cell- or antibody—mediated . Late cause of renal deterioration presenting with gradual decline in kidney function, proteinuria, and hypertension. Treatment is supportive and not effective, but the graft may last several years before it gives out completely. The patient may be ret.ra.nsp.la.nted with a new kidney.

4. Follow creatinine to assess asymptomatic rejection (more reliable than blood urea nitrogen).

5. Immunosuppressive medications: steroids (inhibit interleukin • I production), cyclosporins (inhibits interleukin-2 production), azathioprine (antineoplastic that is cleaved into mercaptopurine and inhibits DNA/RNA synthesis, which decreases IV cell and'('cell production), antithymocyte globulin (antibody against T cells), and OKT3 (antibody to CD3 receptor on T cells).

6. Cyclosporine causes nephrotoxicity, which can be difficult to distinguish from graft rejection clinically. When in doubt, a percutaneous needle biopsy of the graft should be done if the patient is taking cyclosporine, because the two usually can be distinguished histologically. Renal ultrasound also helps to distinguish between the two. Practically speaking, if you increase the immunosuppressive dose, acute rejection should decrease, whereas cyclosporine toxicity stays the same or worsens.

1. immunosuppression carries the risk of infection (with common as well as the strange bugs that infect patients with AIDS) and increased risk of cancer (especially lymphomas and epithelial cell cancer).

Penile anomalies: hypospadias occurs when the urethra opens on the dorsal side of the penis; epispadias, when the urethra opens on the ventral side of (he penis (also associated with, extrophy of the bladder).Treat both surgically.

Potter's syndrome: bilateral renal agenesis causes oligohydramnios in utero (the fetus swal lows fluid but cannot: excrete it), limb deformities, abnormal fades, and hypoplasia of the lungs. It is generally incompatible with life.

Burns may be thermal, chemical, or electrical. Initial management of ail burns includes lots of IV fluids (use lactated Ringers solution or normal saline if Ringer's solution is not a choice), removal of all clothes and other smoldering items on the body, copious irrigation of chemical burns, and, of course, the ABCs (airways, breathing, circulation). You should have a very low threshold for intubation; use 100% oxygen until significant carboxyhernoglobin from carbon monoxide inhalation is ruled out.

a Electrical burns: most of the destruction is internal and may lead to myoglobinuria, acido sis, and renal failure. Use lots of IV fluids to prevent such complications.'t he immediate, life-threatening risk with electricity exposure or burns (including lightning and putting the finger in an electrical outlet) is cardiac arrhythmias. Get an EKG.

* Chemical burns: alkali burns are worse than acidic burns, because alkali penetrates more deeply. Treat all chemical burns with copious irrigation from the nearest source (e.g., tap water).

Burned skin is much more prone to infection, usually by Staphylococcus Aureus or Pseiniomoiuis sp. (with Pseudomorws sp., look for a fruity smell and/or blue-green color). Prophylactic antibiotics are given topically only. Give tetanus booster to all burn patients unless they received it recently (within the past S years). Severity classification:

1. First-degree burns involve epidermis only (painful, dry, red areas with no blisters). Keep clean.

2. Second degree burns involve epidermis and some dermis (painful and swollen, with blisters and open weeping surfaces). Remove blisters; apply antibiotic ointment (e.g., silver nitrate, silver sulfadiazine, neomycin) and dressing.

3. Third-degree burns involve all layers of the skin, including nerve endings (painless, dry, and charred). Surgical excision of eschar and skin grafting are required. Watch for compartment syndrome; treat with escliarotorny.

Hypothermia: body temperature < 95°E (35°C), usually accompanied by mental status changes and generalized neurologic deficits. If the patient is conscious, use slow rewarming with blankets. If the patient is unconscious, consider immersion in a tub of warm water. It is most important to monitor the EKG for arrhythmias, which are common with hypothermia. You also may see the classic } wave, a small, positive deflection following the QRS complex. Also monitor electrolytes, renal function, and acid -base status.

¡a With frostnip (cold, painful areas of skin, mild) and frostbite (cold, anesthetic areas of skin, more severe), treat with warming of affected areas using warm water (not scalding hot) and generalized warming (e.g., blankets).

a A patient is not considered dead until "warm and dead"; in other words, do not give up re suscitation efforts until the patient has been warmed.

Hyperthermia; may be due to heat stroke. look for history of heat: exposure and high temperature (>104° F).Treat with immediate cooling (wet blankets, ice, cold water). The immediate threats to life are convulsions (which should be treated with diazepam) and cardiovascular collapse. Rule out infection and other classic culprits:

1. Malignant hyperthermia: look for succinylcholine or halothane exposure. Treat with dantrolene.

2. Neuroleptic malignant syndrome: caused by taking an antipsychotic. First, stop the medication. Second, treat with support (especially lots of IV fluids to prevent renal shutdown from rhabdomyolysis) and dantrolene.

3. Drug fever: idiosyncratic reaction to a medication that usually was started, within the past week.

Near-drowning: fresh water is worse than sea water, because fresh water, if aspirated, can cause hypervolemia, electrolyte disturbances, and hemolysis. Intubate such patients if they are unconscious and monitor arterial blood gases if they are conscious. Patients who drown in cold water often do better than those who drown in warm water because of decreased metabolic needs. Death usually results from hypoxia and/or cardiac arrest.

Milestones; there are a million of them, but concentrate on the common ones. The following table gives rough average ages when milestones are achieved.


AC Is*

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