Page 276 - Medicine and Surgery

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272 Chapter 6: Genitourinary system

decreasing the solubility of phosphate. Infection can also Clinical features
be a complication of stones. Characteristically the patient presents with an acutely
tender swollen testis of sudden onset, there may be a
Clinical features history of minor trauma or recent vigorous exercise.
Maybeasymptomaticinearlystages.Later,pain,haema- Nausea and vomiting are common associated symp-
turia and impaired renal function. toms. There may be history of previous self-resolving
episodes of pain, particularly at night in young boys
(can be associated with nocturnal sexual arousal that
Investigations
As for urinary stones. Assess the kidney function with occurs during REM sleep). Examination classically re-
radionuclide imaging. If <10% renal function the kid- veals a red hemiscrotum, with an asymmetrically high,
ney should be removed. If there is >25% function in a swollen testis (pulled up by the shortened, twisted sper-
younger patient many would probably try to preserve matic cord). However, it may be difficult to examine
the kidney. due to pain. The cremasteric response is absent in tor-
sion (stroking or pinching the inside of the thigh should
Management cause the ipsilateral testis to rise), but this response is not
Open surgery, or very slow gradual breaking up of reliable below the age of 30 months or over 12 years.
the calculus using ‘perc-bang’ combination therapy, The main differential is epididymo-orchitis in which
which involves placing a stent from the kidney to the the tenderness may be localised to the epididymis and
bladder for stones to descend, then debulking the stone pain may be relieved by support of the scrotum, but it
with repeated lithotripsy. Nephrectomy is advised for a can be difficult to distinguish particularly as the testis
symptomatic stag horn calculus in a poorly functioning can also swell in this condition.
kidney.
Complications
If surgery is delayed beyond 12–18 hours the blood sup-
Disorders of the male genital ply is compromised and infarction occurs requiring sur-
system gical orchidectomy.

Torsion of the testis Investigations
Diagnosis is clinical and surgery should not be delayed.
Definition However, in dubious cases, colour Doppler USS may be
Twisting of testis on its pedicle is a surgical emergency. performedtolookforbloodflow,ifabsenttorsionisvery
likely.
Age
Most occur in young children and peri-pubertally, less Management
common over 25 years. The scrotum is explored, the twist is reversed and if the
testis is viable both testes are fixed in position as the
Sex
condition is a bilateral defect. If surgical fixation is per-
Male
formed promptly fertility is unimpaired.
Aetiology
Torsion occurs if the testis is insufficiently fixed by its Hydrocele
lower pole to the tunica vaginalis by the gubernaculum
testis, so allowing it to twist. Definition
Collection of fluid within the coverings of the testes.
Pathophysiology
Twisting of the testis on the spermatic cord leads to ve- Incidence/prevalence
nous/haemorrhagic infarction. Common.