Acute Conditions in Urology & Scrotal Swellings

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Acute Conditions in Urology Scrotal Swellings

• Done by Khadija S. El-Hammasi
• Supervised by Dr. Yhaya Elshebiny

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Acute Conditions in Urology

• Acute Urological conditions
• Urolithiasis (Calculus Disease)
• Trauma of Genitourinary system
• Infection of Genitourinary system
• Testicular torsion
• Priapism
• Phimosis Paraphimosis

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Urolithiasis (Calculus Disease)

• -Incidence 1 of the population.
• Causes of calculi formation
• 1.Primary (idiopathic)
• 2.Secondary due to stasis ? Infection
• ?
  Metabolic disorders (cystinuria)
• -Types of the calculi
• 1.Calcium oxalate (75)
• 2. Phosphate (15)
• 3. Urate (5)
• 4.Cystine (2)
• 5. Xanthine pyruvate (rare)

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- Factors predispose to the development of renal
stones? 1.Recent reduction in fluid intake
2. Increased exercise with dehydration
3.Medications that cause hyperuricemia (high uric
acid) 4.History of gout

• Symptoms
• Asymptomatic
• Renal colic is what brings pts to the ER
• a collection of symptoms that occur as the
  stone is in transit from the kidney to the
  bladder. This may result in partial or complete
  urinary obstruction.
• These symptoms include
• Sudden onset of severe colicky pain that
  originates in the flank and may radiate to the
  lower abdomen, groin or testes (labia) depending
  on the site

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Cont

• The pain may be associated with nausea and
  vomiting
• Symptoms of irritative bladder such as increased
  frequency and urgency ?the stone is in the distal
  ureter
• Symptoms of UTI
• Hematuria
• O/E
• Pt is rolling on bed or pacing
• Vitals important to take T. it defines your
  management.
• T is high ?obstructive pyelonephritis ? PCN or
  DJ stent
• Tenderness overlying the stone

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• Investigations
• CBC ? WBCgt 15,000/cm²
• RFT electrolytes. Impaired RFT is a
  contraindication for IVU
• Urine analysis microscopy.
• KUB 90 of stones are radio-opaque. (urate
  cystien stones are radiolucent)
• U/S
• Emergency IVU to detect site of obstruction.
• CT scan
• MRU (in case of pregnant women)
• Radio nuclear study ? To confirm diagnosis
• ? To
  evaluate kidney function

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Nephrolithiasis Renal Calculi

• Only The Radioopaque (i.e. White) calculi are seen

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Ureteric and Bladder Calculi

• Only The Radioopaque (i.e. White) calculi are seen

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Intravenous Urography IVUNORMAL

• Minor calyx
• Major calyx
• Ureter
• Bladder

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IVU Ureteric calculus with minor obstructive
changes
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• Treatment For acute symptoms (renal colic)
• Conservative management
• relive pain e.g. pethidine / NSAID
• admit to hospital ? if persistent colic
• ? fever
• ? Renal failure
• Antispasmodics e.g. desmopressin to inhibit
  uretric peristalsis? relief the renal colic
• bed rest, IV fluid
• collect urine to retrieve calculus for analysis
• check radiograph to asses progress of stones.
• Broad spectrum antibiotic after urine sample is
  obtained. (in case of infection)

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Cont

• Further management depends on
• Response to analgesia
• Size of the stone
• lt4mm will pass spontaneously.(50 of stone 4-6
  mm will pass spontaneously)
• Stone gt6mm requires removal.
• Presence of infection/obstruction ?decompression
• Percutaneous nephrostomy (PCN)
• DJ stent

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• Stone management
• ESWL
• -Kidney ? stones 0.5 2.5 cm /- DJ
  stint.
• -Ureter ? stones 0.5 2.5 cm /- DJ
  stint for stones located in the upper middle
  part of the ureter (possible lower).
• Percutaneous nephrolithotomy
• Uretric stone
• Bladder ? resectoscope sheath, broken up with
  forceps and washed out
• Open surgery
• Ureterolithotomy( stone gt5mm, or in the ureter)
• Pyelolithiotomy
• Nephrolithotomy (stones pushed into the renal
  pelvis)

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Trauma of Genitourinary system

• Upper tract (kidney ureter)
• Lower tract (bladder, urethra, scrotum).

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Kidney Trauma

• Most common injuries of urinary system.
• Most injuries occur from car accident or sport
• gt50 occur in males lt30 yrs
• FM is 14
• Pts with renal abnormalities are more prone to
  renal injuries
• Causes
• Blunt trauma directly to abdomen, flank or
  back.(80-85)
• Penetrating injuries gunshot knife wounds

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Classification and Management of Renal Injuries

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Types of Renal Injuries
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• History
• H/O trauma
• Pain localized to flank or abdomen.
• Hematuria.
• Abdominal distention nausea
  vomiting(retroperitoneal bleeding)
• O/E
• Vitals low BP rapid pulse ?Shock
• Bruising over the ribs posteriorly, evidence of
  penetrating injury
• Lower rib fractures.
• Diffuse abdominal tenderness and guarding.
• Mass (represent retroperitoneal hematoma or
  urinary extravasations).
• Exclude pneumothorax or bleeding into the chest
  and peritoneum

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• Who to investigate?
• Penetrating injury to the flanks
• Rapid deceleration injury?renal vascular injury
• Blunt injury associated with hematuria,
  tenderness, rib fracture
• Investigations
• CBC ? dropping Hb? bleeding
• Cross matching
• Urine analysis
• RFT ? IVU is needed
• X-ray.
• U/S
• CT ? the gold standard (adequately stage 85 of
  renal injuries).
• Excretory urograph (IVU)? in case of emergency
• Arteriography detect arterial thrombosis
  avulsion of renal pedicle.

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Arteriogram following blunt abdominal trauma
shows acute renal artery thrombosis of left
kidney.
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Contrast Enhanced CTRenal Laceration
Small perirenal hematoma
Renal laceration
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• managenent
• Patient is not stable
• Emergency measure
• Treat shock hemorrhage.
• Complete resuscitation evaluation of associated
  injuries.
• Surgery
• Indications Shock, persistent hematuria.
• Can vary from Simple suture of laceration to
  partial or total nephrectomy.
• Patient is stable
• Keep under observation
• Investigate treat accordingly (table)

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Ureteric trauma

• rare
• Causes
• 1. Large pelvic mass that displace the
  ureter laterally.
• 2.Surgical procedure e.g. Gynecological
  procedure in
• female (hysterectomy) Endoscopic
  manipulation of
• ureteral calculus.
• 3.Stap wound
• Symptoms
• Fever (post operatively)
• Flank lower abdominal pain
• Nausea vomiting.
• Anuria ( post operative bilateral ureteral
  injury).

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• Signs
• ?Signs of acute peritonitis may be present due to
  urinary extravasations into the peritoneal
  cavity.
• Investigations
• ?Catheterization microscopic heamaturia
• ?Excretory urography (IVU) delayed excretion of
  contrast due to hydronephrosis.
• ?U/S detect hydroureter or urinary
  extravasation.
• ?CT scan
• Treatment
• ?Immediate re-exploration repair.
• ?Stinting.

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Stab wound of right ureter shows extravasation
on intravenous urogram.
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Anuria

• Absence of urinary output
• Causes
• Underperfusion of the kidneys e.g. shock or
  dehydration
• Sepsis
• Bilateral ureteric obsruction
• Tumors of the pelvis or retro peritoneum ?
  chronic
• Retroperitonial obstruction ? progressive
• Bilateral stones causing obstruction ? acute

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Cont

• Management
• History, examination
• KUB
• U/S
• IVU
• CT
• Observation
• PCN
• DJ stenting
• Treat the undelyig cause

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Bladder Trauma

• Mostly due to external force like urological
  procedure (bladder tumor)? iatrogenic
• 90 associated with pelvic fracture
• Penetrating injury
• Indirect trauma to the lower abdomen with
  distended kidney
• Trauma to the bladder may lead to intra or
  extraperitonial extravasation

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• History
• H/O lower abdominal trauma.
• H/O alcohol consumption followed by lower
  abdominal trauma
• Patient unable to urinate
• Gross hematuria (with spontaneous voiding)
• Usually pelvic or lower abdominal pain.
• O/E
• Signs of shock.
• Lower abdominal suprapubic tenderness
• Palpable mass (in case of pelvic hematoma).
• Investigations
• X-ray for pelvic fracture.
• IVU to detect any ureteric or kidney injuries or
  bladder leak.
• CT scan
• Cystography detect extraperitoneal extravasation
  of blood urine. This is the procedure of choice
  to R/O bladder injury

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Contrast Enhanced CT Traumatic Urinary Bladder
Injury
Rupture of bladder with extravasation of urine
intothe peritoneal cavity
Cystogram demonstrating extravastion
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• Treatment
• Emergency measure treat shock hemorrhage
• Conservative catheter drainage
• The majority of cases will require surgical
  intervention
• Intraperitoneal extravasation
• Laparoscopy or laparotomy (lower midline
  abdominal incision.)
• Suction of urine and irrigation
• Repair
• Urethral and Suprapubic catheters are inserted to
  ensure complete urinary drainage control of
  bleeding.
• 1-2 weeks later a cystogram is done
• Extraperitoneal extravasation
• Repair the tear
• SPC and urethral cath
• Drainage Cath in the retropubic space. Left for
  10- 14 days

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Acute Urinary Retention

• Inability to empty the bladder
• 10 of pt with BPH present with acute urinary
  retention
• Causes
• In males the most common cause is prostatic
  obstruction that may be precipitated by alcohol,
  anticholinergic drugs, constipation, infection,
  anaesthetics
• Urethral stricture
• Bladder tumor, stone or any other cause of
  bladder outlet obstruction
• In a female, a gravid uterus may lead to
  retention

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• History
• Inability to pass urine for several hours
• Severe suprapubic pain
• Abdominal distension
• /- H/O BPH
• D/H anticholinergics, alcohol
• H/O UTI, constipation
• O/E
• Pt unable to stay still
• Bladder may be palpable
• PR enlarged prostate that is pushed down ?size
  may be exaggerated
• Refluxes of lower limb and perianal sensation?
  R/O prolapsed lumber disc

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• Investigations
• CBC ?WBC (UTI, prostatitis)
• MSU ?UTI
• PSA? Ca or prostatitis
• U/S? bladder and prostate
• X-ray
• IVU ? filling defect
• Treatment
• Aim is to relieve the pain
• Analgesia, short course of alpha adrenergic
  blocker
• Catheterization urethral or SPC
• After 4-7 days, trail to void at the hospital
• Treat the underlying condition
• BPH
• Voiding? medication
• Unable to void? TURP

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Urethral Injury

• The most common cause is iatrogenic (catheter,
  cystoscopy)
• 30 pelvic fractures are associated with urethral
  injuries
• Not a common injury. More in in males. Rare in
  females
• If a urethral injury is suspected, DO NOT insert
  a urethral cath
• Retrograde urethrogram is the investigation of
  choice. It delineates the severity of the injury
• If there is extravasation, SPC is inserted for
  3weeks. A cystourethrogram is then done to ensure
  resolution

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Scrotal trauma

• This is usually occurs in sport injuries or
  violence.
• Trauma maybe result in bleeding into the layer of
  tunica vaginalis resulting in hematocele.
• Symptoms signs
• -Sever pain
• -Scrotal swelling /- ruptured
  testis
• -Bruising
• -Tender enlarged testis.
• Investigation
• -U.S.
• - CT scan
• Treatment
• -Bed rest.
• -Surgical exploration may be require to
  evacuate hematocele repair a split in the
  tunica albuginea.

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Genitourinary Infection

• Include
• -Pyelonephritis
• -Cystitis
• -Prostatitis
• -Epedidemo-orchitis
• Risk Factors
• -Vesicoureteric reflux
• -Obstruction
• -Neurogenic bladder
• -Pregnancy
• -DM

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Pyelonephritis

• -Bacterial infection of one or both kidneys.
• -Most common organism is E-coli.
• -Symptoms
• 1.Loin pain
• 2.Dysuria Frequency
• 3.Fever rigors
• -Lab findings
• 1.Leukocytosis
• 2.pyuria, bacteruria microscopic
  
• Hematouria
• 3.gt100,000 colonies/ml in urine culture

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CT  
Right kidney is markedly enlarged andhas a
wedge-shaped area of low attenuation
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• Radiological findings
• -IVU ? renal enlargement
• -U/S ? dilated collecting system from
  obstruction, presence of urinary stones or renal
  abscess
• - CT scan
• Tx
• -I.V Abx /- nephrostomy

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Cystitis

• -Common organism is E-coli.
• -Bladder infection
• -Symptoms
• 1.Irritative Sx (Dysuria, frequency urgency)
• 2. Hematuria
• 3. Suprapubic pain tenderness
• -Lab findings
• 1.Pyuria, bacteruria hematuria
• -Radiological investigation is limited to cases
  where renal infection is suspected
• -Tx ? Abx

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Prostatitis

• -Commonly in young males
• -Common organism is E-coli, Pseudomonas
• -Sigh Symptoms
• 1.Fever
• 2.Low back pain, perenial pain
• 3.Bladder irritation outflow obstruction
• 4.Tender, warm, large firm prostate on PR
  examination
• -Lab findings
• 1.Pyuria, bacteruria microscopic hematuria
• Tx ?I.V Abx

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ParaPhimosis

• Paraphimosis occurs when the foreskin has been
  retracted and narrows below the glans,
  constricting the lymphatic drainage and causing
  the glans to swell.
• If not corrected, blood flow in the penis
  becomes impeded by the increasingly constricting
  band of foreskin, which causes further swelling
  of the glans. Because lack of oxygen from the
  reduced blood flow can cause tissue death
  (necrosis)
• paraphimosis is considered a medical emergency
  and requires immediate treatment.

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• Causes
• Bacterial infection (e.g., balanoposthitis)
• Catheterization (i.e., if the foreskin is not
  returned to its original
• position after a urethral catheter is inserted,
  the glans may become swollen, which can initiate
  paraphimosis)
• Poor hygiene
• Swelling-producing injury
• Vigorous sexual intercourse
• Symptoms and Signs
• Inability to urinate (urinary retention)
• Penile pain
• Swollen glans (the shaft of the penis is not
  swollen)
• Redness, Black tissue on the glans (indicates
  necrosis
• Band of retracted foreskin tissue beneath the
  glans
• Tenderness

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• Diagnosis
• Paraphimosis is diagnosed during physical
  examination.
• Treatment
• Injection of hyaluronidase with lidocane followed
  by gentel pressure. This usually results in
  reduction
• Failure ? incision of he constricting band
• Circumcision to prevent reoccurrence

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Priapism

• -Persistent, painful erection.
• -Causes
• 1.Idiopathic
• 2. Leukemia, sickle cell dx
• 3.Pelvic malignancy
• 4.Pt on hemodialysis
• -Tx
• 1.Aspiration of blood from the corpora
  cavernosa
• 2.Anastomosis of the great saphenous vein to
  the engorged corpora cavernosa thus establishing
  venous drainage of the corpora

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Phimosis

• Phimosis is the inability to retract the prepuce
  (foreskin) of penis over the shaft due to a
  narrow opening.Phimosis can be congenital or
  acquired- In acquired phimosis there is
  chronic inflammation of the tip of the penis and
  prepuce (fore skin) or there are adhesions
  between glans prepuce or due to malignancy.
  In congenital causes it is present since birth.
  Phimosis is usually caused by thickening and
  repeated inflammation of the foreskin.     

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• Symptoms of Phimosis ?
•  Inability to retract foreskin.
• Straining during urination.
• Thin stream of urine.
• Recurrent urinary infections.
• Pus from penis - due to belanophosthitis. How
  can we diagnose Phimosis ?From history
  examination On Examination
• Pin hole opening of foreskin
• Difficulty to push back the foreskin over the
  shaft of the penis.
• Balooning of foreskin - A bulge in the tip of
  penis as urine accumulates under the foreskin.

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• How can Phimosis be treated ?Circumcision
• If untreated complications of phimosis can
  occur
• Infected foreskin leads to infection of glans
  also.
• Paraphimosis
• Back pressure due to obstruction of flow of
  urine.
• Meatal Stenosis - narrowing of penile opening.
• Sometimes a cancerous ulcer on glans can cause
  the adhesion to take place. 

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Epididymo-orchitis

• This is primarily an infection of the epididymis,
  but some oedema inflammatory changes spread
  into the testis
• There maybe an associated urinary tract
  infection.
• Types
• Acute
• Under 40 years old ?chalmydia trachomatis
  gonorrhea
• In old pt ?enterococci, E.coli
• Chronic
• Follow recurrent acute attacks
• TB

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• Hisory
• Sever pain (comes quickly-hrs- ,can be relieved
  by scrotal support) swelling in one side of the
  scrotum
• Malaise, fever, sweating loss of appetite
• Symptoms of urinary tract infection
• O/E
• Swelling confined to one side of the scrotum
• Scrotal skin red shiny, four days later become
  bronze in color
• Scrotal skin hot
• Not-tender but the testis epididymis are very
  tender
• Surface of epididymis smooth
• Swelling is fluctuant (secondary hydrocele)

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• Investigation
• CBC ,Leukocytosis
• MSU
• U/S doplar
• Treatment
• Bed rest
• Analgesia
• Scrotal support
• Broad spectrum Ab (ciprofloxacin)
• The swelling may take as long as 2 months to
  resolve

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Testicular torsion

• This is twisting of the testis with interference
  to the arterial blood supply.
• the actual torsion is usually of the spermatic
  cord
• Possible mechanism it is associated with
• Imperfectly descended testis
• High investment of tunica vaginalis with a
  horizontal lie of testis
• Epididymis testis are separated by a mesorchium,
  twisting occurs at the mesorchium.
• The incidence is highest between 10 20 years.

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• Symptoms
• pain in the scrotum groin
• Sever
• Sudden onset
• Radiating to the lower abdomen
• Associated with vomiting
• May follow strain, lifting, exercise, or
  masturbation
• Signs
• Swollen testis
• Tender
• Drawn up to the groin

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• Treatment
• Explore testis as soon as possible (untwisting
  should be carried out within 6 hrs of symptoms).
• Check that it is not irreversibly infarcted.
• Fix it to the scrotal septum.
• The other testis should be fixed at the same
  operation, since it is likely to have abnormal
  position.
• However
• If the testis is infarcted, it should be removed

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Scrotal Swellings
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Hydrocele

• A collection of serous fluid in the tunica
  vaginalis
• Types
• Congenital occurs in infants due to patent
  processus vaginalis ? peritoneal fluid can enter
  the scrotum

• Secondary
• develop rapidly
• small
• lax
• secondary to inflammation, trauma or tumor of
  underling testes
• younger age group(20-40)

• Primary. (idiopathic)
• Develop slowly
• Large
• Hard tense
• No defined cause
• Over 40s

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• Congenital hydrocele processus vaginalis is
  patent connects to the peritoneal cavity. In
  children lt3yrs
• Infentile hydrocele the tunica and processus
  vaginalis are distended to the superficial
  inguinal ring. There is no conection. Occurs in
  all ages
• Hydrocele of the cord swelling near the
  spermatic cord. D/D hernia, lipoma of the cord

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• Symptoms
• Scrotal swelling
• Pain discomfort if its secondary
• Frequent painful micturation if secondary to
  epididymo-orchitis
• Malaise weight loss if secondary to tumor with
  distant metastases
• Dont affect fertility

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• O/E
• often bilateral
• Can get above it
• Testes cannot be felt separately
• Transilluminates
• Fluctuant
• Fluid thrill
• Dull to percussion

• Not campressible or pulsatial
• Cant be reduced
• Normal skin color temp
• Not tender if primary (may be tender if
  secondary)
• Size can be reach up to 10-20cm in diameter
• Surface smooth

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U/S of hydrocele

• Done to exclude testicular tumor or epididymitits

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Treatment

• If congenital hydrocele persists beyond the age
  of 1year, surgical treatment is indicated. This
  involves the division and ligation of the
  processus.
• In an adult with primary hydrocele
• Surgery
• Opening the tunica vaginalis longitudinally
• Emptying hydrocele
• Everting the sac
• Suturing it behind the cord thus obliterating the
  potential space
• Aspiration ? reccurance
• In elderly patient who are not fit for surgery
• Secondary hydrocele ? treat the underlying cause

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Epididymal cyst

• Fluid-filled swellings connected with the
  epididymis.
• If cyst contains clear fluid ,it is called
  epididymal cyst .
• However, if the fluid is grey opaque contains
  few spermatozoa, it is called spermatocele (after
  aspiration)
• Symptoms
• Over age of 40 years
• Scrotal swelling (as if having a 3rd testis)
• Painless
• Often multiple, bilateral
• Enlarge slowly
• Doesnt affect fertility (maybe after surgical
  removal)

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• O/E
• Frequently bilateral
• Lies above slightly behind the testes, the cord
  is felt above it
• Cysts are not tender
• Elongated, measures from few millimeters to
  5-10cm diameter
• Smooth surface
• Testis can be felt separately
• Can get above it
• Fluctuant, fluid thrill, dull to percussion
• Cant be reduced
• Transilluminates if contains clear fluid i.e
  Epididymal cyst (spermatocele sometime depend on
  density of the fluid)

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U/S

• Must be done to confirm your diagnosis R/O
  testicular tumore

spermatocele
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• Treatment
• None if asymptomatic
• But if large interfere with walking
• Aspiration may help
• Excision for large cysts this may affect
  fertility of the testis

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Hematocele

• Blood in the scrotum
• H/O trauma
• Symptoms include severe disomfort with an
  expanding mass
• O/E ecchmosi, swelling, may not palpate the
  testes, no transillumination
• Main concerns are testicular rupture or atrophy
• U/S to confirm
• Surgical exploration and clot evacuation

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Testicular tumors

• Commonest malignancy in men lt 35
• Rare in men of African ancestry and before
  puberty
• Peaks in the early twenties
• 90 arise from germ cells are either
  seminomas(30-40 years) or teratomas(20-30 years)
• 10 are lymphomas, sertoli cell tumors or leydig
  cell tumors
• One in 10 testicular tumors occurs in association
  with maldescent of the testis.
• Prognosis is good particularly if there was no
  lymph node involvement

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• Symptoms
• Painless swelling of the testis, (sometime dull
  aching, dragging pain )(80)
• Heaviness in the scrotum
• Maybe history of trauma ?delays diagnosis
• General malaise, wasting ,loss of appetite
• Abdominal pain if lymph nodes are enlarged
• Swelling of legs caused by lymphatic or venous
  obstruction
• Infertility
• Secondary hydrocele

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• Signs
• can get above it
• Testes can not be felt separately
• Not translucent
• Not fluctuant
• Harder than normal testis
• Dull to percussion ? hydrocele
• If skin is affected, it maybe warm discolored
• Usually not tender
• Irregular, different sizes
• Surface usually smooth (sometime irregular or
  nodular)
• Examine the para-aortic supraclavicular lymph
  nodes for metastasis
• The liver maybe enlarged there maybe sign of
  pulmonary secondaries (collapse, consolidation or
  a pleural effusion).

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• Investigation
• US testis
• CXR ? mets
• Tumor markers AFP (yolk-sac cell), ßHCG
  (trophoblastic cells).
• CT scan ?abdomen and chest to identify lymph
  nodes and pulmonary mets

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• Treatment
• Explore testis through an inguinal incision
• Orchidectomy
• Further treatments depends on the type and stage

DXTdeep x-ray therapy, RPLNDretroperitoneal
lymph node dissection
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Varicocele

• It is a bunch of dilated tortuous veins of the
  pampiniform plexus i.e. (varicose vines in the
  spermatic cord).
• More common on the left side
• 25 of normal men have small symptomless
  varicoceles.
• Causes of varicocele
• Incompetent valve btw the renal and testicular
  veins
• Nephrectomy
• Lt. Renal neoplasm
• Lymphadenopathy

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• Symptoms
• Varicose veins in the scrotum on standing.
  Disappear on lying down
• Heavy or dragging sensation in scrotum
• Aching pain
• Bilateral varicoceles may case subfertility
• O/E
• The pt must be examined standing, not to miss the
  diagnosis
• Vein often visible
• They are also palpable fell like a bag of
  worms
• Affected testis may be smaller more soft

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U/s PIC
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• Treatment
• In Asymptomatic pt ,no treatment is required
• Scrotal support for aching discomfort
• If symptoms fail to settle or there is evidence
  of subfertility there are two options for
  treatment
• Embolization obliteration under radiological
  control (majority)
• Surgery is via an inguinal approach, all
  testicular veins bar on being ligated at the deep
  inguinal ring.
• Microsurgery is used in most cases. Has less
  recurrence rate and better success.
• Embolization is preferred in case of recurrence
  

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Indirect inguinal hernia

• A peritoneal sac protrudes through the deep
  inguinal ring, passes down the inguinal canal,
  may extend as far as the upper pole of the
  testis.
• The defect is congenital is due to persistent
  processus vaginalis
• Symptoms
• Often none (scrotal swelling that can be pushed
  back by the pt.
• Aching dragging sensation in the groin
• Some pt relate the development to an episode of
  straining or lifting

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• Signs
• Cant get above it
• There is a cough impulse
• Reducible
• Treatment
• Herniotomy Herniorrhaphy (excision of the sac
  repair of the defect) in adult By
• Lichtenstein repair (tension free mesh repair)
• Shouldice repair

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History

• Age?tumors (20-40). Rare before puberty
• Torsion usually in teens and children
• Hydrocele in an infant?communicating
• H/o trauma
• Pain?epididymo-orchitis, varicocele, torsion
• Infertility
• Constitutional symp?malignancy
• PSH?varicocele
• SOH? marital status extramarital relation?
  epididymo-orchitis

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investigations

• CBC? WBC
• MSU for culture and sensitivity
• Tumor markers if indicated
• U/S doplar
• CT if indicated? tumor

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