Download Urology Primer

Urology Primer
TOPIC
Page
1.
Quick Referral Guide: Indications for Urology Referrals
2
2.
Bladder Outlet Obstruction/Prostatism
4
3.
Hematuria
6
4.
Erectile Dysfunction
7
5.
Urinary Incontinence
8
6.
Prostate Cancer
9
7.
Prostatitis
12
8.
Renal Calculi
9.
Urinary Tract Infection
13
14
10. Scrotal Masses
15
11. Circumcision
16
12. Testicular Torsion
17
13. Orchalgia
18
14. Appendix: AUA Scoring System
19
Urology primer -
1. Indications for Referral to Urology
1. Bladder Outlet Obstruction
1. Moderate to severe obstructive and/or irritative symptoms that interfere with the
quality of life. Are the symptoms severe enough that the patient would want to take
chronic medications or consider surgery on the prostate to relieve the symptoms? Is
the AUA Symptom Score greater than 15?
2. Moderate to severe symptoms with post-void residual (PVR) 25% of bladder capacity or
greater than 100cc – noted on imaging studies, when available.
3. Prostatism associated with a urinary tract infection
4. Hydronephrosis
5. Bladder calculi
6. Obstructive symptoms associated with urinary incontinence
7. Hematuria (see topic 2)
2. Hematuria
Urological consultation should be obtained for a patient with hematuria once a UTI has been
excluded or if the hematuria persists after as UTI has been appropriately treated.
3. Erectile Dysfunction
This condition can be treated initially by the PCP and a referral to Urology clinic is not
necessary. Please do not refer Erectile Dysfunction to Urology at ACMC.
4. Urinary Incontinence
Overflow incontinence should be referred to urology. Stress and Urge incontinence should be
managed in primary care. For women, the Gynecology service may be helpful.
5. Prostate Cancer Screening
1. Abnormal prostate exam in a male less than 75 years of age
2. PSA >10 in a male under the age of 75
6. Prostatitis
Refer treatment failures to Urology.
7. Renal Calculi
1.
2.
3.
4.
Recurrent calculi
Obstructing/symptomatic stone that has not passed in 2-3 weeks
Residual renal calculi or staghorn calculi
Obstructing stone > 4mm in diameter
2
Urology primer -
3
5. Recurrent UTI
6. History of renal anomaly (solitary kidney, duplicated ureter, horsehoe kidney) or prior
urological surgery.
8. Urinary Tract Infections
1.
2.
3.
4.
History of urinary calculi
Persistent hematuria (gross or microscopic) when uninfected
Bacteria persistence in spite of adequate antibiotic therapy
UTI symptoms in spite of negative cultures, and no other obvious cause
9. Scrotal Masses
If uncertain about your clinical diagnosis, get a scrotal ultrasound. Refer solid masses to
Urology.
10. Circumcision
Adult Circumcision will not be preformed unless medically necessary (e.g. phimosis or recurrent
balanitis)
11. Testicular Torsion
Every torsion should be referred as a Urological Emergency, that is, send to an Emergency
Department and call a Urologist.
Urology primer -
4
2. Bladder Outlet Obstruction (BOO)
Symptoms:
1. Frequency: (normally every 3-5 hours) may increase due to detrusor irritability or
incomplete bladder emptying or both.
2. Nocturia: (awakening at night to urinate, normally once or twice during a night). Same
etiology as for urinary frequency.
3. Nycturia: The passage of increased volumes of urine during the night resulting from the
mobilization of dependent edema or from the use of diuretics.
4. Hesitancy: The interval of time before the urinary stream begins.
5. Intermittent Stream: Stopping and starting the urinary stream.
6. Difficulty stopping micturation/Terminal (post-void) dribbling
7. Decreased force (and caliber) or urinary stream
8. Feeling of incomplete bladder emptying
9. Urgency and urge incontinence
10. Overflow incontinence
Quantifying the symptoms: see AUA Symptom Score
Differential Diagnosis:
1. Benign prostatic hyperplasia-BPH/Prostatism
2. Prostate cancer-see discussion in this Primer (topic 5)
3. Urethreal obstruction-history of prior instrumentation, catheterization, trauma or STD
4. Inflammatory/Infectious conditions-cystitis, TB, prior pelvic radiation, bladder cancer
5. Impaired detrusor contractility- history of neurological disease, prescribed and OTC Rx
most commonly the anti-histamines, decongestants, tricyclic antidepressants, ETOH).
6. Prostatitis/Prostatodynia-see discussion in this Primer (topic 6)
Physical Examination:
1. Peripheral edema and signs of renal failure
2. Abdomen-distended bladder, sense of urgency during suprapubic palpation
3. Digital rectal examination (DRE)
Estimating prostate size
Normal
20 gm
chestnut
1+
25 gm
plum
2+
30-40 gm
lemon
3+
50-70 gm
orange
4+
70+ gm
small grapefruit
Urology primer -
Texture
Normal: Feels like the thenar eminence
Abnormal (nodule): Feels like a knuckle
Natural history of bladder neck obstruction secondary to BPH:
30-60%-spontaneous symptomatic improvement
20-50%-subjective worsening of symptoms
05-20%-risk of developing acute urinary retention
Indications for Urological referral:
1. Moderate to severe obstructive and/or irratative symptoms that interfere with the
quality of life. Are the symptoms severe enough that the patient would want to take
chronic medications or consider surgery on the prostate to relieve the symptoms? Is
the AUA Symptom Score greater than 15?
2. Moderate to severe symptoms with post-void residual (PVR) 25% of bladder capacity or
greater than 100cc – noted on imaging studies, when available.
3. Prostatism associated with a urinary tract infection
4. Hydronephrosis due to BPH
5. Bladder calculi
6. Obstructive symptoms associated with urinary incontinence
7. Hematuria (see topic 3)
Try alpha antagonists (Terazosin, Flomax, Cardura) prior to Urological consultation:
Start with:
Hytrin 1 mg qhs then after 3 days increase to 2 mg qhs
Cardura 2 mg qhs then after 3 days increase to 4 g qhs
Flomax 0.4 mg qam
Obtain the following prior to Urological consultation:
1. UA/UC (per protocol)
2. Serum creatinine
3. AUA Symptoms Score
5
Urology primer -
3. Hematuria
Definition: Blood in the urine
Types of Hematuria:
 Microscopic (microhematuria – MH) - >5 RBC’ss per hpf,
 Gross Hematuria (GH) – blood you can see (tea to red colored)
 Heme + by dipstick is not enough. Obtain a microscopic analysis for RBCs
Etiology:
Stones
Trauma/Sports
Infection
Inflammation
Medications Hematologic disease
Tumors of GU tract
Renal (interstitial) disease
Idiopathic
Background:
 Microscopic hematuria is common (seen in approximately 15% of the general
Population.
 Hematuria can be intermittent even if associated with significant urological disease.
 Smoking has an extremely strong association with bladder (transitional cell) cancer.
 Significant urological lesions (those needing treatment) are found in 5-10% of patients
with microscopic hematuria and in 15-20% of patients with gross hematuria.
 Urological consultation should be obtained for a patient with hematuria once a UTI has
been excluded or if the hematuria persists after as UTI has been appropriately treated.
Obtain the following prior to Urological consultation:
1. At least 2 consecutive UA/Microscopic analysis performed 2 weeks apart in a lab to
assess for microscopic hematuria. Dipstick UA is not sufficient.
2. Serum Creatinine
3. Imaging of the upper urinary tract: Contrast CT
4. Renal ultrasound and KUB if allergic to contrast or increased creatinine.
5. Please inform the patient that cystoscopy may be performed at the time of the
Urological consultation.
6
Urology primer -
7
4. Impotence / Erectile Dysfunction
This condition can be treated initially by the PCP and a referral to Urology clinic is not
necessary.
Definition: The inability to attain and/or sustain an erection adequate for sexual intercourse.
TYPES
Psychogenic impotence:




Related to anxiety and/or stress preventing normal sexual function.
A clue to this diagnosis is history of normal nocturnal or morning erections.
Psychogenic impotence is likely in the absence of underlying medical conditions or drugs
which can affect erections.
Prior to trying empiric therapy, it is reasonable to try one of the following:
o a book titled, Male Sexuality, by Bernie Zibergeld
o Mental health referral
Organic Impotence:



May be subdivided into endocrine, vasculogenic, neurogenic, or drug related.
Evaluation included urologic specific history and physical exam.
A serum testosterone is indicated in only those who complain of decreased libido or
who have bilateral or atrophic testicles. If serum testosterone is low, a pooled serum
testosterone (PST) should be obtained. If PST is low, then consider Endocrinology
consultation. Use of testosterone therapy can cause accelerated progression of both
benign and neoplastic growth of the prostate. If it is used, a patient must be made
aware of these risks.
Treatment:



Continue to treat underlying conditions such as diabetes, tobacco use and hypertension.
Treatment is mainly empiric. We recommend Viagra with a starting dose of 50 mg taken
an hour prior to intercourse. Patients must not be taking nitrates or alpha blockers.
Patients also need to be told to review potential side effects with their pharmacist and
that it is not a covered medication.
The vacuum erection device costs approximately $160. The vacuum erection device is
effective in treating ALL types of impotency and produces satisfactory erections in 80%
of men. Problems with the device can be referred directly to the supplier’s 1-800 phone
number. Other treatments are available to patients include MUSE (prostaglandin
Urology primer -
urethral suppositories), intracavernosal injection of prostaglandin and implants
(surgery).
Suggested treatment protocol for impotence:
1.
2.
3.
4.
5.
Rule out/treat diabetes
Encourage cessation of smoking and reducing alcohol consumption
Optimize anti-hypertension medications
Offer vacuum erection or phosphodiesterase inhibitor
Patients with premature ejaculation or anorgasmia should be treated by PCP.
8
Urology primer -
9
5. Urinary Incontinence
Definition: Involuntary loss of urine
Classification:




Stress Urinary Incontinence (SUI): Incontinence associated with abdominal/pelvic
stress, straining, or valsalva due to the loss of urethral and bladder support. SUI occurs
most frequently in postmenopausal, multiparous women.
Urge Incontinence: Incontinence due to the bladder contracting without the patients
intention to void. It is commonly associated with neurological diseases such as multiple
sclerosis, Parkinson’s disease, spinal cord injury, myelodysplasia, stroke, cerebral palsy,
and CNS tumor, but most frequently occurs due to overactive bladder without an
apparent cause. In men, the most common cause is bladder outlet obstruction. Urge
incontinence can occur at any age and is often a self-limiting process in those patients
with an obvious cause.
Mixed Incontinence: Many women have both stress and urge incontinence. Usually one
form of incontinence predominates in terms of causing the most distress and will dictate
what form of treatment will be selected.
Overflow Incontinence: Occurs when a patient’s bladder no longer contracts so urine
simply “pours over the top of the dam”. It can occur secondary to other medical
conditions such as diabetes, spinal cord injury and myelodysplasia but is very often
acquired through infrequent/inadequate voiding leading to bladder decompensation. It
can also be precipitated by medications with anticholinergic properties (antihistamines,
tricyclic antidepressants, etc…)
Treatment:
Stress incontinence:
1. Kegel’s exercises to strengthen the pubococcygeus muscle.
2. Alpha agonists like Sudafed.
3. Referral for surgery if nonsurgical measures fail.
Urge incontinence:
Treatment is pharmacological with antimuscarinic agents like Ditropan, Detrol etc
Overflow incontinence should be referred to urology.
Urology primer - 10
6. Prostate Cancer Screening
Recommendation:
“Rather than screening all men for prostate cancer as a matter of routine,
physicians should describe the potential benefits and known harms of screening,
diagnosis, and treatment; listen to the patient's concerns; and then individualize
the decision to screen.” (American College of Physicians)
Recommendations for specific modes of screening:
For men over age 75, there is no need for routine prostate evaluation in absence of significant
symptoms.
1. Digital Rectal Exam (DRE): A digital rectal examination can be used to assess the
prostate gland in male patients over the age of 50.
a. There is no need for routine prostate evaluation in asymptomatic men over age
75.
b. For men below age 75 with abnormal prostate exams (nodules, induration, or
asymmetry), refer to Urology.
2. PSA: If after individualized risk/benefit discussion, the patient and physician decide
PSA is appropriate, the following guidelines should be followed
a. There is no role for obtaining a free PSA in primary screening. The free PSA is
helpful for patients who have had a negative biopsy, with a PSA in 4-10 range, to
determine whether another biopsy would be appropriate.
b. No PSA testing should occur within:
i. 48 hrs of digital prostate exam,
ii. 8 weeks after treatment of an episode of acute prostatitis or cystoscopy,
etc.
c. Men with mild-moderate obstructive symptoms and no mass or asymmetry,
refer to 2a.
d. For a normal exam and PSA results between 4-10, recheck after 8 weeks, before
sending for consult. If the second recheck is below 4, do not refer. Recheck PSA
in 12 months
e. For men with obstructive symptoms and moderately enlarged prostate, but no
palpable mass, and PSA between 4-10, see 2a.
f. For a single result above 10 for men under the age of 75, referral to Urology is
appropriate.
Urology primer - 11
Discussion and Data for Use of PSA
Other causes of elevated PSA:
1. Benign prostatic hyperplasia
2. Acute prostatitis (wait 8 weeks after treatment to draw PSA)
3. Prostate biopsy
4. Cystoscopy
5. TURP
6. Urinary retention
7. Ejaculation
8. Digital rectal examination
9. Perineal trauma
10. Prostatic infarction

PSA measurements have considerable short-term variability

Roughly 70% of patients with an elevated PSA level between 4 and 10 will have a
negative prostate biopsy. (source: American Urological Association)
“The use of PSA testing for the early detection of prostate cancer remains
controversial, owing to its biological variability, high prevalence, and the strong
evidence for over diagnosis and over treatment.” ( Prostate Specific Antigen Best
Practice Statement: 2009 Update, American Urological Association)
“ Major scientific or medical organizations, including the American Cancer
Society (ACS), US Preventive Services Task Force (USPSTF), American College
of Physicians (ACP), National Cancer Institute (NCI), American Academy of
Family Physicians (AAFP), and American College of Preventive Medicine
(ACPM) do not support routine testing for prostate cancer at this time.
These organizations (the ACS, AUA, ACP, NCI, AAFP, ACPM, and the
USPSTF) recommend that health care professionals discuss the possible benefits,
side effects, and questions about early prostate cancer detection and treatment so
that men can make informed decisions taking into account their own situation and
risk.” (source: American Cancer Society)
How useful is a PSA for prostate cancer screening?
Sensitivity: 70-80%
Specificity: 60-70%
Urology primer - 12
If you chose to order a PSA for prostate cancer screening:
The American College of Physicians in addition to several other professional societies and task
forces emphasize the need for shared decision making.
“Rather than screening all men for prostate cancer as a matter of routine,
physicians should describe the potential benefits and known harms of screening,
diagnosis, and treatment; listen to the patient's concerns; and then individualize the
decision to screen.” (American College of Physicians)
Risks of prostate biopsy
1.
2.
3.
4.
5.
Physical discomfort
Urinary tract infection, urosepsis
Hematuria, hemospermia
Urinary retention
1% of men have risks which require hospitalization
6. High anxiety level because of high false negative rate
Risks of radical prostatectomy
1.
2.
3.
4.
Operative mortality rate is 0 .5%
urinary incontinence, (15-50%)
sexual dysfunction (20%-70% of patients)
bowel problems.
Risks of external beam radiation
5.
6.
7.
8.
Erectile dysfunction in 20 to 45 percent of men with previously normal erectile function,
Urinary incontinence in 2 to 16 percent of previously continent men,
Bowel dysfunction in 6 to 25 percent of men with previously normal bowel function
Prostatorectal fistula.
More detail as of July 2009
Recommendation
The United States Preventive
Services Task Force Guidelines
Age <75 years, the benefits of screening for prostate cancer are
uncertain and the balance of benefits and harms cannot be determined.
www.ahrq.gov/clinic/uspstfix.htm. Age >75, there is moderate certainty that the harms of screening for
prostate cancer outweigh the benefits.
Found convincing evidence that treatment for prostate cancer detected
by screening causes moderate-to-substantial harms, such as erectile
dysfunction, urinary incontinence, bowel dysfunction, and death. These
harms are especially important because some men with prostate cancer
who are treated may never have developed symptoms related to cancer
Urology primer - 13
during their lifetime.
There is also adequate evidence that the screening process produces at
least small harms, including infection, pain and discomfort associated
with prostate biopsy and psychological effects of false-positive test
results
Canadian Task Force on the
Periodic Health Examination
Recommends against screening for prostate cancer with PSA
American Urologic Association
Prostate cancer screening leads to over detection and overtreatment of
some patients. Therefore, the AUA supports that men be informed of
the risks and benefits of prostate cancer screening before biopsy
www.auanet.org
American Cancer Society
www.cancer.org
American College of Physicians
At this time, routine screening should not be recommended for all men.
Rather, these early findings support the recommendation that men
should make informed decisions based on available information,
discussion with their doctor, and their personal perspectives on the
benefits and side effects of screening and treatment
Rather than screening all men for prostate cancer as a matter of routine,
physicians should describe the potential benefits and known harms of
screening, diagnosis, and treatment; listen to the patient's concerns; and
then individualize the decision to screen
Urology primer - 14
7. Prostatitis
Acute Bacterial:
 Symptoms of chills, perineal and low back pain, dysuria, and occasionally bladder outlet
obstruction. Tender and swollen prostate on digital rectal exam.
Chronic bacterial:
 The most common cause of relapsing UTI in men.
 Irritative voiding symptoms, pelvic pain, bilateral testicular pain.
 Prostate may be tender or normal on DRE.
 IVP and cystoscopy usually not indicated. Results in a relapsing UTI from the same
organism.
 Makes up only 10% of the prostatitises.
Non-bacterial:
 The most common form of prostatitis.
 The symptoms are the same as for bacterial prostatitis through the urine and expressed
prostatic secretion (EPS) cultures are negative.
 The EPS will show WBC’s
 This condition is intermittent and will likely recur. Therefore, patient education is very
important. Helpful remedies include:
1. Increased water consumption
2. Avoid straining when voiding
3. Stress reduction techniques
4. Warm sitz baths
5. NSAIDs
6. Decrease alcohol
7. Decrease coffee
8. Reassurance
Prostatodynia:


The findings and treatment are the same as for non-bacterial prostatitis though the EPS
will show no WBC’s.
Antibiotics are not indicated! Use alpha blockers (Terazosin, Doxazosin, Tamsulosin)
Urology primer - 15
The treatment of bacteria prostatitis:
1. Treat with either Septra DS (BID), or Doxycycline (100mg BID), or Quinolones (Cipro,
Levaquin) for 2 weeks for acture prostatitis and 8 weks for chronic prostatitis. Relapses
are common. Sometimes the therapy needs to be extended to 12 weeks.
2. Warm sitz baths prns.
3. NSAIDs prn
4. Inform the patient that the resolution of symptoms will be gradual, relapses are
common
5. Treat urinary retention as discussed in Bladder Outlet Obstruction.
6. Refer treatment failures to Urology.
Urology primer - 16
8. Renal Calculi
Background:
Up to 12% of the American population will develop renal calculi, causing considerable morbidity
and cost approximately $100,000,000 per year in lost wages and in medical expenses.. 50% of
all patients will have recurrence of renal calculi within 5 years if no preventative measures are
undertaken
Types of calculi (and frequency of occurrence):
Calcium oxalate (75%)
Uric Acid (6%)
Calcium phosphate (9%)
Cystine (2%)
Struvite (8%)
1.
2.
3.
4.
Of the store forming salts in urine, Uric Acid crystallizes the easiest.
Uric Acid crystals often form the nidus around with a a CaOx stone may form.
Only the calcium containing stones are readily seen on plain X-rays.
Struvite stones are formed by urea-splitting bacteria which include Proteus, Kleb,
Pseudomonas, and Staph. Epidermidis but not E. coli.
5. For small stones (<4 mm) and those in the ureter, start an alpha blocker.
Indications for Urological referral:
1.
2.
3.
4.
5.
6.
Recurrent calculi
Obstructing/symptomatic stone that has not passed in 2-3 weeks
Residual renal calculi or staghorn calculi
Obstructing stone > 4mm in diameter
Recurrent UTI
History of renal anomaly (solitary kidney, duplicated ureter, horsehoe kidney) or prior
urological surgery.
Obtain the following prior to Urological consultation:
1. UA. If positive, obtain a culture.
2. Creatinine
3. Current GU imaging (non contrast)
Urology primer - 17
9. Urinary Tract Infections
Urinary tract infections in adult women:
Background:
80-90% of women with dysuria and occasional bacterial reinfections do not require radiologic
evaluation or Urologic referral. Most commonly, these lower urinary tract, nonfebrile,
infections reflect a defect in local host defenses. The aim of therapy is to help the immune
system until the defense barriers can be repaired. Suggestions toward this goal include:
1. Increase fluid consumption
2. Void frequently (ex. every 2-3 hours)
3. Be sure to void after sexual intercourse
4. Consider suppressive antibiotic therapy
5. Consider Estrogen replacement therapy in post-menopausal women
Suppressive antibiotic therapy:
Trimethoprim/sulfamethoxazole
If sulfa allergic then try:
Trimethoprim
or Macrodantin
1 tab (SS) QD for 6 to 12 months
50mg 1 tab QD for 6 to 12 months
50mg 1 cap QD for 6 to 12 months
If the infections are temporally related to intercourse, then the above medications can be
taken post-coitus only.
Urinary tract infections in adult men:
Cystitis:
Evaluation and treatment is as for Prostatitis
Urethritis:
Treat men <35 years of age for Chlamydia STD (ex. Doxycycline 100mg po bid
x 7 days)
Treat men >35 years of age for Postatitis (e. Septra)
Consider treating the partner to avoid re-infection
Indications for Urological referral:
1.
2.
3.
4.
5.
History of urinary calculi
Persistent hematuria (gross or microscopic) when uninfected
Bacteria persistence in spite of adequate antibiotic therapy
UTI symptoms in spite of negative cultures, and no other obvious cause
Children/Infants
Urology primer - 18
10. Scrotal Masses
Background:
The key to evaluating patients with a scrotal mass is to first determine if the mass is fluid filled
versus solid and secondly to decide whether or not emergent Urological consultation is needed.
The history and physical examination plays an important role in helping make this decision.
Transillumination of the scrotum performed in a dark room will detect most hydroceles and
spermatoceles.
Urological non-emergencies:
1. Hydrocele
2. Spermatocele
3. Varicocele
4. Epididymitis/Orchitis
5. Sperm Granuloma
6. Inguinal Hernia
Seen in 6% of full term boys. Don’t refer if the mass is less
than the size of an orange.
Usually located adjacent to superior pole of the testicle.
Do not refer if the mass is less than the size of an orange.
Seen in 9.5% of adult males and 90% occur on the left side.
Frequently refractory to surgery. Treat only if indicated for
infertility.
35-40% of infertile men have varicoceles
Treat as for UTI (topic #8) and with reassurance,
scrotal elevation, warm compresses and NSAIDs.
Severe cases may be Urological emergencies
occur in <1% of vasectomy patients.
These are usually palpated as tender pea- to marble- sized
nodules on the vas deferens. Treat conservatively with
reassurance, elevation, warm compresses and NSAIDs
refer to General Surgery if symptomatic and/or large
Urological emergencies:
1. Testicular cancero:
2. Testicular torsion:
peak incidences - <10 y/o, 20/40 y/o, >60 y/o
Risk – White: 1/500, Black: 1/2000
History of cryptorchidism – found in 7-10% of patients
with cancer
see topic 12 in this Primer
If uncertain about your clinical diagnosis, get a scrotal ultrasound. Refer solid masses to
Urology.
Urology primer - 19
11. Circumcision
Background:
1. Management of the foreskin:
a. The foreskin should never be forcibly retracted from the glans. It will naturally
peel away from the glans as the child grows – usually after 3-4 years.
b. 10% of boys will still have an adherent foreskin at age 3, so be patient.
2. If previous foreskin trauma has resulted in a tight circular scar (phimosis), then
circumcision is indicated.
3. Circumcision done after the newborn period requires general anesthesia.
4. Circumcision is not routinely recommended in adults without medical reasons.
5. Circumcision is sometimes done in men who have recurrent balanitis (often associated
with diabetes mellitus) or phimosis.
Urology primer - 20
12. Testicular Torsion
Types of Torsion:
1. Extravaginal
2. Intravaginal
3. Torsion of the peritesticular appendages
Extravaginal Torsion:
1.
2.
3.
4.
Torsion of all spermatic cord structures at the external ring
Occurs in utero or in the neonatal period
Infants are noted to have a hard but nontender lump and are usually free of distress
Testicular salvage is unlikely so surgery is probably not indicated, but the Urology
service should be consulted.
Intravaginal Torsion: Every torsion should be referred as a Urologic Emergency
1.
2.
3.
4.
5.
6.
7.
8.
Torsion of the testicle and epididymis occurs within the tunica vaginalis.
Usually occurs in adolescents and young adults.
Can occur after sports, after trauma, during sleep, or, in other words, at any time.
Patients often give a past history suggestive of episodes of torsion and spontaneous
detorsion.
On exam, the testicle is usually swollen and very tender. It is often, but not always,
fixed and high riding. The contra-lateral testicle often has the “bell clapper” of
horizontal orientation.
The cremasteric reflex is usually lost in the present of testicular torsion.
The rotation of the testicle during torsion will alter the normal posterio-lateral
orientation of the epididyis relative to the testicle.
Surgical exploration needs to be done expeditiously to preserve testis viability:
 Torsion corrected in <6 hours:
Almost 100% testicular survival
 Torsion corrected in 6-12 hours:
70% testicular survival
 Torsion corrected in >12 hours:
<20% testicular survival
Torsion of peritesticular appendages:
1. The peak incidence is prior to puberty.
2. The patient presents with moderately severe pain which early in is confined to the
upper pole of the testicle but later on can involve the entire scrotum.
3. Swelling is present but ht testicle hangs normally in the scrotum.
4. One may the “Blue Dot” sign – a blue subdermal spot adjacent to the upper pole of the
testicle.
Urology primer - 21
5. Testicular torsion is unlikely if a normal Cremasteric Reflex can be elicited.
6. If the diagnosis is made with certainly, the patient many be managed with pain
medications, ice pack and NSAIDs. The pain and swelling can be bothersome for a week
or more.
7. If the diagnosis is in doubt, emergent Urological consultation is needed.
Urology primer - 22
13. Indiopathic Orchalgia
Background:
Often adults present with long standing history of intermittent pain in testes with no fever, no
pyuria, no bacteriuria.
Scrotal ultrasound – normal:
1. Treatment is reassurance that there are no significant abnormalities in the form of
infection or neoplasm.
2. Prescribe NSAID as needed
3. Do not refer to urology.
Urology primer - 23
Appendix
American Urological Association BPH Symptom Index Questionnaire
Never
Less
than 1
time in
5
Less
About
than half half the
the time time
More
than
half the
time
Almost
always
0 pts
1 point
2 points
3 points
4 points
5 points
never
1 time
2 times
3 times
4 times
5 times
or more
1. Over the past month or so, how
often have you had a sensation of
not emptying your bladder
completely after you finished
urinating?
2. Over the past month or so, how
often have you had to urinate
again less than two hours after
you finished urinating?
3. Over the past month or so, how
often have you found you stopped
and started again several times
when you urinated?
4. Over the past month or so, how
often have you found it difficult to
postpone urination?
5. Over the past month or so, how
often have you had a weak urinary
stream?
6. Over the past month or so, how
often have you had to push or
strain to begin urination?
7. Over the last month, how many
times did you usually get up to
urinate from the time you went to
bed at night until the time you got
up in the morning?