Renal and urology for AMC MCQ

A 14 year old boy wakes with sudden severe pain in his right testis and has vomited. The right testis is swollen, exquisitely tender, lying high and horizontally, and the cremasteric reflex is absent on that side. The pain began about three hours ago. A junior doctor suggests waiting for a Doppler ultrasound before deciding. What is the most likely diagnosis?

1. Inguinal hernia A groin swelling that reaches down into the scrotum. But a sudden severe pain with the testicle sitting high and the normal reflex missing does not point to it.
2. Prostatitis, epididymitis and orchitis A slower start with fever, pain passing urine and a normal reflex. Here, a sudden severe pain with the testicle sitting high and the normal reflex missing points elsewhere.
3. Torsion of a testicular appendage Pain at the top of the testicle with a small blue spot under the skin, in a younger boy. That does not match a sudden severe pain with the testicle sitting high and the normal reflex missing.
4. Testicular torsion correct Correct. Sudden severe testicle pain with the testicle sitting high and the reflex missing, in a teenage boy. This is torsion.
5. Testicular trauma Pain and swelling after an injury. It does not fit a sudden severe pain with the testicle sitting high and the normal reflex missing.

The point: Testicular torsion is a surgical emergency. The testicle twists on its cord and its blood supply is cut off. It happens most in teenage boys. It causes sudden, severe pain in one testicle, often with nausea and vomiting. It can wake the patient from sleep or follow minor activity. The signs are a testicle that is swollen, very tender, sitting higher than usual, and lying sideways or at an odd angle. A normal reflex, where stroking the inner thigh should lift the testicle, is missing. The time to save the testicle is short, around six hours. Because of this, torsion is diagnosed by the signs alone, and the patient goes straight to the operating theatre to look inside the scrotum. An ultrasound with Doppler can support the diagnosis, but it must never delay surgery when torsion looks likely. In the operation, the testicle is untwisted. If it is still healthy, it is stitched in place. The other testicle is stitched in place too, because the same risk of twisting is often present on both sides. The two main conditions that can look similar are epididymo-orchitis, which comes on more slowly with fever and a normal cremasteric reflex, and torsion of a small extra piece of tissue near the testicle, which gives a small blue spot under the skin. If there is any doubt, the surgeon looks inside.

Source: Therapeutic Guidelines (Australia) — Urological: acute scrotum Therapeutic Guidelines (Australia) · tier 3, national formulary

A 14 year old boy wakes with sudden severe pain in his right testis and has vomited. The right testis is swollen, exquisitely tender, lying high and horizontally, and the cremasteric reflex is absent on that side. The pain began about three hours ago. A junior doctor suggests waiting for a Doppler ultrasound before deciding. What is the most appropriate initial investigation?

1. Urinalysis A urine test. Pus in the urine points to epididymitis, not torsion. It does not fit a sudden severe pain with the testicle sitting high and the normal reflex missing.
2. Clinical diagnosis and immediate surgical exploration correct Correct. Torsion is diagnosed by the signs alone and taken straight to theatre. Waiting for a scan would waste the time left to save the testicle.
3. Examination for a blue dot sign Checking for a small blue spot under the skin. This points to a torted appendage, not the whole testicle. But a sudden severe pain with the testicle sitting high and the normal reflex missing does not point to it.
4. Doppler ultrasound only if it does not delay surgery A blood-flow scan that can support the diagnosis, but it must never delay surgery. That does not match a sudden severe pain with the testicle sitting high and the normal reflex missing.
5. Assessment of viability at operation Checking how healthy the testicle looks during the operation. This decides whether it is fixed in place or removed. Here, a sudden severe pain with the testicle sitting high and the normal reflex missing points elsewhere.

The point: Testicular torsion is a surgical emergency. The testicle twists on its cord and its blood supply is cut off. It happens most in teenage boys. It causes sudden, severe pain in one testicle, often with nausea and vomiting. It can wake the patient from sleep or follow minor activity. The signs are a testicle that is swollen, very tender, sitting higher than usual, and lying sideways or at an odd angle. A normal reflex, where stroking the inner thigh should lift the testicle, is missing. The time to save the testicle is short, around six hours. Because of this, torsion is diagnosed by the signs alone, and the patient goes straight to the operating theatre to look inside the scrotum. An ultrasound with Doppler can support the diagnosis, but it must never delay surgery when torsion looks likely. In the operation, the testicle is untwisted. If it is still healthy, it is stitched in place. The other testicle is stitched in place too, because the same risk of twisting is often present on both sides. The two main conditions that can look similar are epididymo-orchitis, which comes on more slowly with fever and a normal cremasteric reflex, and torsion of a small extra piece of tissue near the testicle, which gives a small blue spot under the skin. If there is any doubt, the surgeon looks inside.

Source: Therapeutic Guidelines (Australia) — Urological: acute scrotum Therapeutic Guidelines (Australia) · tier 3, national formulary

A 14 year old boy wakes with sudden severe pain in his right testis and has vomited. The right testis is swollen, exquisitely tender, lying high and horizontally, and the cremasteric reflex is absent on that side. The pain began about three hours ago. A junior doctor suggests waiting for a Doppler ultrasound before deciding. What is the most appropriate next step in management?

1. Orchidectomy if the testis is non-viable Removing the testicle, when it can no longer be saved. Here, a sudden severe pain with the testicle sitting high and the normal reflex missing points elsewhere.
2. Conservative management of a torted appendage Pain relief alone, when a small appendage rather than the whole testicle has twisted. That does not match a sudden severe pain with the testicle sitting high and the normal reflex missing.
3. Do not delay surgery for imaging when torsion is likely Never wait for a scan when torsion looks likely. Delay costs the testicle. But a sudden severe pain with the testicle sitting high and the normal reflex missing does not point to it.
4. Immediate scrotal exploration correct Correct. Surgery straight away is the treatment, within the short window to save the testicle.
5. Antibiotics for epididymo-orchitis where that is the diagnosis Antibiotics, given when it turns out to be infection rather than torsion. It does not fit a sudden severe pain with the testicle sitting high and the normal reflex missing.

The point: Testicular torsion is a surgical emergency. The testicle twists on its cord and its blood supply is cut off. It happens most in teenage boys. It causes sudden, severe pain in one testicle, often with nausea and vomiting. It can wake the patient from sleep or follow minor activity. The signs are a testicle that is swollen, very tender, sitting higher than usual, and lying sideways or at an odd angle. A normal reflex, where stroking the inner thigh should lift the testicle, is missing. The time to save the testicle is short, around six hours. Because of this, torsion is diagnosed by the signs alone, and the patient goes straight to the operating theatre to look inside the scrotum. An ultrasound with Doppler can support the diagnosis, but it must never delay surgery when torsion looks likely. In the operation, the testicle is untwisted. If it is still healthy, it is stitched in place. The other testicle is stitched in place too, because the same risk of twisting is often present on both sides. The two main conditions that can look similar are epididymo-orchitis, which comes on more slowly with fever and a normal cremasteric reflex, and torsion of a small extra piece of tissue near the testicle, which gives a small blue spot under the skin. If there is any doubt, the surgeon looks inside.

Source: Therapeutic Guidelines (Australia) — Urological: acute scrotum Therapeutic Guidelines (Australia) · tier 3, national formulary