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 extending into the scrotum. Sudden severe pain with a high-riding testis and absent cremasteric reflex raises it.
2. Prostatitis, epididymitis and orchitis A more gradual onset with fever, dysuria and a positive cremasteric reflex. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes it worth separating.
3. Torsion of a testicular appendage Localised upper pole pain with a blue dot sign in a younger boy. Sudden severe pain with a high-riding testis and absent cremasteric reflex points to it.
4. Testicular torsion correct Correct. Sudden severe testicular pain with a high-riding testis and absent cremasteric reflex in an adolescent is torsion.
5. Testicular trauma Pain and swelling after an injury. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes the history matter.

The point: Testicular torsion is a surgical emergency in which the testis twists on its cord and loses its blood supply. It is commonest in adolescents and presents with sudden severe unilateral testicular pain, often with nausea and vomiting, sometimes waking the patient from sleep or following minor activity. The signs are a swollen, tender, high-riding testis with a horizontal or abnormal lie and an absent cremasteric reflex. The salvage window is short, around six hours, so torsion is a clinical diagnosis and the patient goes straight to theatre for scrotal exploration; a Doppler ultrasound may support the diagnosis but must never delay surgery when torsion is likely. At operation the testis is untwisted and, if viable, fixed, and the other testis is fixed too because the anatomical predisposition is bilateral. The main differentials are epididymo-orchitis, which is more gradual with fever and a positive cremasteric reflex, and torsion of a testicular appendage, which gives a localised blue dot sign. When in doubt, explore.

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 Pyuria suggests epididymitis rather than torsion. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes it useful.
2. Clinical diagnosis and immediate surgical exploration correct Correct. Torsion is a clinical diagnosis taken straight to theatre; waiting for a Doppler would waste the salvage window.
3. Examination for a blue dot sign Suggests torsion of an appendage. Sudden severe pain with a high-riding testis and absent cremasteric reflex indicates it.
4. Doppler ultrasound only if it does not delay surgery May support the diagnosis but never delays exploration. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes the sequence a rule.
5. Assessment of viability at operation Guides fixation or removal. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes it appropriate.

The point: Testicular torsion is a surgical emergency in which the testis twists on its cord and loses its blood supply. It is commonest in adolescents and presents with sudden severe unilateral testicular pain, often with nausea and vomiting, sometimes waking the patient from sleep or following minor activity. The signs are a swollen, tender, high-riding testis with a horizontal or abnormal lie and an absent cremasteric reflex. The salvage window is short, around six hours, so torsion is a clinical diagnosis and the patient goes straight to theatre for scrotal exploration; a Doppler ultrasound may support the diagnosis but must never delay surgery when torsion is likely. At operation the testis is untwisted and, if viable, fixed, and the other testis is fixed too because the anatomical predisposition is bilateral. The main differentials are epididymo-orchitis, which is more gradual with fever and a positive cremasteric reflex, and torsion of a testicular appendage, which gives a localised blue dot sign. When in doubt, explore.

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 Where the testis cannot be salvaged. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes it conditional.
2. Antibiotics for epididymo-orchitis where that is the diagnosis Where infection rather than torsion is confirmed. Sudden severe pain with a high-riding testis and absent cremasteric reflex redirects it.
3. Conservative management of a torted appendage Analgesia where an appendage rather than the testis has torted. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes it appropriate.
4. Immediate scrotal exploration correct Correct. Immediate exploration is the treatment, within the short window for salvage.
5. Analgesia and preparation for theatre Alongside urgent surgery. Sudden severe pain with a high-riding testis and absent cremasteric reflex makes it supportive.

The point: Testicular torsion is a surgical emergency in which the testis twists on its cord and loses its blood supply. It is commonest in adolescents and presents with sudden severe unilateral testicular pain, often with nausea and vomiting, sometimes waking the patient from sleep or following minor activity. The signs are a swollen, tender, high-riding testis with a horizontal or abnormal lie and an absent cremasteric reflex. The salvage window is short, around six hours, so torsion is a clinical diagnosis and the patient goes straight to theatre for scrotal exploration; a Doppler ultrasound may support the diagnosis but must never delay surgery when torsion is likely. At operation the testis is untwisted and, if viable, fixed, and the other testis is fixed too because the anatomical predisposition is bilateral. The main differentials are epididymo-orchitis, which is more gradual with fever and a positive cremasteric reflex, and torsion of a testicular appendage, which gives a localised blue dot sign. When in doubt, explore.

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