1 Cover the right-hand columns and specify the classic differences between testicular torsion and epididymitis. What imaging test can diagnose and distinguish these two conditions?

Ultrasound is the diagnostic test of choice in the setting of testicular/scrotal pain. It can easily differentiate between these two conditions as well as visualize testicular tumors (which sometimes present with pain, although classically they are painless).

2 How does testicular cancer usually present? Describe the major risk factors, histology, and treatment

Testicular cancer usually presents as a painless testicular mass in a young man (15-35 years old). The main risk factor is cryptorchidism. Roughly 90% are germ cell tumors; the most common type is seminoma. Testicular cancer generally is treated with orchiectomy and radiation; if disease is widespread, use chemotherapy. Alpha-fetoprotein (AFP) is a marker for yolk sac tumors; human chorionic gonadotropin is a marker for choriocarcinoma. Leydig cell tumors may secrete androgens and cause precocious puberty.

3 How is renal cell carcinoma diagnosed and treated?

Painless hematuria (gross or microscopic) is the most typical presenting sign. Patients rarely complain of the classic triad of hematuria, flank pain, and a palpable flank mass. Computed tomography (CT) scan (preferred over intravenous pyelography) is a good initial diagnostic test (Fig. 38-1). Treatment for disease confined to the kidney or with extension limited to renal vein invasion (classic) is surgical resection. With other organ invasion or distant metastatic disease (usually to lung or bone), immunotherapy (e.g., interleukin-2) is the preferred treatment.

4 What is the classic cause of orchitis? How is it treated? Does it usually cause infertility?

Mumps can cause orchitis, which classically presents with a painful, swollen testis in a postpubertal male. The best treatment is prevention (immunization against the mumps virus). Mumps orchitis rarely causes sterility because it is usually unilateral. Epididymo-orchitis is more common and typically caused by spread from adjacent bacterial epididymitis.

5 What are the symptoms and sequelae of benign prostatic hyperplasia (BPH)?

BPH can cause urinary hesitancy, intermittency, terminal dribbling, decreased size and force of the urinary stream, sensation of incomplete emptying, nocturia, urgency, dysuria, and frequency. It may result in acute urinary retention, urinary tract infections, hydronephrosis, and even kidney damage or failure in severe cases.

6 How is BPH treated?

Medical therapy, which is started when the patient becomes symptomatic, includes long-acting alpha₁ blockers (e.g., terazosin, doxazosin, tamsulosin, alfuzosin, silodosin) and 5-alpha-reductase inhibitors (finasteride, dutasteride). Transurethral resection of the prostate (TURP) is used for more advanced cases, especially with repeated urinary tract infections, urosepsis, urinary retention, and/or hydronephrosis or kidney damage caused by reflux. Surgical prostatectomy is used in some patients, but is associated with a higher complication rate.

7 How do you recognize and manage acute urinary retention?

Acute urinary retention generally presents with abdominal pain; palpation of a full, distended bladder on abdominal examination; a history of BPH in men; and a lack of urination in the past 24 hours or longer. The first step is to empty the bladder. If you cannot pass a regular Foley catheter, consider the use of a larger catheter with a firm Coude tip, or alternatively do a suprapubic tap to drain the bladder. Then address the underlying cause—usually BPH, which in this setting is generally treated with TURP.

8 What are the common causes of impotence?

Impotence is caused most commonly by vascular problems and atherosclerosis. Medications are also a common culprit (especially antihypertensive and antidepressant agents). Diabetes can cause impotence through vascular (increased atherosclerosis) or neurogenic (diabetic autonomic neuropathy) compromise. Patients undergoing dialysis are often impotent. Remember “point and shoot”: Parasympathetics mediate erection; sympathetics mediate ejaculation.

The history often gives you a clue if the cause of impotence is psychogenic. Look for a normal pattern of nocturnal erections, selective dysfunction (the patient has normal erections when masturbating but not with his partner), and a history of stress, anxiety, or fear.