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Acute Conditions in Urology & Scrotal Swellings. Done by: Khadija S. El-Hammasi Supervised by: Dr. Yhaya Elshebiny. Acute Conditions in Urology. Acute Urological conditions: Urolithiasis (Calculus Disease) Trauma of Genitourinary system Infection of Genitourinary system Testicular torsion

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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

Acute Conditions in Urology

  • Acute Urological conditions:

  • Urolithiasis (Calculus Disease)

  • Trauma of Genitourinary system

  • Infection of Genitourinary system

  • Testicular torsion

  • Priapism

  • Phimosis & Paraphimosis

-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)

Urolithiasis (Calculus Disease)

- 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


  • 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


  • 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

  • Investigations:

    • CBC  WBC> 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

    Nephrolithiasis Renal Calculi

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

    Ureteric and Bladder Calculi

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

    Intravenous Urography= IVUNORMAL

    • Minor calyx

    • Major calyx

    • Ureter

    • Bladder

    IVU; Ureteric calculus with minor obstructive changes

    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)


    Further management depends on

    • Response to analgesia

    • Size of the stone

      • <4mm will pass spontaneously.(50% of stone 4-6 mm will pass spontaneously)

      • Stone >6mm requires removal.

    • Presence of infection/obstruction decompression

      • Percutaneous nephrostomy (PCN)

      • DJ stent

    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 >5mm, or in the ureter)

      • Pyelolithiotomy

      • Nephrolithotomy (stones pushed into the renal pelvis)

    Trauma of Genitourinary system

    • Upper tract (kidney & ureter)

    • Lower tract (bladder, urethra, scrotum).

    Kidney Trauma

    • Most common injuries of urinary system.

    • Most injuries occur from car accident or sport

    • >50% occur in males <30 yrs

    • F:M is 1:4

    • Pts with renal abnormalities are more prone to renal injuries


    • Blunt trauma directly to abdomen, flank or back.(80-85%)

    • Penetrating injuries: gunshot& knife wounds

    Classification and Management of Renal Injuries

    Types of Renal Injuries


    • H/O trauma

    • Pain localized to flank or abdomen.

    • Hematuria.

    • Abdominal distention + nausea & vomiting(retroperitoneal bleeding)


    • 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

    Who to investigate?

    • Penetrating injury to the flanks

    • Rapid deceleration injuryrenal vascular injury

    • Blunt injury associated with hematuria, tenderness, rib fracture


  • 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.

  • Arteriogram following blunt abdominal trauma shows acute renal artery thrombosis of left kidney.

    Contrast Enhanced CT:Renal Laceration

    Small perirenal hematoma

    Renal laceration


    • 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)

    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


    • Fever (post operatively)

    • Flank & lower abdominal pain

    • Nausea & vomiting.

    • Anuria ( post operative bilateral ureteral injury).


    ▪Signs of acute peritonitis may be present due to urinary extravasations into the peritoneal cavity.


    ▪Catheterization: microscopic heamaturia

    ▪Excretory urography (IVU): delayed excretion of contrast due to hydronephrosis.

    ▪U/S: detect hydroureter or urinary extravasation.

    ▪CT scan


    ▪Immediate re-exploration & repair.


    Stab wound of right ureter shows

    extravasation on intravenous urogram.


    • 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



    • History, examination

    • KUB

    • U/S

    • IVU

    • CT

    • Observation

    • PCN

    • DJ stenting

    • Treat the undelyig cause

    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


    • 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.


    • Signs of shock.

    • Lower abdominal & suprapubic tenderness

    • Palpable mass (in case of pelvic hematoma).


    • 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

    Contrast Enhanced CT: Traumatic Urinary Bladder Injury

    Rupture of bladder with

    extravasation of urine intothe peritoneal cavity

    Cystogram demonstrating extravastion


    • 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

    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

    • 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

    • 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

    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

    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


      -Tender enlarged testis.

    • Investigation:


      - CT scan

    • Treatment:

      -Bed rest.

      -Surgical exploration may be require to evacuate hematocele & repair a split in the tunica albuginea.

    Genitourinary Infection






    *Risk Factors:

    -Vesicoureteric reflux


    -Neurogenic bladder




    -Bacterial infection of one or both kidneys.

    -Most common organism is E-coli.


    1.Loin pain

    2.Dysuria & Frequency

    3.Fever & rigors

    -Lab findings:


    2.pyuria, bacteruria & microscopic


    3.>100,000 colonies/ml in urine culture


    Right kidney is markedly enlarged andhas a wedge-shaped area of low attenuation

    *Radiological findings:

    -IVU  renal enlargement

    -U/S  dilated collecting system from obstruction, presence of urinary stones or renal abscess

    - CT scan


    -I.V Abx +/- nephrostomy


    -Common organism is E-coli.

    -Bladder infection


    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


    -Commonly in young males

    -Common organism is E-coli, Pseudomonas

    -Sigh & Symptoms:


    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


    • 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.

    • 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

    • 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


    -Persistent, painful erection.



    2. Leukemia, sickle cell dx

    3.Pelvic malignancy

    4.Pt on hemodialysis


    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


    • 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.

    • 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.

    • 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.


    • 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:


      • Under 40 years old chalmydia trachomatis & gonorrhea

      • In old pt enterococci, E.coli


      • Follow recurrent acute attacks

      • TB


    • 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


    • 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)


    • CBC ,Leukocytosis

    • MSU

    • U/S & doplar


    • Bed rest

    • Analgesia

    • Scrotal support

    • Broad spectrum Ab (ciprofloxacin)

      **The swelling may take as long as 2 months to resolve

    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.


    • pain in the scrotum &groin:

    • Sever

    • Sudden onset

    • Radiating to the lower abdomen

    • Associated with vomiting

    • May follow strain, lifting, exercise, or masturbation


    • Swollen testis

    • Tender

    • Drawn up to the groin


    • 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.


    • If the testis is infarcted, it should be removed

    Scrotal Swellings


    • A collection of serous fluid in the tunica vaginalis


      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

    • Congenital hydrocele: processus vaginalis is patent & connects to the peritoneal cavity. In children <3yrs

    • 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


    • 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

    • Don’t affect fertility


    often bilateral

    Can “get above it”

    Testes cannot be felt separately



    Fluid thrill

    Dull to percussion

    Not campressible or pulsatial

    Can’t 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

    U/S of hydrocele

    • Done to exclude testicular tumor or epididymitits


    • 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

    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)


    • Over age of 40 years

    • Scrotal swelling (as if having a 3rd testis)

    • Painless

    • Often multiple, bilateral

    • Enlarge slowly

    • Doesn’t affect fertility (maybe after surgical removal)


    • 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

    • Can’t be reduced

    • Transilluminates if contains clear fluid i.e Epididymal cyst (spermatocele; sometime depend on density of the fluid)

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




    • None if asymptomatic

    • But if large & interfere with walking:

      • Aspiration may help

      • Excision for large cysts; this may affect fertility of the testis


    • 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

    Testicular tumors

    • Commonest malignancy in men < 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


    • 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


    • 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).


    • US testis

    • CXR  mets

    • Tumor markers :AFP (yolk-sac cell), βHCG (trophoblastic cells).

    • CT scan abdomen and chest to identify lymph nodes and pulmonary mets


    • Explore testis through an inguinal incision

    • Orchidectomy

    • Further treatments depends on the type and stage

    DXT=deep x-ray therapy, RPLND=retroperitoneal lymph node dissection


    • 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


    • Varicose veins in the scrotum on standing. Disappear on lying down

    • Heavy or dragging sensation in scrotum

    • Aching pain

    • Bilateral varicoceles may case subfertility


      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

    U/s PIC


    • 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

    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


    • 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


    • Can’t “get above it”

    • There is a cough impulse

    • Reducible


    • Herniotomy& Herniorrhaphy (excision of the sac &repair of the defect) in adult By:

    • Lichtenstein repair (tension free mesh repair)

    • Shouldice repair


    • 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

  • investigations

    • CBC WBC

    • MSU for culture and sensitivity

    • Tumor markers if indicated

    • U/S ± doplar

    • CT if indicated tumor


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