Hydrocele – common cause of scrotal swelling

  • Hydrocele is the accumulation of fluid inside the covering of the testis called tunica vaginalis and cause the swelling of scrotum.
  • Hydrocele is present in newborn and disappear at around one year of age.
  • Persistance of fluid inside the scrotum or development at later adult age due to various reasons cause this disease.

Symptoms

  • Painless scrotal swelling
  • Discomfort or heaviness in scrotum
  • Redness or severe pain if fluid inside gets infected

Causes

  • In children, the hydrocele may be due to the peristance of fluid normally present at birth.
  • In adult age, hydrocele is due to various reasons such as testis infection (orchitis), epididymis infection (epididymitis), testis tumor, trauma, after varicocele surgery or other testis surgery.

What are the risks of hydrocele

  • Hydrocele fluid can get infected.
  • Hydrocele can hamper sperm production or the quality of sperms.
  • Swelling can get increased to lead impairement of quality of life or pain in it.

Diagnosis

  • Diagnosis of hydrocele is mainly done by doctor after physical examination.
  • Ultrasound of the scrotum region is done to look for any infection inside or to look for underlying cause lead to the formation of hydrocele.
  • Blood or urine test may be required to rule out infection of other causes of hydrocele.

Treatment

  • In newborns, hydrocele may resolve of its own.
  • Opinion of the doctor for conservative management is required to rule out any underlying testicular cause.
  • In adult age or in baby boys where hydrocele fail to resolve and causing symptoms to the patient, doctor look for any cause that leading to fluid formation. If no such cause found, surgical evacuation of fluid along with removal of fluid forming covering of the testis so as to prevent re-accumulation of fluid. 

Know about symptoms, diagnosis and treatment of kidney stones/calculi

  • Kidney stones or otherwise called renal calculi or nephrolithiasis are deposits of combination of various minerals inside the kidney.
  • The constituents of these stones are normally excreted into the urine.
  • Excess concentration of these minerals in the urine leads its crystallization and further stone formation.
  • Various reasons of stone formation include less water intake, dietary factors, excessive calcium level in blood due to Vitamin D deficiency or hormonal imbalance, excess body weight, urinary infections, certain drugs intake etc.
  • Kidney stones are often diagnosed with ultrasound or CT scan test and its management depends on various factors.

Symptoms

  • Dull aching Flank or back pain
  • Radiating pain to lower abdomen
  • Pain while passing urine
  • Colicky pain (pain that comes and go in intervals or waves)
  • Blood in urine
  • Passing cloudy urine
  • Fever
  • Nausea/vomiting

Diagnosis

  • Combination of various tests are done.
  • Blood tests – Tests to look for elevated calcium or uric acid, Vitamin D deficiency, Parathyroid hormone.
  • Urine tests- Urine tests are done to look for active infection. Recurrent infections lead to stone formation. Also 24 hour urine test is done to find the cause of recurrent stone formation.
  • Imaging – Imaging in form of Ultrasound, IVP or CT scan is often used to look for the exact number of stones, its size, location inside kidney, hardness of stone. It also helps the doctor in deciding the treatment to be undertaken for stones.

Treatment

  • Small kidney stones do not require any surgical treatment and kept on surveillance. General mesures such as plenty of oral fluids, painkillers and alkalizers are often used.
  • Large kidney stones are treated with one or other surgical therapy. These include-
  • ESWL – Extracorporeal shock wave therapy uses various kind of shock waves to break the stone by vibration. Doctor chooses which stone to be treated with this therapy. Patient is placed on machine and stone is focused on machine and sound waves then break the stone. Procedure last for about 30-40 min. Small broken stones then passes in urine in following days.
ESWL set up
  • PCNL (Per – cutaneous Nephro-lithotomy) – In this surgery used for large stone, small endoscope is passed through the the cut (<1cm) given in back of the patient. Small instruments passes through this endoscope such as laser and other to break the stone and then these small broken pieces are removed with other instrument. Surgeon may also stent at the end of surgery.  
PCNL procedure
  • RIRS (Retrograde Intra Renal Surgery) – This surgery involves passing the small endoscope (ureteroscope) is passed through the urethra up into the kidney and subsequently the stone is broken with laser machine. This laser breaks and convert the stone into sand particles which gets flushed in urine in following days. Doctor may place a stent in this surgery.  
RIRS procedure
  • Parathyroid gland/adenoma removal – Sometimes the cause of recurrent stone formation lies in parathyroid gland which becomes overactive. It is situated in the front of neck behind thyroid gland. This involves either complete removal of parathyroid gland removal or removal of a small part of it. 

Prevention of stone disease

  • Drink plenty of oral fluids to maintain urine output of about 1.5-2.0 litre/day.
  • Take low salt diet.
  • Cut down the animal protein intake.
  • Cut down oxalate rich diet such as rhubarb, beets, okra, spinach, sweet potatoes, nuts, tea, chocolate and soy products. Calcium rich diet can be safely taken and not avoided.
  • Recurrent calcium stone formers may be prescribed by doctor with certain medicines such as thiazide or potassium citrate.
  • Uric acid stone formers may be given with Allopurinol or oral alkalizer is given.
  • Infection stone former may be treated with antibiotic to keep the urine free of infection.

Prostate cancer and PSA testing

  • Prostate is a small walnut sized organ present in men and is the part of male reproductive organ. It helps in the male fertility. Normal prostate size varies from 15-20 gm.
  • Prostate cancer is the most common cancer in men after skin cancer.
  • PSA (Prostate specific antigen) is the blood test which is specific for the prostate.
  • Though PSA is organ specific, it is not disease specific.
  • PSA is raised in many conditions such as prostatitis (prostate infection), prostate cancer, prostate abscess, BPH (benign prostate hypertrophy), acute retention of urine, urine infection, hematuria, prostate surgery etc.
  • Normal PSA value range from 0-4 ng/ml for an average sized prostate and its upper range value corresponds to the advanced patient age.
  • PSA is used for screening of prostate cancer as it is raised in these patients.
  • Raised PSA need thorough evaluation to rule out any other cause of elevation of PSA other than prostate cancer. These tests include DRE (digital rectal examination), urine routine/culture.
  • Absence of urinary infection or in an asymptomatic men with no prior urologic surgery, raised PSA suggests the possibility of harbouring prostate cancer and need further workup for same. These tests include mpMRI (Multiparametric MRI) prostate if PSA is more than 4 ng/ml and less than 10 ng/ml.
  • Any patients with raised PSA and having prostate which is hard on DRE or harbouring nodule, need prostate biopsy directly. Also, patient with PSA more than 10 ng/ml or more than 4 ng/ml and MRI showing high suspicion for prostate cancer need biopsy of prostate.
  • Free PSA (fPSA) is often useful for patients having PSA in range between 4-10 ng/ml. This blood test tells about the risk of prostate cancer in such patients.
  • Final diagnosis is with prostate biopsy in men having raised PSA and is done by the TRUS (Transrectal Ultrasound) under local anaesthesia.

Male infertility

  • Nearly one in six couple unable to conceive after one year of marriage.
  • Male infertility contributes nearly 40% part in the couple’s infertility.
  • Initial evaluation consists of detailed history, physical examination for testes, vas deferens, varicocele.
  • A simple semen analysis gives information for future direction of investigation and management.
  • Management of infertility may include simple smoking cessation, healthy lifestyle, hormone therapy, varicocele surgery, need for IUI, IVF or ICSI.
  • Many couples with male infertility as a cause, can still have their own child with one of other method of assisted reproductive techniques such as IVF and TESA/TESE with ICSI.

Urinary tract infection (UTI)

  • A urinary tract infection (UTI) is an infection in any part of the urinary system — kidneys, ureters, bladder and urethra.
  • Most commonly it involves the bladder and urethra.
  • Kidney infections are more serious.
  • Women are affected more commonly than men. These infections are typically treated with antibiotics along with other surgical intervention if required.

Symptoms

  • Burning micturition
  • Frequent urination
  • Lower abdominal pain
  • Passing cloudy foul smelling urine
  • Persistent urge to pass urine
  • Passing blood in urine

UTI types

Organ involvedSymptoms
Kidney (acute pyelonephritis/renal abscess/pyonephrosis/emphysematous pyelonephritis)Flank pain on involved side
Fever with chills
Nausea
Vomiting
Tenderness on palpation
Bladder (cystitis)Lower abdominal pain
Frequent small volume urination
Burning micturition
Blood in urine
Prostate (Prostatitis/abscess)Fever with chills
Burning micturition
Pus in urine
Urethra (Urethritis)Pus discharge
Burning micturition

Causes of UTI

  • Main portal of microbial entry causing UTI is through the urethra.
  • Kidney infections sometimes occur secondary to bloodstream infections.
  • Women are more prone to infections due to close proximity of urethra to anus and short urethra length.

Risk factors leading to UTI

  • Chronic indwelling catheter
  • Poorly controlled diabetes mellitus
  • Women gender
  • Urinary tract abnormality
  • Any recent urological surgery
  • Stone disease

Prevention

  • Daily fluid intake of 2.5-3.0 litre.
  • Drinking cranberry juice prevents UTI.
  • After passing urine or bowel movement, women should clean from front to back.
  • Empty the bladder after intercourse.
  • Person developing infection after sexual intercourse should use barrier method.

Diagnosis

  • Urine routine test
  • Urine culture and sensitivity test- this test tells us which bacteria is causing the infection and which medicine will be most appropriate for that bacterial infection.
  • Imaging test in form of Ultrasound/CT scan as per need.
  • Cystoscopy – in case of recurrent UTI of lower tract (bladder, urethra), to look for the source of infection. 

Treatment

  • Antibiotics are mainstay of treatment for urinary tract infections.
  • Simple uncomplicated infections such as urethritis, cystitis are usually treated with oral antibiotics such as fosfomycin, cephalexin trimethoprim/sulfamethoxazole etc. Other supportive medicines for burning and frequent urination are often prescribed.
  • For complicated infections such as acute pyelonephritis, renal abscess, emphysematous pyelonephritis, hospitalisation intravenous antibiotics are often required. 
  • Surgical intervention such as pus drainage with pigtail, DJ stent placement in kidneys etc may be required. 

Recurrent infections

  • Low dose long term oral antibiotic may be required.
  • Single dose oral antibiotic after sexual intercourse, if your infections seems to related to sexual activity.
  • Vaginal estrogens in postmenopausal women.