Testicular Disorders Past Paper PDF

Taxonomy: Surgery, Genitourinary system, Testis and scrotum Overlap: - - Key Boxes - 1. 2. 3. 4. 5. 6. 7. Images - 1. 2. 3. 4. 5. 6. 7. PYQs - 6 Total no. of Qs - 15 **UNDESCENDED TESTIS** ====================== **Q. 1.** A 1-month-old male infant is brought to the cli...

Taxonomy: Surgery, Genitourinary system, Testis and scrotum Overlap: - - Key Boxes - 1. 2. 3. 4. 5. 6. 7. Images - 1. 2. 3. 4. 5. 6. 7. PYQs - 6 Total no. of Qs - 15 **UNDESCENDED TESTIS** ====================== **Q. 1.** A 1-month-old male infant is brought to the clinic by his mother, who has noticed that both sides of his scrotum appear empty while giving him a bath. She reports no history of trauma or swelling in the scrotal area. There have been no feeding difficulties or signs of systemic illness. The infant was born at term via normal vaginal delivery with no perinatal complications. On examination, both scrotal sacs are found to be underdeveloped and empty. Palpable masses are noted in the inguinal regions bilaterally. The infant is otherwise well, with normal growth and development. At what age should orchidopexy be planned for this patient? A. B. C. D. **Answer: B. 6-12 months of age** The given scenario is that of **undescended testis** and it is managed by orchidopexy around 6-12 months of age. An empty scrotal sac with bilateral inguinal masses in a neonate is suggestive of the diagnosis. The child can be managed conservatively till 5 months since spontaneous descent can occur. If it doesn\'t occur, the management is **orchidopexy between 6-12 months of age**. It is done to reduce complications such as infertility, torsion, malignancy and infection. If surgery is done in adulthood, the patients remain infertile. +-----------------------------------------------------------------------+ | **UNDESCENDED TESTIS** | | | | In undescended testis, the testis is arrested along its **normal** | | path of descent, most commonly in the **inguinal** canal, | | particularly on the **right** side. | | | | **Normal descent of the testis** | | | | - - | | | | **Complications** | | | | **Indirect inguinal hernia** - most common, **Seminoma** - most | | common malignancy, Epididymo-orchitis, sterility, torsion, trauma | | | | **Management** | | | | - - - | | | | **Types of orchidopexy** | | | | Fowler Stephens procedure - the vessels are divided and testis is | | brought down into the scrotum in one or two stages | | | | **Differential diagnoses** | | | | 1. | | | | Management: **Orchidopexy** | | | | 2. | | | | Management: **Reassurance** | +-----------------------------------------------------------------------+ **Q. 2.** A 1 year old boy is brought to the OPD after his parents noticed an empty scrotal sac while changing his diapers. On examination, the right testis is found in the inguinal canal and can be easily manipulated back into the scrotum, but it ascends again after a short time. The left testicle is normal in size and position. What is the most appropriate management in this condition? A. B. C. D. **Answer: C. Reassuring the parents** The scenario describes a **retractile testis**, where the testis temporarily ascends into the inguinal canal due to an **overactive cremasteric reflex**. Stimulation of the scrotal or thigh skin triggers the cremaster muscle to contract, causing the testis to ascend. When the cremaster relaxes, the testis reappears, only to retract again if the scrotal skin is touched. A retractile testis is **normal** in size, while an undescended testis is often underdeveloped. A retractile testis can be **gently milked** from the inguinal region to the base of the scrotum. A diagnosis of true incomplete descent is made only when this manoeuvre is not possible. +-----------------------------------------------------------------------+ | **UNDESCENDED TESTIS** | | | | In undescended testis, the testis is arrested along its **normal** | | path of descent, most commonly in the **inguinal** canal, | | particularly on the **right** side. | | | | **Normal descent of the testis** | | | | - - | | | | **Complications** | | | | **Indirect inguinal hernia** - most common, **Seminoma** - most | | common malignancy, Epididymo-orchitis, sterility, torsion, trauma | | | | **Management** | | | | - - - | | | | **Types of orchidopexy** | | | | Fowler Stephens procedure - the vessels are divided and testis is | | brought down into the scrotum in one or two stages | | | | **Differential diagnoses** | | | | 1. | | | | Management: **Orchidopexy** | | | | 2. | | | | Management: **Reassurance** | +-----------------------------------------------------------------------+ **TESTICULAR TORSION AND EPIDIDYMO-ORCHITIS** ============================================= **Q. 3.** A male child experiences acute scrotal pain while playing. He was taken to the ED and USG doppler was taken followed by immediate surgical exploration and the following finding was seen. What is the probable diagnosis? **\[NEET 2024\]** A. B. C. D. **Answer:** **B. Testicular torsion with gangrene** The image shows gangrenous testis suggestive of a diagnosis of testicular torsion with gangrene. Testicular torsion is a surgical emergency where the testis twists in such a way that its blood supply becomes compromised. It presents as acute scrotal pain. This is not a strangulated inguinal hernia because there is no history of swelling, cough impulse. Absence of trauma rules out hematoma. Torsion of testicular appendage has a characteristic blue dot sign. +-----------------------------------------------------------------------+ | **TORSION TESTIS *^\[NEET\ 2024\]^*** | | | | Testicular torsion is a surgical emergency where the testis twists, | | cutting off its blood supply. | | | | **Risk factors** | | | | - - - | | | | **Clinical features** | | | | - - - - - | | | | **Investigations** | | | | It is mainly a clinical diagnosis, with **Doppler ultrasound** used | | sparingly due to potential false positives. | | | | **Management** | | | | Emergency exploration and orchidopexy is performed as testicular | | survival drops after 6 hours. | | | | 1. 2. 3. | | | | **Prophylactic contralateral orchidopexy** is done in all cases | | | | **Differential Diagnoses Of Torsion Testis** | | | | 1. | | | | | | | | 2. 3. | +-----------------------------------------------------------------------+ **Q. 4.** A 15-year-old boy presents to the emergency department with severe, sudden onset of left-sided scrotal pain that began 4 hours ago. He also reports nausea and vomiting. On examination, the left testicle is swollen, tender, and positioned higher than the right. The cremasteric reflex is absent on the affected side. There is no history of trauma. What is the next best step in management? A. B. C. D. **Answer: C. Immediate surgical exploration** Sudden onset scrotal pain associated with a swollen, tender high-riding testis and absent cremasteric reflex points to a diagnosis of **testicular torsion**. **Immediate surgical exploration** is the next best step in management, as testicular salvage rates decrease significantly if detorsion is delayed beyond 6 hours. While a Doppler ultrasound (Option A) may confirm the absence of blood supply to the affected testis, false positives are high. Hence it is not recommended in a patient with high suspicion of torsion. Manual detorsion (Option B) can be attempted if surgical treatment is not immediately available but it is not the definitive management. +-----------------------------------------------------------------------+ | **TORSION TESTIS *^\[NEET\ 2024\]^*** | | | | Testicular torsion is a surgical emergency where the testis twists, | | cutting off its blood supply. | | | | **Risk factors** | | | | - - - | | | | **Clinical features** | | | | - - - - - | | | | **Investigations** | | | | It is mainly a clinical diagnosis, with **Doppler ultrasound** used | | sparingly due to potential false positives. | | | | **Management** | | | | Emergency exploration and orchidopexy is performed as testicular | | survival drops after 6 hours. | | | | 1. 2. 3. | | | | **Prophylactic contralateral orchidopexy** is done in all cases | | | | **Differential Diagnoses Of Torsion Testis** | | | | 1. | | | | | | | | 2. 3. | +-----------------------------------------------------------------------+ **Q. 5.** A 17-year-old male presents to the emergency department with left-sided scrotal pain for the past 6 hours. The pain started gradually and worsened over time. He reports dysuria and fever for the past 2 days. On examination, the left testicle is swollen and tender. The cremasteric reflex is present, and on lifting the testis, there is reduction in pain. What is the most likely next step in management? A. B. C. D. **Answer: B. Doppler ultrasound** The history of acute scrotal pain along with dysuria, fever, positive cremasteric reflex and a positive **Prehn sign** (reduction in pain on lifting testis) suggest a diagnosis of epididymo-orchitis. The next step would be to carry out a Doppler ultrasound to rule out testicular torsion as it is an important differential diagnosis and a surgical emergency. +-----------------------------------------------------------------------+ | **TORSION TESTIS *^\[NEET\ 2024\]^*** | | | | Testicular torsion is a surgical emergency where the testis twists, | | cutting off its blood supply. | | | | **Risk factors** | | | | - - - | | | | **Clinical features** | | | | - - - - - | | | | **Investigations** | | | | It is mainly a clinical diagnosis, with **Doppler ultrasound** used | | sparingly due to potential false positives. | | | | **Management** | | | | Emergency exploration and orchidopexy is performed as testicular | | survival drops after 6 hours. | | | | 1. 2. 3. | | | | **Prophylactic contralateral orchidopexy** is done in all cases | | | | **Differential Diagnoses Of Torsion Testis** | | | | 1. | | | | | | | | 2. 3. | +-----------------------------------------------------------------------+ **Q. 6.** A 25 year old male complains of acute pain at the top of his testis for the last 16 hours. On examination, the scrotum appears as in the image.  What is the diagnosis? A. B. C. D. **Answer: C. Torsion of hydatid of Morgagni** The clinical scenario of **scrotal pain** and image showing a **small dark spot over the testis** is suggestive of torsion of hydatid of Morgagni. Torsion of testicular appendage is a close differential of testicular torsion. **Management:** - - +-----------------------------------------------------------------------+ | **TORSION TESTIS *^\[NEET\ 2024\]^*** | | | | Testicular torsion is a surgical emergency where the testis twists, | | cutting off its blood supply. | | | | **Risk factors** | | | | - - - | | | | **Clinical features** | | | | - - - - - | | | | **Investigations** | | | | It is mainly a clinical diagnosis, with **Doppler ultrasound** used | | sparingly due to potential false positives. | | | | **Management** | | | | Emergency exploration and orchidopexy is performed as testicular | | survival drops after 6 hours. | | | | 1. 2. 3. | | | | **Prophylactic contralateral orchidopexy** is done in all cases | | | | **Differential Diagnoses Of Torsion Testis** | | | | 1. | | | | | | | | 2. 3. | +-----------------------------------------------------------------------+ **HYDROCOELE** ============== **Q. 7.** A 35-year-old male presents with painless scrotal swelling that has been gradually increasing in size for the past six months. On examination, the swelling is tense, the testis is not palpable separately, and transillumination is positive. How do you manage this condition? A. B. C. D. **Answer: C. Eversion of sac** A painless, scrotal swelling that is tense with testis not palpable and positive transillumination test indicates a diagnosis of primary hydrocele. It is managed by Jaboulay\'s procedure where the sac is everted and sutured. In case of small sacs, Lord\'s plication can be done. +-----------------------------------------------------------------------+ | **HYDROCOELE** | | | | It refers to an abnormal collection of fluid in the processus | | vaginalis, usually the tunica vaginalis | | | | **Types** | | | | 1. | | | | - | | | | | | | | - | | | | 2. | | | | | | | | 3. | | | | | | | | 4. | +-----------------------------------------------------------------------+ **VARICOCELE** ============== **Q. 8.** A 25-year-old male presents with a dull, aching pain in the left scrotum, which worsens after prolonged standing and improves when lying down. On physical examination, the scrotum shows a soft, \"bag of worms\" appearance. Which of the following is the most likely diagnosis? A. B. C. D. **Answer: D. Varicocele** A varicocele is a **dilation of the pampiniform venous plexus** within the scrotum, commonly presenting as a \"**bag of worms**\" on palpation. It is more common on the **left** side due to the anatomy of the left testicular vein. Symptoms often worsen with standing or exertion and improve when lying down. +-----------------------------------------------------------------------+ | **VARICOCELE** | | | | It refers to the dilated, tortuous pampiniform plexus of veins. | | | | Varicocele is more common on the **left** side because it is longer | | and drains at a right angle into the left renal vein, near the left | | adrenal vein (which releases adrenaline potentially causing | | vasoconstriction). | | | | **Note:** | | | | - - | | | | **Clinical features** | | | | Majority of the patients are asymptomatic. | | | | Most common symptom is a dull dragging discomfort in the scrotal | | region | | | | O/E : **Bag of worms** consistency | | | | **Investigations** | | | | Investigation of choice - Colour Doppler | | | | **Management** | | | | Microsurgical varicocelectomy or percutaneous embolisation of the | | gonadal veins | | | | Varicocele repair can be effective in symptomatic cases, low sperm | | count and unexplained infertility. | +-----------------------------------------------------------------------+ **Q. 9.** A 30 year-old male presents with dull, aching pain in his left scrotum that has been present for the past three months. He also reports occasional dull ache in the left flank and a recent onset of hematuria. On examination, a left-sided soft irregular scrotal mass with a "bag of worms" consistency is noted. The mass appears to be non-reducible and does not disappear when the patient is lying down. There is no history of trauma or previous scrotal surgery. Which of the following is the most appropriate step in the management of this patient? A. B. C. D. **Answer: C. Contrast-enhanced CT scan of the abdomen and pelvis** The patient's flank pain and hematuria along with a left-sided varicocele raise suspicion for renal cell carcinoma. Therefore a CECT of abdomen and pelvis is the most appropriate step here. +-----------------------------------------------------------------------+ | **VARICOCELE** | | | | It refers to the dilated, tortuous pampiniform plexus of veins. | | | | Varicocele is more common on the **left** side because it is longer | | and drains at a right angle into the left renal vein, near the left | | adrenal vein (which releases adrenaline potentially causing | | vasoconstriction). | | | | **Note:** | | | | - - | | | | **Clinical features** | | | | Majority of the patients are asymptomatic. | | | | Most common symptom is a dull dragging discomfort in the scrotal | | region | | | | O/E : **Bag of worms** consistency | | | | **Investigations** | | | | Investigation of choice - Colour Doppler | | | | **Management** | | | | Microsurgical varicocelectomy or percutaneous embolisation of the | | gonadal veins | | | | Varicocele repair can be effective in symptomatic cases, low sperm | | count and unexplained infertility. | +-----------------------------------------------------------------------+ **MISCELLANEOUS CONDITIONS** ============================ +-----------------------------------------------------------------------+ | **SPERMATOCELE** | | | | This is a **unilocular retention cyst** derived from a portion of the | | sperm-conducting mechanism of the epididymis. | | | | It typically lies in the **epididymal head** above and behind the | | upper pole of the testis. | | | | The fluid contains spermatozoa and resembles **barley water**. May | | not transilluminate well | | | | **Management:** Excision, if symptomatic | | | | **EPIDIDYMAL CYST** | | | | It represents cystic degeneration of the epididymis. | | | | It is multi loculated, with a **bunches of grapes** appearance | | | | It contains clear fluid, hence it transilluminates brilliantly | | (**Chinese lantern** appearance) | | | | **Management:** Excision, if symptomatic | +-----------------------------------------------------------------------+ **FOURNIER\'S GANGRENE** ======================== **Q. 10.** A diabetic patient presents with pain in the perineum and is unable to sit comfortably. There is oozing of pus within 24 hours along with foul-smelling discharge seen around the scrotum. Black necrotic tissue extending deep to the fascia is also seen. Which of the following statements is true regarding the condition shown below? **\[NEET 2023\]** A. B. C. D. **Answer: B. It is a mixed aerobic and anaerobic flora infection** Image shows a combination of **fournier's** gangrene and **meleney\'s** gangrene ( involving the abdominal wall) It is managed by **extensive debridement** of the involved area. Testes and urethra are spared due to their separate blood supply, hence orchidectomy and urinary diversion need not be done routinely. Faecal and urinary diversion can be done if necessary. +-----------------------------------------------------------------------+ | **FOURNIER\'S GANGRENE *^\[NEET\ 2022\]^*** | | | | - - - | | | | **Clinical features** | | | | - - - - | | | | **Note:** | | | | 1. 2. | | | | **Treatment** | | | | It is a surgical emergency | | | | - - - | | | | **Note:** When Fournier\'s gangrene involves the abdominal wall, it | | is called Meleney\'s gangrene ***^\[NEET\ 2023\]^*** | +-----------------------------------------------------------------------+ **Q. 11.** An elderly male presents with sudden onset of pain in scrotum and discharge. Based on the image below, what is the likely diagnosis? **\[NEET 2022\]** A. B. C. D.  **Answer: D. Fournier\'s gangrene** The image shows a necrotic area around the scrotum which points towards Fournier\'s gangrene. It is a form of **necrotizing fasciitis** of the perineum, genitalia, and perianal region. It is a **polymicrobial** infection involving aerobic and anaerobic organisms, often seen in immunocompromised patients like diabetics. +-----------------------------------------------------------------------+ | **FOURNIER\'S GANGRENE *^\[NEET\ 2022\]^*** | | | | - - - | | | | **Clinical features** | | | | - - - - | | | | **Note:** | | | | 3. 4. | | | | **Treatment** | | | | It is a surgical emergency | | | | - - - | | | | **Note:** When Fournier\'s gangrene involves the abdominal wall, it | | is called Meleney\'s gangrene ***^\[NEET\ 2023\]^*** | +-----------------------------------------------------------------------+ **Q. 12.** Which of the following statements is true regarding the condition shown below **\[NEET 2021\]** A. B. C. D. **Answer: B It is a mixed aerobic and anaerobic infection** Image shows a combination of **fournier's** gangrene and **meleney\'s** gangrene ( involving the abdominal wall) It is managed by **extensive debridement** of the involved area. Testes and urethra are spared due to their separate blood supply, hence orchidectomy and urinary diversion need not be done routinely. Fecal and urinary diversion can be done if necessary. +-----------------------------------------------------------------------+ | **FOURNIER\'S GANGRENE *^\[NEET\ 2022\]^*** | | | | - - - | | | | **Clinical features** | | | | - - - - | | | | **Note:** | | | | 5. 6. | | | | **Treatment** | | | | It is a surgical emergency | | | | - - - | | | | **Note:** When Fournier\'s gangrene involves the abdominal wall, it | | is called Meleney\'s gangrene ***^\[NEET\ 2023\]^*** | +-----------------------------------------------------------------------+ **Q. 13.** A woman presents with blackish discoloration of the abdomen as shown below. Which of the following is true regarding this condition? **\[NEET 2023\]** A. B. C. D.  **Answer: C. Case of Meleney\'s gangrene** The image shows gangrene with involvement of abdominal wall, indicating a case of Meleney\'s gangrene. It is managed by extensive debridement of the involved area. Radical surgery every 24 hours is not a treatment for this condition. (Option A) Hyperbaric oxygen therapy is a recent update in the management of Fournier\'s and Meleney\'s gangrene. +-----------------------------------------------------------------------+ | **FOURNIER\'S GANGRENE *^\[NEET\ 2022\]^*** | | | | - - - | | | | **Clinical features** | | | | - - - - | | | | **Note:** | | | | 7. 8. | | | | **Treatment** | | | | It is a surgical emergency | | | | - - - | | | | **Note:** When Fournier\'s gangrene involves the abdominal wall, it | | is called Meleney\'s gangrene ***^\[NEET\ 2023\]^*** | +-----------------------------------------------------------------------+ **TESTICULAR TUMOURS** ====================== **Q. 14.** A male patient presents with painless enlargement of the testis. LDH values are increased. What is the next step in management? **\[INICET JULY 2021\]** A. B. C. D. **Answer: C. High inguinal orchidectomy** Painless enlargement of the testis is concerning for testicular malignancy. Key points for management include: **High inguinal orchidectomy:** This is the recommended management for suspected testicular cancer. It allows for the removal of the affected testis along with the spermatic cord for definitive diagnosis and staging. FNAC (Option A) and biopsy (Option B) is not recommended for testicular masses because it can cause seeding of cancer cells into overlying skin and upstage the disease. +-----------------------------------------------------------------------+ | **TESTICULAR TUMOURS *^\[INICET\ JULY\ 2021\]^*** | | | | **Risk factors** | | | | Testicular maldescent, Klinefelter\'s syndrome, history of | | contralateral testicular tumour | | | | **Types** | | | | - - - | | | | **Clinical features** | | | | - - - | | | | **Investigations** | | | | - - | | | | | | | | - - - | | | | | | | | - | | | | **Chevassu manoeuvre** | | | | Through a high inguinal incision, testis is delivered and spermatic | | cord is clamped before testis is split and sent for frozen section. | | | | If it shows the presence of cancer, **high inguinal orchidectomy** is | | carried out. If not, the testis is placed back. | | | | **Note:** Transscrotal biopsy/FNAC are **not** done in testicular | | tumours due to risk of upstaging the disease | | | | **Staging and Management** | | | | **Stage I: Tumour confined to the testis and epididymis** | | | | **Seminomas:** Treated with a single cycle of carboplatin plus | | radiotherapy (to para-aortic lymph nodes in an inverted Y field). | | | | **Non-Seminomatous Germ Cell Tumours (NSGCTs):** Treated with BEP | | chemotherapy (Bleomycin, Etoposide, Cisplatin). | | | | **Stages II-IV: Nodal disease or metastatic disease** | | | | **Seminomas and NSGCTs:** Treated with combination BEP chemotherapy. | | | | Management may also include retroperitoneal lymph node dissection, | | radiotherapy, or metastasectomy, depending on the case. | +-----------------------------------------------------------------------+ **Q. 15.** A 40 year old male presents with a painless, firm swelling in his right testicle for the past 2 months. He denies any history of trauma or infection. On physical examination, the testis is non-tender, and there is no transillumination of the swelling. He underwent orchidectomy and the specimen is shown below. What is the diagnosis? [](https://www.google.com/search?safe=active&q=seminoma+gross&tbs=sur:fmc&udm=2#vhid=M8Y1UvzHQxe4RM&vssid=mosaic) [](https://www.google.com/search?safe=active&q=seminoma+hpe#vhid=f2IYm4I5G0P_gM&vssid=l) A. B. C. D. **Answer: C. Seminoma** The gross specimen shows a well circumscribed, fleshy, homogenous mass. Histopathology shows uniform tumour cells with clear cytoplasm and large, rounded nuclei and prominent acidophilic nucleoli. Sheets of cells resembling spermatocytes are separated by fine fibrous stroma. Lymphocytic infiltration may be present. Combined box