Family medicine #2

 

HY lecture notes:

Family med favorite Q: vegan with nutrient deficiency and B12 isn’t listed –> answer = calcium –> normally present in fish and dairy in high amounts.

Varicocele

• Enlargement of pampiniform venous plexus in the scrotum.
• Presents as a “bogginess” or “bag of worms” –> USMLE will rarely use buzzwords like that, but there is in fact an FM NBME Q where they say “bag of worms,” making the question absurdly easy.
• Almost always occurs on the left because the left testicular vein –> left renal vein –> IVC, whereas the right testicular vein drains straight into the IVC. The left testicular vein drains into the left renal vein at roughly a 90-degree angle; the effect of this geometry enables a pressure backup that results in the varicocele.
• Can increase the risk of infertility due to increased testicular temperature.
• Dx –> valsalva maneuver can make veins more salient on physical exam; modality-wise, a scrotal ultrasound may be ordered.
• Tx is done for men with pain, infertility, and abnormal semen analysis –> embolization or varicocelectomy may be performed.

Testicular torsion vs epididymitis

• Torsion presents with a negative cremasteric reflex (when the thigh is stroked, the ipsilateral testicle should normally retract toward the inguinal canal; in testicular torsion, this does not occur; this reflex is driven by the sensory fibers of both the genitofemoral and ilioinguinal nerves at L1+L2; the motor component resulting in testicular movement is the genitofemoral nerve), whereas it’s positive in epididymitis.
• A congenital malformation of the processus vaginalis (“bell-clapper deformity”) accounts for 90% of cases of torsion.
• Prehn sign (relief of pain with lifting/elevation of the testis in epididymitis but not torsion) is not considered reliable.
• For Dx and Tx of torsion: if clinical suspicion is high, do a urologic consult with immediate surgical exploration. If Dx is questionable, order a Doppler ultrasound; if reduced blood flow, go to surgery; if unremarkable, torsion is less likely.
• For Dx of epididymitis: cremasteric reflex (intact) + Doppler ultrasound (showing intact blood flow) are effective initial approaches.
• Abx Tx for epididymitis depends on age and risk factors.
  • Chlamydia and gonorrhea are most common causes in <35 sexually active patients; E. coli is most common in older patients.
  • If sexually active, cotreat with ceftriaxone PLUS either doxycycline or azithromycin to cover chlamydia and gonorrhea. This cotreatment will be the answer on the USMLE if they ask you.
  • If not sexually active or have BPH or recent urologic instrumentation, give just a fluoroquinolone to cover E. coli.
  • If receptive male anal intercourse as risk factor, give fluoroquinolone + ceftriaxone.
  • Once again, for USMLE, just know the above bolded cotreatment.

Testicular torsion vs strangulated hernia

• Based on relevance, it should be noted that on the surgery NBME forms, they ask a few questions with a presentation very similar to testicular torsion, but the answer is inguinal hernia instead.
• They’ll say there’s a kid with severe scrotal pain + has blue-black discoloration of the superior pole of the testis + bowel sounds are decreased + abdomen is rigid –> answer = strangulated hernia, not torsion. Another question asked very similarly has “surgical exploration” as the answer; Doppler ultrasound is wrong. For these Qs, they will not mention the cremasteric reflex having been performed. If they want torsion, they’ll definitely say the reflex is negative. So essentially what I’ve been able to gather is that if they give you a presentation similar to torsion but say anything about bowel sounds being decreased + a rigid abdomen, go with strangulated hernia.

Testicular torsion vs torsion of appendix testis

• On the peds forms, they want you to know “blue dot sign” means torsion of appendix testis.
• They will say cremasteric reflex is intact + there is a blue dot on the superior pole of the testis –> answer = torsion of appendix testis, not testicular torsion.

Hydrocele vs testicular cancer

• USMLE wants “persistent processus vaginalis” as the embryologic cause of hydrocele, resulting in serous fluid accumulation around the testis.
• Positive transillumination is seen with hydrocele; it’s negative for cancer.
• Testicular cancer on the Step will present as a rock hard nodule (yolk sac tumor or mixed germ cell tumor in peds; seminoma most common in teens and adults).
• Most hydroceles spontaneously resolve before the age of 1. Surgery is only performed in older patients in select circumstances, as most hydroceles are aysmptomatic. Testicular cancer requires orchiopexy; seminoma is notably radiosensitive.

Cryptorchidism

• Undescended testis.
• Increased risk of infertility if bilateral due to increased temperature.
• Hormonal changes may not be seen, but if the USMLE asks you, select up-arrow for LH + FSH and down-arrow for testosterone + inhibin B.
• Do not perform orchiopexy under the age of 1, as most will spontaneously descend.
• Risk of testicular cancer is increased even after testis spontaneously descends or post-orchiopexy –> essentially any added time the testis spends in the abdomen, risk is permanently increased; however, once again, orchiopexy under the age of 1 on the USMLE is the wrong answer; choose observation for these questions.