Long case Volume 1

Why pain in GUTB - 

D/D of Pain abdomen and LUTS in young patients - B/L UPJO with recurrant UTI, Bilateral nephrolithiasis with bladder calculi with obstructive uropathy may give features of weight loss too, complicated UTI , neurogenic bladder with vesical calculus 

to rule in or out each differential diagnosis - lithuria, history of TB in family, cough, nature of fever,  

• History of apetite 
• Presence of hematospermia - 

• Anemia - either can be blood loss, decrease food intake, anemia of chronic disease, renal failure leading to anemia 
• Lymphadenopathy 
• History for chronic renal failure - decreased output, facial puffiness, anorexia, nausea, CNS - alteration of sleep rhythm is earliest feature of CRF in CNS

Rule out tuberculosis in other organs - abdomen lump, ascitis, spine abnormalities, pulmonary 

Features of LUTS can be secondary to neurogenic bladder - secondary to Spinal TB

First send for urine RME and Urine c/s - if you find out sterile pyuria - then only send the Urine AFB and AFB c/s 


When there is upper tract and lower tract finding - always keep the GUTB in differential diagnosis

• Bladder diary as a part of investigation - 
• To know the status of outflow tract - RGU may be required,

Dont forget cytology in GUTB to rule out malignancy 

Dont forget bladder diary in GUTB cases 

For neurogenic bladder, always ask the history of consitipation

Ask about bladder spasms - gives idea about reflux, more spasm, more reflux, epididymorchitis , it is also seen postoperatively because spasm continues

previous surgical management of stricture 

• Present with prostatitis and epididymitis - 
• May present with urinary retention 
• Examination - fibrosis, inflammation, fistula

• - How did it appear?
• - Where did it appear first? - inguinal hernia appears from above whereas an in fantile hydrocele, testicular growth and varicocele appear from below. encysted hydrocele of the cord and diffuse lipoma of the cord appear first in the cord and then gradually enlarge.
• - Does it disappear automatically on lying down? - A varicocele disappears spontaneously when the patient lies down with the scrotum elevated
• - patient with GUTB - evening rise of temperature, excessive coughing, haemoptysis etc, Rapid onset of varicoccle on the left side with haematuria indicates carcinoma of the kidney on that side

• Painless testicular mass, Pain if there is rapid growth of tumor, as in NSGCT  (are more vascular, tend to grow more rapidly) 
• Larger mass - more prone to trauma 
• Hydrocele - present in 15-20% of cases
• LUTS, fever, urethral discharge- to rule of epididymorchitis 
• R/O - hernia
• Retroperitoneal mass - abdominal mass, lower limb swelling, hydro, back pain
• Neck swelling 
• Weight loss, anorexia, bone pain 
• Chest pain, cough, dysnea

Mariatal status, family completed or not - even in uniltateral tumors, there is fertility issue after surgery like after radiotherapy or RPLND 

History of TB 

• Pulmonary mets - respi symptoms 
• Supraclavicular LN 
• Breast - Gynecomastia - hCG production 

• Fertility issue
• Sensation over scrotum - 
• Previous surgery - orchidopexy 

Leydig cell tumors (LCTs) are rare testicular tumors that may be a cause of precocious puberty in males 

• Local examination
• - skin over swelling 
• - consistency, getting over the swelling, 
• - epididymis and vas are separate from testis or not 
• - 

D/d - epididymorchitis, hematoma, torsion, paratesticular tumour, hernia, varicocele, hydrocele

• Occupation 
• smoking 
• Penile growth
• - duration
• - pain/painless - carcinoma penis are usually painless
• - where did the growth first start
• - Ulceratoproliferative growth 
• - blood discharge 
• Inguinal swelling present or not. If present ask -
• - duration
• - unilateral/Bilateral
• - ulceration

• LUTS 
• Ask about the risk factors
• - Phimosis, multiple sexual partners, Whitish discoloration of the glans, penile trauma
• - past surgical history - circumcision, instrumentation 
• Family history 

• Examination 
• Penile growth
• - size, location, extent, surrounding skin
• - fixation with corpora caernosa and spongiosum
• - Inspection of the base of the penis and scrotum is necessary to rule out extension into these areas.
• - Rectal and bimanual examination provides information about perineal body involvement and presence of a pelvic mass
• - meatus status

• Inguinal swelling
• - explain swelling
• - ulceration over swelling

• D/d of ulcerative growth 
• - Giant condyloma accuminatum
• - benign growth are proliferative, but not ulcerative

• Investigations
• - CBC
• - RFT
• - Calcium
• - USG A/P
• - CECT A/P
• - Incisional biopsy