D: Inflammation of the epididymis or testes (orchitis). 60% of epididymitis are associated with orchitis and most cases of orchitis with epididymitis.
A: Majority of cases are infective in origin.
1/3 are idiopathic. May be associated with underlying testicular tumour.
A/R: Diabetes. Rarely associated with vasculitis, e.g. Henoch-Schonlein purpura. Also with urethral instrumentation and prostatic surgery.
E: Common. Affects all age groups, 50% are 20-30 years. ^^
H: Painful, swollen and tender testes or epididymis (usually unilateral), onset is usually less acute than testicular torsion - the most important differential. Penile discharge may occur (especially in bacterial forms), fever. Important to enquire about sexual history.
E: Swollen and tender epididymis and/or testis.
The scrotum may be erythematous and oedematous. Pyrexia.
Walking or even eliciting a cremaster reflex may be painful.
P: The epididymis is an elongated mass of convoluted efferent tubes posterior and superior to the testes. Spermatozoa mature and gain their mobility within this structure.
I: Urine: Dipstick, early morning urine collection (bacterial C&S and microscopy for acid-fast bacilli if TB suspected). Blood: FBC, " WCC, " CRP, U&Es.
Imaging: " Blood flow on Duplex examination, ultrasound may reveal local collection or abscess.
Following treatment of acute episode, older patients should be investigated for causes of bladder outlet obstruction, e.g. flow studies or underlying malignancy.
M: Medical: Antibiotic treatment, if severe may need IV treatment initially. Young patients where chlamydia is likely, doxycycline for 2 weeks and attendance as a genitourinary clinic for follow-up and contact tracing. In older patients, quinolones (e.g. ciprofloxacin) are recommended for 2-4 weeks. Adequate analgesic and scrotal support. Follow-up is still recommended to exclude testicular malignancy. If TB is suspected, antituberculous regimen is necessary.
Surgical: Exploration of scrotum if testicular torsion cannot be excluded or if an abscess develops that requires drainage. Also performed in cases of tuberculous epididymo-orchitis not responding to medical treatment.
C: Pain, abscess; if untreated, risk of spreading infection and Fournier's gangrene. Minimal risk to fertility if unilateral and treated. Mumps orchitis may cause testicular atrophy and future fertility problems.
_P Good if treated. May take up to 2 months for swelling to completely resolve.
Bleeding and accumulation of blood into the extradural space.
Trauma, most commonly fractures of the temporal or parietal bones causing rupture of the middle meningeal artery.
Risk factors are haemorrhagic diathesis (e.g. haemophilia, anticoagulation therapy), dural vascular anomalies (e.g. dural AVMs).
Annual incidence of 20/100 000 in the UK. 10% of severe head injuries. Most commonly seen in young adults. Uncommon in elderly (subdural haemorrhages are more common in that age group).
Head injury with a temporary loss of consciousness, followed by a lucid interval, then development of progressive deterioration in conscious level.
Signs of scalp trauma or fracture. Headache.
Deteriorating GCS, signs of raised ICP (e.g. dilated unresponsive pupil on the side of the injury).
Rising BP and bradycardia (Cushing's reflex) is a late sign.
Trauma causes a fracture, most commonly of the squamous temporal bone as this is the thinnest part of the cranial vault. This can rupture the middle meningeal artery, with the arterial bleeding causing rapid accumulation of blood and stripping the dura from the inner table of the skull. This results in raised ICP and compression of the underlying brain parenchyma.
Urgent CT scan: Diagnostic and identifies location of haematoma. An arterial bleed produces a convex or lens-shaped haematoma. Associated signs of raised ICP include midline shift, compression of ventricles, obliteration of basal cisterns sulcal effacement.
M: Early management of head injuries: Following ATLS guidelines, which requires establishing ABC and cervical spine control. Once stabilised, assessment is made of severity of head injury with an urgent CT scan. Surgical: Urgent craniotomy and decompressive evacuation of the haematoma with diathermy or clipping of source of bleeding. An ICP monitor may be placed for post-op monitoring. Close observation and supportive care is required, often in an ITU setting.
_C Acutely, the greatest risk is cerebral herniation and death. In the longer term, neurobehavioural changes (e.g. postconcussive syndrome, retrograde amnesia).
P: Mortality rates relate to initial GCS and associated intracerebral injuries. If treated early, prognosis is good with underlying brain usually suffering limited injury.
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