Hydrocele

• Fluid accumulation within the tunica vaginalis surrounding the testis
• Usually benign and painless
• Common in infants (congenital) and older men

Risk Factors

• Congenital patent processus vaginalis
• Trauma or infection
• Testicular tumor (secondary hydrocele in adults)

Clinical Presentation

• Painless scrotal swelling
• Smooth, fluctuant mass
• Testis may be difficult to palpate
• The question stem would likely describe painless scrotal enlargement without systemic symptoms

Diagnostics

• Transillumination positive
• Scrotal ultrasound if diagnosis unclear or to exclude tumor

Treatment

• Infants: observation, often resolves spontaneously
• Adults: treat underlying cause
• Surgery if large, symptomatic, or persistent

Exam Keys

• Painless swelling + transillumination = hydrocele
• New-onset adult hydrocele → rule out malignancy
• Usually benign

Varicocele

• Dilated veins of the pampiniform plexus
• Caused by impaired venous drainage
• Most common on the left side

Risk Factors

• Increased intra-abdominal pressure
• Renal vein compression (left-sided predominance)

Clinical Presentation

• Dull, aching scrotal pain
• Worse with standing or exertion
• Improves when supine
• “Bag of worms” on palpation
• Associated with infertility
• The question stem would likely describe a young man with infertility or aching scrotal discomfort

Diagnostics

• Physical exam
• Scrotal ultrasound with Doppler if uncertain

Treatment

• Observation if asymptomatic
• Surgical ligation or embolization if pain, infertility, or testicular atrophy

Exam Keys

• Bag of worms = varicocele
• Left-sided predominance
• Infertility association
• Sudden right-sided varicocele → evaluate for retroperitoneal mass

Testicular Torsion

• Twisting of the spermatic cord causing acute testicular ischemia
• Surgical emergency
• Most common in adolescents and young adults

Risk Factors

• Bell-clapper deformity (high-riding, freely mobile testis)
• Adolescence
• Trauma or sudden movement
• Cold exposure or sleep-related cremasteric contraction

Clinical Presentation

• Sudden onset of severe unilateral testicular pain
• Scrotal swelling and erythema
• Nausea and vomiting common
• High-riding testis with horizontal lie
• Absent cremasteric reflex (key exam finding)
• The question stem would likely describe a teenage boy with sudden severe testicular pain and vomiting

Diagnostics

• Clinical diagnosis. Do not delay surgery
• Doppler ultrasound: decreased or absent blood flow if time allows
• Normal urinalysis helps distinguish from infection

Treatment

• Immediate surgical exploration and detorsion
• Orchidopexy of both testes
• Manual detorsion may be attempted if surgery delayed, but does not replace surgery

Exam Keys

• Sudden severe testicular pain = torsion until proven otherwise
• Absent cremasteric reflex is highly suggestive
• Time-sensitive: salvage window ~6 hours
• Always rule out torsion before epididymitis

Urethral Stricture

• Narrowing of the urethra due to scarring
• Causes obstruction of urinary flow
• More common in men

Risk Factors

• Prior urethral trauma
• Instrumentation (catheterization, cystoscopy)
• Sexually transmitted infections
• Pelvic surgery

Clinical Presentation

• Weak urinary stream
• Spraying or split stream
• Straining or urinary retention
• Recurrent UTIs
• The question stem would likely describe a man with prior catheterization and progressive difficulty urinating

Diagnostics

• Retrograde urethrogram
• Cystoscopy

Treatment

• Urethral dilation
• Endoscopic urethrotomy
• Surgical reconstruction for severe cases

Exam Keys

• Weak or spraying stream + history of instrumentation = urethral stricture
• Diagnosed with retrograde urethrogram
• Treated with dilation or surgery

Urethral Prolapse

• Circumferential protrusion of urethral mucosa through the external meatus
• Rare condition
• Seen most often in prepubertal girls and postmenopausal women

Risk Factors

• Estrogen deficiency
• Increased intra-abdominal pressure (coughing, constipation)
• Obesity

Clinical Presentation

• Visible round, reddish or purple mass at urethral opening
• Vaginal or urethral bleeding
• Dysuria or urinary frequency
• Often painless
• The question stem would likely describe a young girl or postmenopausal woman with a small bleeding mass at the urethral opening

Diagnostics

• Clinical diagnosis
• Differentiate from urethral caruncle, prolapse, or sexual trauma

Treatment

• Topical estrogen cream
• Sitz baths
• Surgical excision if persistent or severe

Exam Keys

• Young girl or postmenopausal woman + urethral mass = urethral prolapse
• Treat with topical estrogen
• Surgery only if refractory

Nephrolithiasis / Urolithiasis

• Formation of stones in the kidney or urinary tract
• Most stones originate in the kidney and may migrate into the ureter
• Causes acute obstruction and severe pain

Common Stone Types

• Calcium oxalate (most common)
• Uric acid
• Struvite (infection-related)
• Cystine (rare, genetic)

Risk Factors

• Dehydration
• High sodium or animal protein intake
• Prior kidney stones
• Obesity
• Gout
• Recurrent UTIs (struvite stones)

Clinical Presentation

• Sudden onset severe flank pain radiating to groin
• Colicky pain that comes in waves
• Hematuria common
• Nausea and vomiting
• Patient unable to get comfortable
• The question stem would likely describe a patient pacing in pain with flank-to-groin radiation

Diagnostics

• Noncontrast CT abdomen/pelvis = test of choice
• Urinalysis: hematuria ± crystals
• Ultrasound: preferred in pregnancy
• BMP: assess renal function if obstructed

Treatment

• Pain control: NSAIDs first-line, opioids if needed
• Alpha-blocker (tamsulosin) to facilitate stone passage
• Hydration
• Stones ≤5 mm often pass spontaneously
• Urology referral if infection, obstruction, or stone fails to pass

Exam Keys

• Flank pain radiating to groin + hematuria = kidney stone
• Noncontrast CT = best diagnostic test
• NSAIDs first-line for pain
• Struvite stones = recurrent UTIs
• Infected obstructing stone = emergency