NURS 6531 FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS 100%CORRECT/VERIFIED BEST GRADED A+, Exams of Pharmacology

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NURS 6531 FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS

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1.) Hydrocele (member did not use template, no review questions received-this is all I got) Definition : an accumulation of fluid within the tunica vaginalis surrounding the testicle; it may also result from a patent processus vaginalis at birth and sometimes closes spontaneously within the first 1 to 2 years of life. Hydroceles are the most common cause of painless scrotal swelling.; in adults they are often the result of trauma, a hernia, testicular tumor, or torsion or a complication of epididymitis. Presenting Symptoms : Usually painless and may be present for long periods, partially resolve, and recur before the patient seeks medical attention. Gradual enlargement of the scrotum occurs with marked edema, which may be uncomfortable because of the added weight. A hydrocele may occur secondary toa tumor when excess serous fluid accumulates in the scrotal sac. It will transluminate but may make testicular palpation difficult. Leik Review: Hydrocele more common in infants. Serous fluid collects inside the tunica vaginalis. During scrotal exam,hydroceles are located superiorly and anterior to the testes Most hydroceles are asymptomatic. Will glow with transillumination. If new-onset hydrocele in an adult or enlarging hydrocele, order scrotalultrasound and refer to urologist. Differential Diagnoses : Epididymitis, Testicular torsion, epididymal cyst Review questions:

1. A patient who has had a swollen, nontender scrotum for one week is found to have a mass within thetunica vaginalis that transilluminates readily. The family nurse practitioner suspects: a.) a hydrocele.b.)

a varicocele. c.) an indirect inguinal hernia.d.) carcinoma of the testis. 2.) Chronic Kidney failure: (member did not use template, no review questions received-this is allI got) Definition : The absence of kidney function. Kidney failure is also known as End Stage Kidney Disease. Itis characterized by anuria and the need for renal replacement therapy or kidney transplant. The kidneysand urinary tract system no longer filter blood, create filtrate. Or excrete urine in amounts sufficient toclear waste and balance fluid intake with output. Key highlights: Proteinuria or hematuria, and /or a reduction in the glomerular filtration rate, for more than 3 months duration. The most common causes

are diabetes mellitus and hypertension. Most people are asymptomatic and the diagnosis is determinedonly by laboratory studies. Differential diagnosis: obstructive uropathy, nephrotic syndrome, glomerulonephritis 3.) Acute tubular necrosis (member did not use template, no review questions received-this is allI got) Definition : reversible or irreversible type of renal failure caused by ischemic or toxic injury to renal tubular epithelial cells. The injury results in cell death or detachment from the basement membranecausing tubular dysfunction. A history of hypotension, fluid depletion, or exposure to nephrotic agents is usually present. In otherwisehealthy individuals, when the underlying insult is corrected, the patient frequently has a good outcome with complete renal recovery. There is no specific therapy for acute tubular necrosis apart from supportive care. Differential diagnosis -Prerenal azotemia, intrinsic renal azotemia Treatment Options: There is no specific treatment apart from supportive care in maintaining volume status and controlling electrolyte and acid-base abnormalities. Nephrotoxins should be ceased or if thisis not possible, dose should be decreased. Review questions: A client had excessive blood loss and prolonged hypotension during surgery. His postoperative urine output is sharply decreased, and his blood urea nitrogen (BUN) is elevated. The most likely cause for thechange is acute: A) Prerenal inflammation Bladder outlet obstruction C) Tubular necrosis D) Intrarenal nephrotoxicity

Which of the following is a sign or symptom of acute tubular necrosis (acute kidney injury)?answer-Thirst and increased rapid pulse symptoms of ATN can vary depending on severity. and one may have- problems waking up, feeling drowsy even during day time , feeling lethargic or physically drained, being excessively thirsty or experiencing dehydration, urinating very little or even not at all, retaining fluid or experiencing swellingin body, having episodes of confusion and experiencing nausea and vomit

4. Indirect inguinal hernia Definition : Indirect inguinal hernia – Indirect inguinal hernia is caused by a birth defect in the abdominalwall that is present at birth. A scrotal-inguinal hernia results when a segment of the bowel slips through the internal inguinal ring, where it may remain in the inguinal canal or pass into the scrotal sac. An inguinal hernia may occur as a result of a defect in the anterior abdominal wall or because of a patent process vaginalis. Inguinal hernias predominantly affect men (9:1) and have the highest incidence in menaged 40 to 59. A hernia may move freely between the abdomen and the scrotum or can be spontaneously reduced by digital manipulation. When a hernia becomes strangulated or is unreducible, this compromises the blood supply and requires emergent surgical reduction. Strangulation should be suspected when a tender mass is palpated in the scrotum in addition to redness, nausea, and vomiting Presenting Symptoms : Scrotal swelling, mild to moderate pain on straining, scrotal heaviness, and the possible presence of a bulge are common complaints. Increased edema after standing in an erect position but decreases when the patient is recumbent.

3 Differential Diagnoses : undescended testis, lymphadenopathy, femoral hernia Pattern Recognition: Enlarged hemiscrotum or a bulge in the groin area that may spontaneously reducewhen the patient is supine or with manual reduction. The provider will not be able to move the fingersabove the mass, which should be soft and mushy but painless unless it is incarcerated and ischemic. Scrotal hernias do not transilluminate. Auscultation of bowel sounds over the mass is significant for thediagnosis of bowel in the scrotal sac. Treatment options : If the herniated bowel is reducible, surgical referral for possible future repair isindicated. Difficulty in reducing a hernia is cause for urgent surgical intervention. However, pain mayindicate incarceration of the bowel or complete inability to reduce the hernia, which is cause for immediate emergency department referral and surgical exploration. Review questions:

1. Mr.^ S.^ comes^ to^ you^ with^ scrotal^ pain.^ The^ examinations^ of^ his^ scrotum, penis, and rectum arenormal. Which of the following conditions outside of the scrotum may present as scrotal pain? A. Inguinal herniation and peritonitis ** B. Renal colic and cardiac ischemia C. Pancreatitis and Crohn ’ s disease D. Polyarteritis nodosa and ulcerative colitis Rationale: Conditions outside of the scrotum that may present with scrotal pain are abdominal aorticaneurysm, inguinal herniation, pancreatitis, renal colic, peritonitis, intraperitoneal hemorrhage, and polyarteritis nodosa. Keep in mind that any client with scrotal pain should be considered to have testicular torsion until proved otherwise, especially in the age groups of the neonate and adolescents.
2. The most common type of hernia is a(n): A. indirect inguinal hernia. ** B. direct inguinal hernia.

C. femoral hernia. D. umbilical hernia. Rationale: An indirect inguinal hernia is the most common type of hernia affecting all ages and both genders and accounts for 50% of hernias treated. The point of origin is above the inguinal ligament andoften travels into the scrotum. A direct inguinal hernia is less common (accounts for about 25% of hernias seen) and usually occurs in men older than age 40. The point of origin is above the inguinal ligament and rarely travels into the scrotum. The femoral hernia is the least common (about 10% of hernias seen) and occurs more often in women than in men. The point of origin is below the inguinal ligament and never travels into the scrotum in men. An umbilical hernia occurs more frequently in infants and is a protrusion of part of the intestine at the umbilicus.

3. Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that it is not painful, but it is annoying. You note that the origin of swelling is above the inguinalligament directly behind and through the external ring. You diagnose this as a(n): A. indirect inguinal hernia. B. direct inguinal hernia. ** C. femoral hernia. D. strangulated hernia. Rationale: A direct inguinal hernia usually occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or chronic obstructive pulmonary disease (COPD). The origin of swelling is above the inguinal ligament directly behind and through the external ring. An indirect inguinal hernia is congenital or acquired and is more common in infants younger than 1 year ofage and in men ages 16 – 25. The origin of swelling is above the inguinal ligament. The hernia sac enters

the canal at the internal ring and exits at the external ring. A femoral hernia, which occurs more frequently in women, is acquired and results from an increase in abdominal pressure, as well as muscle weakness. The origin of swelling is below the inguinal ligament. Because Max is not having any pain and the condition has been this way for months, you know that the hernia is not strangulated. A strangulatedhernia, which requires immediate referral to a surgeon, results in no blood supply to the affected boweland causes nausea, vomiting, and tenderness.

5. Orchitis Definition : Orchitis is a systemic, blood-borne infection that results in an acute inflammation of one or both testicles. It may coexist with infections of the prostate and epididymis; causes – viral infection (ex.Mumps), C. trachomatis and N. gonorrhoeae in adolescents, E. coli – men, complication of syphilis, mycobacterial, fungal; hydrocele and scrotal wall thickening may be seen as a complication of mumps Presenting Symptoms: Gradual onset of acute or moderate pain, testicular swelling, and fever 3 Differential Diagnoses : epididymitis, testicular tumor, hernia, testicular torsion Pattern Recognition : Testicular edema may be so pronounced that it is difficult to distinguish the testesfrom the epididymis. Palpation may reveal swollen, very tense testes that are painful, and the patient may be febrile. Inflammation of the testis usually involves systemic viral infections (commonly mumps) and includes unilateral or bilateral erythema, edema, and scrotal tenderness, which occurs 4 to 7 days after initial fever. Treatment options : Anti-infective therapy is recommended, with guidance by local sensitivity reports. The following antibiotic regimens are effective against the most common causes of epididymitis: single- dose ceftriaxone given intramuscularly (IM), 250 to 500 mg, and doxycycline, 100 mg twice daily for 10 days for men younger than 35 years; in men older than 35 years, levofloxacin

(given intravenously [IV] or orally [PO]), 500 to 750 mg/day, or ciprofloxacin, 500 mg (IV or PO), for 10 to 14 days. Antipyretics shouldbe used to reduce discomfort and fever, and an anti-inflammatory agent should be prescribed. An antiemetic can also be prescribed for nausea and vomiting. Bed rest and scrotal elevation are also recommended for epididymitis. Hot or cold compresses may be helpful for orchitis. Review questions: A 35 year old sexually active man presents with a 1 week history of fever and pain over the left scrotum.It is accompanied by frequency and dysuria. The scrotum is edematous and tender to touch. He denies flank pain, nausea, and vomiting. He reports that eh pain is lessend when he uses scrotal-support briefs.The urinalysis shows 2 + blood and a large number of leukocytes. What is the most likely diagnosis? A. Acute urinary tract infection B. Acute pyelonephritis C. Acute orthitis D. Acute epididymitis ** Orchitis is caused by which of the following? A. Mumps virus ** B. Measles virus C. Chlamydia^ trachomatis D. Chronic urinary tract infections that are not treated adequately A 10 year old boy complains of sudden onset of scrotal pain upon awakening that morning. He is also complaining of severe nausea and vomiting. During the physical examination, the nurse practitioner finds

a tender, warm, and swollen left scrotum. The cremastic reflex is negative and the urine dipstick isnegative for leukocytes, nitrites, and blood. The most likely diagnosis is: A. Acute epididymitis B. Severe salmonella infection C. Testicular torsion ** D. Acute orchitis What type of follow up should this patient receive? A. Refer to a urologist within 48 hours B. Refer him to the emergency department as soon as possible ** C. Prescribe ibuprofen (advil) 600 mg QID for pain D. Order a testicular ultrasound for further evaluation

6. Testicular torsion Definition : Testicular torsion - obstruction of blood flow to the testes because of a twisting of the arteries and veins in the spermatic cord resulting in occlusion of blood flow. Occurs in 12-18 year olds.Usually unilateral, effecting the left testis. Two types: extravaginal and intravaginal. Extravaginal (rare,seen in neonates)- twisting of the spermatic cord, testis, and process vaginalis; intravaginal (seen in adolescents)- failure of the testis to adhere to the scrotal wall, creating a “bell clapper deformity.” Different from torsion of the appendix testis. Presenting Symptoms : sudden in onset, extremely painful, and may awaken the patient from sleep or betrauma induced. Testicular pain, experience abdominal pain, nausea, and vomiting; 25% of patients have a fever. Clinical manifestations-testicle that rides high in the scrotum and an absent cremasteric reflex on examination 3 Differential Diagnoses : testicular appendix torsion, epididymitis, epididymo- orchitis, hydrocele Pattern Recognition : Most common in the left hemiscrotum. Scrotal edema and erythema may be seen.The affected side may have a higher

position as a result of rotation. The spermatic cord is swollen and extremely tender, the epididymis may be felt anteriorly, and the majority of patients will have an absent cremasteric reflex. In some instances a small area of cyanosis (blue dot sign) may be present on the scrotal skin and indicates torsion of the appendix testis. Treatment options : Surgical consultation with surgical exploration – needs to occur in 6 hours. Review questions :

1. A 24-year-old man presents with sudden onset of left-sided scrotal pain. He reports having intermittent unilateral testicular pain in the past but not as severe as this current episode. Confirmationof testicular torsion would include all of the following findings except: A.unilateral loss of the cremasteric reflex. B.the affected testicle held higher in the scrotum.C.testicular swelling. D.relief of pain with scrotal elevation. **
2. In assessing a man with testicular torsion, the NP is most likely to note:A.elevated PSA level. B. white blood cells reported in urinalysis. C. left testicle most often affected. ** D.increased testicular blood flow by color-flow Doppler ultrasound.

3. Anticipated organ survival exceeds 85% with testicular decompression within how many hours oftorsion? A. B. ** C. D.
4. To prevent a recurrence of testicular torsion, which of the following is recommended?A.use of a scrotal support B.avoidance of testicular traumaC.orchiopexy ** D.limiting the number of sexual partners 7. Epididymitis 1 Definition : Inflammation or infection of the epididymis. Commonly occurs in men younger than 35 yrs.of age with chlamydia as the cause. Men older than 35 yrs. is likely as a result of bacterial ascension frombladder or bacteria introduced during cauterization/surgery. Diagnostic test STD testing, urine culture and scrotal ultrasound R/O testicular torsion. 2 Presenting Symptoms: pain, dysuria, urgency/frequency, low back pain/perineal pain,fever/chills/malaise, scrotal edema 3 Differential Diagnoses: testicular torsion, inguinal hernia, hydrocele, testicular tumor, 4 Pattern Recognition : Enlarged, tender epididymis, Urethral discharge may be evident, Positive prehnssign, Normal cremasteric reflex R/O testicular torsion. 5 Treatment options: A Adult under 35yrs ceftriaxone 250mg IMx 1 PLUS Doxy 100mg BID a day or Azithromycin 1gm once.B Adult over 35 yrs Bactrim DS 1 tab BID a day x 10

days or cipro 250 mg BID x 10 days. C support/elevate scrotum D Analgesic NSIADs,ice(early),heat (late),bed rest. 6 Review questions:

1. Jordan appears with a rapid onset of unilateral scrotal pain radiating up to the groin and flank. You aretrying to differentiate between epididymitis and testicular torsion. Which test to determine whether swelling is in the testis or the epididymis should be your first choice? A. X-ray B. Ultrasound C. Technetium scan D. Physical examination Answer B If your client has a rapid onset of unilateral scrotal pain radiating up to the groin and flank and you aretrying to differentiate between epididymitis and testicular torsion, an ultrasound test is useful to determine whether the swelling is in the testis or the epididymis and should be your first choice. Initially, before the swelling has reached its peak, a physical examination will probably differentiate, butwithin a few hours, when the testis also swells, it may not be possible to differentiate between epididymis and testis by palpation. A reactive hydrocele may also develop. A technetium scan will show an increased uptake in the case of epididymitis and decreased uptake in the case of torsion, but the leastinvasive and most inexpensive test is an ultrasound.
2. The nurse practitioner recognizes that the most common cause of epididymitis in a young man is:A chlamydia

B E. coli C mycoplasma D Proteus species Answer A Chlamydia is a sexually transmitted infection which is the leading cause for epididymitis and nongonococcal urethritis in men less than 35 years old. Symptoms of epididymitis include unilateraltesticular pain and tenderness, hydrocele and palpable swelling of the epididymis

3. Your 25-year-old male patient has had a fever, dysuria, low back pain, and scrotal edema. Which of thefollowing is likely the diagnosis? A acute bacteria prostatitisB acute pyelonephritis C epididymitis D urinary tract infection Answer C The combination of urinary tract infection symptoms and scrotal edema is often the case in epididymitis. Treatment for those aged < 35 years is ceftriaxone (Rocephin) or doxycycline because themost common causative agent is chlamydia. For those aged over 35 years, (Bactrim) Trimethoprim/sulfamethoxazole is the common treatment. The proper treatment for urinary tract infection, acute pyelonephritis, and acute bacterial prostatitis istrimethoprim/sulfamethoxazole (Bactrim); however, scrotal edema is not present in these differentialdiagnoses 8. Benign prostatic hyperplasia Definition : a non-cancerous enlargement of the prostate gland. Seen in 50% of

men older than 50 and90% alder than 80. BPH is related to elevations of androgen and estrogen that stimulate prostatic growth. Presenting Symptoms : Symptoms are develop gradually. Obstructive BPH: urinary hesitancy, decreasedcaliber and force of the stream, and post void dribbling related to bladder outlet obstruction. Irritative symptoms include frequency, urgency, and nocturia and occur as a result of decreased functional bladder capacity and instability of infection. Hematuria may be present. 3 Differential Diagnoses : Bladder Calculi, Uretheral Stricture, Cancer of the Prostate, Bladder neckcontracture, and UTI, and Bladder cancer Pattern Recognition : UA should be ordered to exclude UTI. PSA is appropriate for men with a life- expectancy of more than 10 years in the presence of physical finding on DRE and if 5a-reductase inhibitor therapy (Proscar) is planned. DRE: Prostate that is enlarged but is symmetrical in texture andsize (rubbery texture). Treatment options : Lifestyle changes may decrease symptoms such as reduction of caffeine and alcoholintact, avoiding fluids before bedtime, and avoidance of diuretic medications. Meds:

1. Alpha-adrenergic antagonist: (Terazosin, Tamsulosin, Doxazosin) relax smooth muscle in thebladder neck, prostate capsule, and prostatic urethra. Take at night. Watch for orthostatic hypotension. Tamsulosin may have less effect on BP than other alpha blockers.
2. 5-alpha-reductase inhibitors (blocks testosterone): Finasteride (Proscar): shrink the prostatic glandular hyperplasia by decreased tissue DHT levels, but it may take up to 6-12 months to seeimprovement in symptoms.

3. Phosphodiesterase-5 (PDE%): Sildenafil or Tadalafil: used for men with mild to moderatesymptoms and erectile dysfunction
4. Saw^ Palmetto:^ herbal,^ may^ increase^ bleeding Balloon dilation: reduces symptoms in the short term TURP: effective for severe BPH, Gold standard treatment for bladder outlet obstruction, limited toprostates weighing less than 100g Review questions:
5. Which statement is true about the use of alpha blockers in the treatment of symptomatic BPH?They do not lower blood pressure in normotensive clients.
6. Milton, a 72 year old unmarried, sexually active white man presents to your clinic with complaints of hesitancy, urgency, and occasional uncontrolled dribbling. Although you suspect benign prostatic hypertrophy, what else should your differential diagnosis include? Urethral stricture (may develop as a result of sexually transmitted diseases and should be considered in a sexually active individual no matterwhat the age)
7. The action of a 5 alpha-reductace inhibitor in the treatment of BPH is to:reduce action of androgens in the prostate.
8. Harry has BPH and complains of some incontinence. Your first step in diagnosing overflowincontinence would be to order a: Post void residual urine measurement
9. Lower urinary tract symptoms in males can present as a constellation of storage or voiding symptoms.Storage symptoms include: urgency and nocturia

6. A 63-year-old man presents to you with hematuria, hesitancy, and dribbling. DRE reveals a moderatelyenlarged prostate that is smooth. The client’s PSA is 1.2. What is the most appropriate management strategy for you to follow at this time? Prescribe an alpha adrenergic blocker, which will relax bladder and prostate smooth muscle to improveflow and relieve symptoms.
7. In deciding whether to treat Morrison, who has BPH, you use the American Urological Associationscale. No treatment is indicated if the AUA score is 7 or lower.
8. According to the AUA guideline on the management of BPH, when is referral for invasive surgeryautomatically warranted? With the presence of refractory retention and bladder stones.
9. What differentiates prostate cancer symptoms from BPH? Symptoms of prostate cancer in general tend to progress more rapidly than those of BPH. 9. Chronic prostatitis-

Definition : Inflammatory infection of the prostate. Usually caused by gram negative bacteria like E. coli.nonbacterial prostatitis mostly in young men caused by chlamydia, mycoplasma, Gardnerella. Diagnostic test is urine culture. Presenting Symptoms : fever /chills, low back pain, dysuria, urgency /frequency, nocturia Differential Diagnoses : cystitis, BPH, Kidney stones, bladder ca, prostatic abscess, enterovesical fistula. Pattern Recognition : Edematous prostate, may be warm and tender/boggy in palpitation, pain. Treatment options : Antibiotic choices : Bactrim,Levaquin,noroxin,ofloxacinB sitz bath 3 times a day for 30mins C no sexual intercourse until acute phase resolves Review questions : 1 The most common gram-negative bacteria that causes both acute and chronic bacterial prostatitis is A. Staphylococcus aureus. B. Klebsiella. C. Escherichia coli. D. Enterobacteriac eae .Answer C The most common gram-negative bacterium that causes both acute and chronic bacterial prostatitis isEscherichia coli. The other aerobic gram-negative bacteria include Klebsiella, Pseudomonas, Enterobacteriaceae, Proteus mirabilis, and Neisseria gonorrhoeae. Occasionally other bacteria (Staphylococcus aureus and Streptococcus faecalis) are causes.

2 A history of urinary tract infections in males is often seen in men with chronic bacterial prostatitis.Other signs and symptoms of chronic bacterial prostatitis includes A. irritative^ voiding^ symptoms,^ low^ back^ pain,^ and^ perineal^ pain. B. nausea and vomiting, as well as fever. C. loss of appetite and weight loss. D. irritative voiding symptoms, inability to ambulate, and fever.Answer A Chronic bacterial prostatitis may have a variety of clinical presentations, but nausea and vomiting, loss ofappetite and weight loss, as well as an inability to ambulate are rarely among the presenting symptoms of this disorder. Even fever is typically not present in chronic cases. Typically, there are irritative voiding symptoms that have persisted over time, low back pain, and perineal pain, although any one, or all, maybe present. Sometimes clients are completely asymptomatic, although bacteria might be present on urinalysis, and expressed prostatic secretions usually demonstrate increased numbers of leukocytes. Physical examination may be unremarkable as well, although in some cases the prostate will feel boggyor indurated. There is often history of repeated urinary tract infections. Cystitis and/or chronic urethritismay be secondary or mimic prostatitis; however, cultures of the fractionated urine may localize the source of infection. Anal disease may share some of the symptoms of prostatitis, but physical examination should permit a distinction between the two. 3 When performing a prostate examination, you note a tender, warm prostate. What do you suspect? A. Benign prostatic hypertrophy B. Prostatic abscess C. Prostate cancer D. Bacterial

prostatitisAnswer D

Bacterial prostatitis, in which the prostate feels very tender and warm, is usually caused by Escherichiacoli. Clients with bacterial prostatitis usually also have a sudden onset of high fever, chills, malaise, myalgias, and arthralgias. In benign prostatic hypertrophy, the prostate gland would feel soft and nontender and would be enlarged. With prostatic abscess, the prostate feels like a firm, tender, or fluctuant mass. With prostate cancer, the prostate may have single or multiple nodules that are firm, hard, or indurated and are usually nontender.

10. Inguinal hernia Definition : An inguinal hernia happens when contents of the abdomen—usually fat or part of the small intestine—bulge through a weak area in the lower abdominal wall. Inguinal hernias occur at the inguinalcanal in the groin region. In males, the spermatic cords pass through the inguinal canals and connect to the testicles in the scrotum—the sac around the testicles. The spermatic cords contain blood vessels, nerves, and a duct, called the spermatic duct, that carries sperm from the testicles to the penis. In females, the round ligaments, which support the uterus, pass through the inguinal canals. Presenting Symptoms : The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sides of the groin—the area just above the groin crease between the lower abdomen and the thigh. The bulge may increase in size over time and usually disappears when lying down. Other signs and symptoms can include - discomfort or pain in the groin—especially when straining, lifting, coughing, or exercising—thatimproves when resting - feelings such as weakness, heaviness, burning, or aching in the groin - a swollen or an enlarged scrotum in men or boys - Incarceration. An incarcerated hernia happens when part of the fat or small intestine from inside the abdomen becomes

stuck in the groin or scrotum and cannot go back into the abdomen. A health care provider is unable to massage the hernia back into the abdomen.

• Strangulation. When an incarcerated hernia is not treated, the blood supply to the small intestine may become obstructed, causing “strangulation” of the small intestine. This lack of blood supply is an emergency situation and can cause the section of the intestine to die. 3 Differential Diagnoses : Ectopic testis, Femoral or inguinal adenitits, femoral hernia, sports hernia Pattern Recognition : Physical exam: Feel for a bulge in the inguinal area when a patient strains or coughs. If the hernia is causing problems and it is not reducible then x-ray, CT scan or Ultrasound may beneeded to see if it is incarcerated or strangulated. Treatment options : Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias andcan prevent incarceration and strangulation. Health care providers recommend surgery for most people with inguinal hernias and especially for people with hernias that cause symptoms. Research suggests that men with hernias that cause few or no symptoms may be able to safely delay surgery until their symptoms increase.3,^6 Men who delay surgery should watch for symptoms and see a health care provider regularly. Health care providers usually recommend surgery for infants and children to prevent incarceration.^1 Emergent, or immediate, surgery is necessary for incarcerated or strangulated hernias. Review questions:

1. Gerard is complaining of a scrotal mass; however, the scrotum is so edematous that it is difficult to assess. How do you determine if it is a hernia or a hydrocele? Bowel sounds may be heard over a hernia.

2. Mr. S comes to you with scrotal pain. The examinations of his scrotum, penis, and rectum are normal.Which of the following conditions outside of the scrotum may present as scrotal pain? Inguinal hernia and peritonitis. Conditions outside of the scrotum that may present with scrotal pain are abdominal aortic aneurysm, inguinal herniation, pancreatitis, renal colic, peritonitis, intraperitoneal hemorrhage, and polyarteritis nodosa. Keep in mind that any client with scrotal pain should be considered to have testicular torsion until proved otherwise, especially In the age groups of the neonate and adolescents.
3. The most common type of hernia is an: indirect inguinal hernia
4. Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that is not painful, but it is annoying. You note that the origin of swelling is above the inguinalligament directly behind and through the external ring. You diagnose this as a: direct inguinal hernia: which occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or COPD. An indirect inguinal hernia is congenital or acquired and is more common in infants younger than 1 and in men ages 16-25. 11. Varicocele Definition : Enlarged pampiniform plexus veins within the scrotum. They form during puberty and cangrow larger over time. More common on the left side. Presenting Symptoms : Often asymptomatic. When there are symptoms they are: pain, infertility, andthey may cause one testicle to grow slower or shrink. 3 Differential Diagnoses : testicular tumor, inguinal hernia, hermatocele or spermatocele Pattern Recognition: Described as a “bag of worms” because of how they look and feel. Mass disappearswhen the patient lies down and reappears when the patient

stands. Often found using the “Valsalva maneuver.” Scrotal Ultrasound can definitively diagnose. New onset varicocele can signal testicular tumor or mass that impedes venous drainage. Treatment options : asymptomatic varicoceles do not need treatment. Surgical treatment is offered to those with fertility problems, pain, or asymmetrical growth of one testicle. Ibuprofen and Tylenol can help with pain. Least invasive, Percutaneous embolization, is done under general anesthetic and involvesblocking blood flow to the pampiniform plexus veins and the varicocele shrink. If necessary, open or laparoscopic surgery is done. Review questions :

1. A 17 year old boy reports feeling something on his left scrotum. On palpation, soft and movable bloodvessels that feel like a “bag of worms” are noted underneath the scrotal skin. It is not swollen or reddened. The most likely diagnosis is (D) A. Chronic orchitis B. Chronic^ epididymitis C. Testicular torsion D. Varicocele ** Rationale: Varicose veins in the scrotal sac feels like “a bag of worms”
2. What risk factors contribute to varicocele? (D) A. Younger age B. Current cigarette smoker C. Multiple sex partners D. None of the above **

Rationale: There are no apparent significant risk factors for varicocele, but being overweight may slightlyincrease risk.

3. Treatment options for varicocele repair include all of the following except:(C) A. Open surgery B. Laparoscopic surgery C. Treatment with a thrombolytic agent ** D. Percutaneous^ embolization Rationale: Treatment for varicocele might not be necessary unless it causes pain, testicular atrophy, or infertility. Repair can involve open surgery, laparoscopic surgery or percutaneous embolization. A scrotalsupport may also provide relief of discomfort associated with this condition. 12. Balanitis Definition : Inflammation of the glans penis. Presenting Symptoms : Erythema, tenderness, edema, foul smelling discharge, ulceration, plaque. 3 Differential Diagnoses : psoriasis, Reiter syndrome, Lichen planus Pattern Recognition : Most common in uncircumcised men, diabetics, and/or immunocompromised. Treatment options : Local hygiene, warm compresses or sitz baths. Consider circumcision for prevention of recurrent balanitis. Most common pathogen is candida. Treat with antifungals (Clotrimazole, Nystatin, Fluconazole) or Abx (Bacitracin, Neosporin). If cellulitis present use po or IV cephalosporin or sulfa drug.Osmotic agents like granulated sugar placed on edematous tissue for several hours can reduce swelling.The puncture technique involves puncturing the edematous foreskin with 21 g needles allowing fluid to drain. Review questions :

There is a higher risk of balanitis in which of the following conditions? A. Renal Insufficiency B. Diabetes Mellitus ** C. Graves’ disease D. Asthma Rationale: Balanitis is more common in uncircumcised, diabetic, and/or immunocompromised males.

2. Balanitis is caused by: A. Staphylococcus aureus B. Streptococcus pyogenes C. Candida albicans ** D. Trichomonads Rationale: Balanitis is most often caused by a Candidal infection of the glans penis.
3. Balanitis is a symptom of which one of the following diseases A. Psoriatic arthritis B. Reactive arthritis ** C. Alkylosing Spondylitis D. Rheumatoid arthritis Rationale: Circinate balanitis occurs in reactive arthritis (formerly known as Reiter Syndrome) presents aspainless, asymptomatic, shallow, ulcerative lesions on the glans of the penis.