Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the urethral meatus, and a high-riding prostate on digital rectal examination are the typical features of urethral injury.

Up to 10% of male pelvic fractures are associated with urethral or bladder injuries. Urethral injury occurs mainly in males. It has two types.
1.Bulbar rupture:
a. most common
b. mostly associated with straddle-type injury, e.g. from bicycles
c. presentation with a triad of urinary retention, perineal haematoma, and blood at the meatus

2. Membranous rupture:
a. can be extra- or intraperitoneal
b. occurs commonly due to pelvic fracture
c. symptomology may include penile or perineal oedema/haematoma
d. prostate displaced upwards (high-riding prostate)

Ascending urethrogram is carried out in patients of suspected urethral injury. Suprapubic catheter is surgically placed and is indicated in:
1. External genitalia injuries (i.e. the penis and the scrotum)
2. Injury to the urethra caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation.

Adductor canal compression syndrome most commonly presents in young males, and it is important to differentiate it from acute limb ischaemia on exertion. Of the listed options, popliteal fossa entrapment is the main differential diagnosis. However, the popliteal pulse disappears when the knee is fully extended in popliteal fossa entrapment.

Adductor canal compression syndrome is caused by compression of the femoral artery by the musculotendinous band of adductor magnus muscle. The treatment consists of division of the abnormal band and restoration of the arterial circulation.

Priapism is defined as a prolonged penile erection lasting for >4 h in the absence of sexual stimulation and remains despite orgasm.

The classification of priapism is conventionally divided into three main groups. The commonest classification is into non‐ischaemic (high flow), ischaemic (low flow), and stuttering (recurrent) subtypes.

The EAU guidelines refer to the subtypes as ischaemic (low flow, veno‐occlusive) and arterial (high flow, non‐ischaemic). Of these, ischaemic priapism is the commonest, with refractory cases at risk of smooth muscle necrosis in the corpus cavernosum leading to sequelae of corporal fibrosis and erectile dysfunction (ED).

One of the key considerations in the management of priapism is the duration of the erection at presentation.
The EAU guidelines do differentiate the periods such that the intervention varies accordingly, which is particularly important for prolonged episodes that are refractory to pharmacological interventions and allow a step‐wise intervention.

Ischaemic priapism is a medical emergency as the progressive ischaemia within the cavernosal tissue is associated with time‐dependent changes in the corporal metabolic environment, which eventually leads to smooth muscle necrosis. As the duration of the penile erection becomes pathologically prolonged, as in the case of low‐flow priapism, the partial pressure of oxygen (pO2) progressively falls as the closed compartment prevents replenishment of stagnant blood with freshly oxygenated arterial blood.
Investigations using corporal blood aspiration, that in itself can be a therapeutic intervention leading to partial or complete penile detumescence, helps to differentiate ischaemic from non‐ischaemic priapism subtypes based on the pO2, pCO2 and pH levels. The AUA guidelines state that typically the blood gas analysis would give a pO2 of <30 mmHg and pCO2 of >60 mmHg and a pH of <7.25 in ischaemic priapism, whereas non‐ischaemic blood gas analysis would show values similar to venous blood. Once the diagnosis of priapism has been made, the initial management involves corporal blood aspiration followed by instillation of α‐agonists directly into the corpus cavernosum.
The EAU guidelines recommend several possible agents for intracavernosal injection, as well as oral terbutaline after intracavernosal injection.
Phenylephrine – 200 μg every 3–5 min to a maximum of 1 mg within 1 h.
Etilephrine – 2.5 mg diluted in 1–2 mL saline.
Adrenaline – 2 mL of 1/100 000 solution given up to 5 times in a 20‐min period.
Methylene blue – 50–100 mg intracavernosal injection followed by aspiration and compression.

Shunt surgery allows diversion of blood from the corpus cavernosum into another area such as the corpus spongiosum (glans or urethra) or the venous system (saphenous vein). Both the EAU and AUA guidelines recommend surgical intervention using firstly distal shunts and then proximal shunts in cases where aspiration and instillation of pharmacological agents fails to achieve penile detumescence. The EAU guidelines recommend that distal shunts should be attempted before proximal shunts, although the specific technique is left to the individual surgeon’s preference. The EAU guidelines also define a time point (36 h) when shunt surgery is likely to be ineffective in maintaining long‐term erectile function and may serve to reduce pain only. This is an important consideration when contemplating early penile prosthesis placement.

Suspected penile fractures should be surgically explored and the injury repaired.

Penile fractures are a rare type of urological trauma. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classical history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination, a tense haematoma is most commonly noted, and if the urethra is injured, blood may be seen at the meatus.

The correct management involves surgical exploration and repair of the injury. A circumferential incision is made immediately inferior to the glans and the penile shaft is inspected. Injuries are usually sutured and the urethra is repaired over a catheter.

Abdominal Ultrasound is the imaging method of choice for varicocele.
A varicocele is abnormal dilation and enlargement of the scrotal venous pampiniform plexus which drains blood from each testicle. While usually painless, varicoceles are clinically significant because they are the most commonly identified cause of abnormal semen analysis, low sperm count, decreased sperm motility, and abnormal sperm morphology. Varicoceles are far more common (80% to 90%) in the left testicle. If a left varicocele is identified, there is a 30% to 40% probability it is a bilateral condition.

There are three theories as to the anatomical cause:

– The Nutcracker effect which occurs when the left internal spermatic vein gets caught between the superior mesenteric artery and the aorta. This entrapment causes venous compression and spermatic vein obstruction.
– Failure of the anti-reflux valve where the internal spermatic vein joins the left renal vein. This failure causes reflux and retrograde flow in the testicular vein.
– Angulation at the juncture of the left internal spermatic vein and the left renal vein.

Varicoceles are usually asymptomatic. The patient may describe a bag of worms if the varicocele is large enough. Varicoceles present as soft lumps above the testicle, usually on the left side of the scrotum. Patients may sometimes complain of pain or heaviness in the scrotum.
A sudden onset of varicocele in a man over the age of 30 years requires the exclusion of renal tumours, particularly in elderly patients. In such cases it is necessary to extend diagnostic ultrasonography with abdominal examination. The diagnosis of varicocele is based on medical history and physical examination, which involves palpation and observation of the scrotum at rest and during the Valsalva manoeuvre.

A sperm granuloma is a lump of extravasated sperm that appears along the vasa deferentia or epididymides in vasectomized men.
Sperm granulomas are rounded or irregular in shape, one millimetre to one centimetre or more, with a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. Sperm granulomas can be either asymptomatic or symptomatic (i.e., either not painful or painful, respectively). If it is painful, it can be treated using over-the-counter anti-inflammatory /pain medication. If it causes unbearable discomfort, it may need to be surgically removed. However, they generally heal by themselves. Statistics suggest that between 15-40% of men may develop a granuloma post-vasectomy.

In a radical nephrectomy, the surgeon removes the whole kidney, the fatty tissues surrounding the kidney and a portion of the tube connecting the kidney to the bladder (ureter). The surgeon may remove the adrenal gland that sits atop the kidney if a tumour is close to or involves the adrenal gland. Radical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken.

Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more commonly affected than females and sporadic tumours typically affect patients in their sixth decade.

Vesicovaginal fistula (VVF) is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence. It is one of the most distressing complications of gynaecologic and obstetric procedures. Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour.

A renogram, which may also be known as a MAG3 scan, allows a nuclear medicine physician or a radiologist to visualize the kidneys and learn more about how they are functioning.
After injection into the venous system, the compound is excreted by the kidneys and its progress through the renal system can be tracked with a gamma camera. A series of images are taken at regular intervals.

If the kidney is not getting blood for example, it will not be viewed at all, even if it looks structurally normal in medical ultrasonography or magnetic resonance imaging. If the kidney is getting blood, but there is an obstruction inferior to the kidney in the bladder or ureters, the radioisotope will not pass beyond the level of the obstruction, whereas if there is a partial obstruction then there is a delayed transit time for the MAG3 to pass. More information can be gathered by calculating time activity curves; with normal kidney perfusion, peak activity should be observed after 3–5 minutes. The relative quantitative information gives the differential function between each kidney’s filtration activity.

Mesenteric venous thrombosis (MVT) is a blood clot in one or more of the major veins that drain blood from the intestine. The superior mesenteric vein is most commonly involved. The exact cause of MVT is unknown. However, there are many diseases that can lead to MVT. Many of the diseases cause swelling (inflammation) of the tissues surrounding the veins, and include:
Appendicitis
Cancer of the abdomen
Diverticulitis
Liver disease with cirrhosis
High blood pressure in the blood vessels of the liver
Abdominal surgery or trauma
Pancreatitis
Inflammatory bowel disorders
Heart failure
Protein C or S deficiencies
Polycythaemia vera
Essential thrombocythemia
People who have disorders that make the blood more likely to stick together (clot) have a higher risk for MVT. Birth control pills and oestrogen medicines also increase risk.

MVT is more common in men than women. It mainly affects middle aged or older adults. Symptoms may include any of the following:
Abdominal pain, which may get worse after eating and over time; Bloating; Constipation; Bloody diarrhoea; Fever; Septic shock; Lower gastrointestinal bleeding; Vomiting and nausea.
Blood thinners (most commonly heparin or related medicines) are used to treat MVT when there is no associated bleeding. In some cases, medicine can be delivered directly into the clot to dissolve it. This procedure is called thrombolysis. Less often, the clot is removed by thrombectomy.

Klippel-Trenaunay syndrome is a condition that affects the development of blood vessels, soft tissues (such as skin and muscles), and bones. The disorder has three characteristic features: a red birthmark called a port-wine stain, abnormal overgrowth of soft tissues and bones, and vein malformations.

Most people with Klippel-Trenaunay syndrome are born with a port-wine stain. This type of birthmark is caused by swelling of small blood vessels near the surface of the skin. Port-wine stains are typically flat and can vary from pale pink to deep maroon in colour.

Klippel-Trenaunay syndrome is also associated with overgrowth of bones and soft tissues beginning in infancy. Usually this abnormal growth is limited to one limb, most often one leg. However, overgrowth can also affect the arms or, rarely, the torso.

Malformations of veins are the third major feature of Klippel-Trenaunay syndrome. These abnormalities include varicose veins and deep veins in the limbs. Malformations of deep veins increase the risk of a deep vein thrombosis (DVT).

Other complications of Klippel-Trenaunay syndrome can include cellulitis, lymphedema, and internal bleeding from abnormal blood vessels. Less commonly, this condition is also associated with fusion of certain fingers or toes (syndactyly) or the presence of extra digits (polydactyly).

As the stone is smaller in size, there is a strong likelihood (75%) of it to be passed spontaneously. Furthermore, distally sited stones are more likely to pass spontaneously than proximally sited ones. Hence, it should be arranged to review the patient in two weeks with a KUB X-ray.

Urolithiasis affects up to 15% of the population worldwide. The development of sudden-onset, colicky loin to groin pain is a classical feature in the history. It is nearly always associated with haematuria that is either micro- or macroscopic. The most sensitive and specific diagnostic test is helical, non-contrast CT scanning.

Management options for urolithiasis are:
1. Most renal stones measuring <5mm in maximum diameter typically pass within four weeks of onset of symptoms. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney, and previous renal transplant.
2. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters, and ureteric stent placement.
3. In the non-emergency setting, the preferred options for treatment include extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, and open surgery (selected cases). Minimally invasive options are the most popular first-line treatment.

Catheter-directed thrombolysis (CDT) is recommended as the next step of management for patients with proximal upper-extremity deep vein thrombosis (UEDVT) of recent onset or severe symptoms.

Primary UEDVT is less common than secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in otherwise healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.

Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.

Diagnosis is made by:
1. FBC: platelet function
2. Coagulation profile
3. Liver function tests
4. Duplex scan: investigation of choice
5. D-dimer testing
6. CT scan: for VTOS

Treatment options for primary UEDVT are as follows:
1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.

2. Early thrombus removal and restoration of venous patency should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.

Lymphadenitis is the inflammation or enlargement of a lymph node. Lymph nodes are small, ovoid nodules normally ranging in size from a few millimetres to 2 cm. They are distributed in clusters along the course of lymphatic vessels located throughout the body. The primary function of lymph nodes is to filter out microorganisms and abnormal cells that have collected in lymph fluid. Lymph node enlargement is a common feature in a variety of diseases and may serve as a focal point for subsequent clinical investigation of diseases of the reticuloendothelial system or regional infection. The majority of cases represent a benign response to localized or systemic infection. The red streaks that are noted along the line of lymphatics are indicative of lymphadenitis.

Groin masses are common and include:
Herniae
Lipomas
Lymph nodes
Undescended testis
Femoral aneurysm
Saphena varix

Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein of the legs, thigh, or pelvis. Thrombosis is most often seen in individuals with a history of immobilization, obesity, malignancy, or hereditary thrombophilia. Vascular endothelial damage, venous stasis, and hypercoagulability, collectively referred to as the Virchow triad, are the main factors contributing to the development of DVT.
Symptoms usually occur unilaterally and include swelling, tenderness, and redness or discoloration. Pulmonary embolism (PE), a severe complication of DVT, should be suspected in patients with dizziness, dyspnoea, and fever. The diagnostic test of choice for DVT is compression ultrasound. In most cases, a negative D-dimer test allows thrombosis or PE to be ruled out, but a positive test is nonspecific.
Initial acute treatment of DVT consists of anticoagulation with heparin and, if the thrombus is large or unresponsive to anticoagulation, may also include thrombolysis or thrombectomy. Secondary prophylaxis is achieved with oral warfarin or direct factor Xa inhibitors and supportive measures such as regular exercise and compression stockings.

Intravenous drug users are at a high risk of right-sided cardiac valvular endocarditis. The character of the murmur described in the scenario fits with the diagnosis of tricuspid valve endocarditis.

Other listed options are ruled out because:
1. Aortic regurgitation—Early diastolic murmur
2. Mitral regurgitation—Pansystolic murmur
3. Aortic valve stenosis—Ejection systolic murmur
4. Tricuspid valve stenosis—Mid-diastolic murmur

The following history findings are associated with acute epididymitis and orchitis:
– Gradual onset of scrotal pain and swelling, usually unilateral, often developing over several days (as opposed to hours for testicular torsion)
– Dysuria, frequency, or urgency
– Fever and chills (in only 25% of adults with acute epididymitis but in up to 71% of children with the condition)
Usually, no nausea or vomiting (in contrast to testicular torsion)
– Urethral discharge preceding the onset of acute epididymitis (in some cases)

Physical examination findings may fail to distinguish acute epididymitis from testicular torsion. Physical findings associated with acute epididymitis may include the following:
– Tenderness and induration occurring first in the epididymal tail and then spreading
– Elevation of the affected hemiscrotum
– Normal cremasteric reflex
– Erythema and mild scrotal cellulitis
– Reactive hydrocele (in patients with advanced epididymo-orchitis)
– Bacterial prostatitis or seminal vesiculitis (in post pubertal individuals)
– With tuberculosis, focal epididymitis, a draining sinus, or beading of the vas deferens
– In children, an underlying congenital anomaly of the urogenital tract
Findings associated with orchitis may include the following:
– Testicular enlargement, induration, and a reactive hydrocele (common)
– Non-tender epididymis
In 20-40% of cases, association with acute epididymitis

Answer: Torsion of a testicular hydatid

The appendix testis (or hydatid of Morgagni) is a vestigial remnant of the Müllerian duct, present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time. The appendix of testis can, occasionally, undergo torsion (i.e. become twisted), causing acute one-sided testicular pain and may require surgical excision to achieve relief. One third of patients present with a palpable blue dot discoloration on the scrotum. This is nearly diagnostic of this condition. If clinical suspicion is high for the serious differential diagnosis of testicular torsion, a surgical exploration of the scrotum is warranted. Torsion of the appendix of testis occurs at ages 0-15 years, with a mean at 10 years, which is similar to that of testicular torsion.

Occasionally a torsion of the hydatid of Morgagni can produce symptoms mimicking those created by a testicular torsion; a torsion of the hydatid, however, does not lead to any impairment of testicular function.
Absence of the cremasteric reflex is a sign of testicular torsion. This therefore confirms that the diagnosis is Torsion of a testicular hydatid.

Saphenopopliteal (SPJ) reflux may be present in 20–25% of patients with primary varicose veins. Pre-operative colour duplex marking increases the accuracy of localisation of the SPJ at operation and is considered to be the gold standard for this purpose. A prospective study of 50 consecutive primary SSV ligations was undertaken and it showed that duplex was highly accurate in correctly locating the SPJ to within an accuracy of 20 mm in 98% of cases. The comparative figure for short saphenous vein (SSV) palpation was 48%. Palpation alone therefore cannot be recommended as a means of determining the site of SPJ and duplex continues to remain the gold standard for the preoperative localisation of the SPJ.

Tuberous sclerosis is a genetic disorder characterized by the growth of numerous noncancerous (benign) tumours in many parts of the body. These tumours can occur in the skin, brain, kidneys, and other organs, in some cases leading to significant health problems. Tuberous sclerosis also causes developmental problems, and the signs and symptoms of the condition vary from person to person.

Virtually all affected people have skin abnormalities, including patches of unusually light-coloured skin, areas of raised and thickened skin, and growths under the nails. Tumours on the face called facial angiofibromas are also common beginning in childhood.

Tuberous sclerosis often affects the brain, causing seizures, behavioural problems such as hyperactivity and aggression, and intellectual disability or learning problems. Some affected children have the characteristic features of autism, a developmental disorder that affects communication and social interaction. Benign brain tumours can also develop and these tumours can cause serious or life-threatening complications.

Kidney tumours are common in people with tuberous sclerosis; these growths can cause severe problems with kidney function and may be life-threatening in some cases. Additionally, tumours can develop in the heart, lungs, and the retina.

The presence of a necrotic and infected forefoot with necrosis of the heel and a boggy indurated swelling anterior to the ankle joint in a patient with sepsis secondary to diabetic foot ulcer indicates that a below knee amputation is the best option.

Based on Wagner’s Classification of Diabetic Foot Ulcers, this patient has a grade of 5 where there is gangrene or necrosis of large portion of the foot
requiring major limb amputation.

Infection in a diabetic foot is usually secondary to ulceration. Rarely, infection itself causes ulceration. It can either be local or systemic. Treatment requires early incision and drainage or debridement and empirical broad-spectrum antibiotic therapy. If there is co-exiting gangrene or extensive tissue loss, early amputation at the appropriate level should be considered to remove the focus of infection.

Answer: MAG 3 renogram

This is the agent of choice due to a high extraction rate, which may be necessary for an obstructed system. Diuretic (furosemide) renogram is performed to evaluate between obstructive vs. nonobstructive hydronephrosis. The non-obstructive hydronephrosis will demonstrate excretion (downward slope on renogram) after administration of diuretic from the collecting system. Whereas mechanical obstructive hydronephrosis will show no downward slope on renogram, with retained tracer in the collecting system.

Pelviureteric junction (PUJ) obstruction/stenosis can be one of the causes of an obstructive uropathy. It can be congenital or acquired with a congenital PUJ obstruction being one of the most common causes of antenatal hydronephrosis. This is defined as an obstruction of the flow of urine from the renal pelvis to the proximal ureter.
Many cases are asymptomatic and identified incidentally when the renal tract is imaged for other reasons. When symptomatic, symptoms include recurrent urinary tract infections, stone formation and even a palpable flank mass. They are also at high risk of renal injury even by minor trauma.

Symptom: Classically intermittent pain after drinking large volumes of fluid or fluids with a diuretic effect is described, due to the reduced outflow from the renal pelvis into the ureter.

Tc-99m DMSA (dimercaptosuccinic acid) is a technetium radiopharmaceutical used in renal imaging to evaluate renal structure and morphology, particularly in paediatric imaging for detection of scarring and pyelonephritis. DMSA is an ideal agent for the assessment of renal cortex as it binds to the sulfhydryl groups in proximal tubules at the renal cortex with longer retention than other agents. This results in higher concentration and hence much higher resolution with pinhole SPECT imaging. Also, it allows better assessment of differential renal function. It is a static scan as opposed to dynamic DTPA or MAG3 scans.

A mid diastolic murmur at the apex is a classical description of a mitral stenosis (MS) murmur.
MS a valvular anomaly of the mitral valve that leads to obstruction of blood flow into the left ventricle. The most common cause of MS is rheumatic fever. The clinical manifestations depend on the extent of stenosis: reduced mitral opening leads to progressive congestion behind the stenotic valve. Acute decompensation can cause pulmonary oedema. Echocardiography is the main diagnostic tool for evaluating the mitral valve apparatus, left atrial size, and pulmonary pressure. In the event of high grade and/or symptomatic stenosis, percutaneous valvuloplasty or surgical valve replacement is often required.

Types and causes of murmurs:
Ejection systolic: Aortic stenosis, pulmonary stenosis, HOCM, ASD, Fallot’s
Pan-systolic: Mitral regurgitation, tricuspid regurgitation, VSD
Late systolic: Mitral valve prolapse, coarctation of aorta
Early diastolic: Aortic regurgitation, Graham-Steel murmur (pulmonary regurgitation)
Mid diastolic: Mitral stenosis, Austin-Flint murmur (severe aortic regurgitation)

This patient has an axillary vein thrombosis. It classically presents with pain and swelling of the affected limb. Venous duplex scan is needed to exclude a thrombus.

Primary proximal upper-extremity deep vein thrombosis (UEDVT) is less common than its secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in, otherwise, healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton/tennis, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.

Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.

Diagnosis is made by:
1. FBC: platelet function
2. Coagulation profile
3. Liver function tests
4. Venous duplex scan: investigation of choice, provides information relating to flow and characteristics of the vessels.
5. D-dimer testing
6. CT scan: for VTOS

Treatment options for primary UEDVT are as follows:
1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.

2. Early thrombus removal and restoration of venous patency aim should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.

A cervical rib in humans is an extra rib which arises from the C7 vertebra. Its presence is a congenital abnormality located above the normal first rib, and it consists of an anomalous fibrous band that often originates from C7 and may arc towards but rarely reaches the sternum. It is estimated to occur in 0.2% to 0.5% of the population. People may have a cervical rib on the right, left, or both sides.

Most cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally. However, they vary widely in size and shape, and in rare cases, they may cause problems such as contributing to thoracic outlet syndrome due to compression of the lower trunk of the brachial plexus or subclavian artery.

Compression of the brachial plexus may be identified by weakness of the muscles near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson’s sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.

Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary approach is the traditional operative method for excision of the cervical rib.

The most likely diagnosis is median arcuate ligament syndrome (MALS).

MALS, also known as coeliac artery compression syndrome, is a condition characterized by abdominal pain attributed to compression of the coeliac artery and the coeliac ganglia by the median arcuate ligament. The pain may be related to meals, may be accompanied by weight loss, and may be associated with an abdominal bruit.

The diagnosis of MALS is one of exclusion, as many healthy patients demonstrate some degree of coeliac artery compression in the absence of symptoms. Consequently, a diagnosis of MALS is typically only entertained after more common conditions have been ruled out. Once suspected, screening for MALS can be done with USS and confirmed with CT or MRI scan.

Treatment is generally surgical, the mainstay being open or laparoscopic division or separation of the median arcuate ligament combined with removal of the celiac ganglia. The majority of patients benefit from surgical intervention. Poorer responses to treatment tend to occur in patients of older age, those with a psychiatric condition or who use alcohol, have abdominal pain unrelated to meals, or who have not experienced weight loss.

Lymphatic filariasis, commonly known as elephantiasis, is a painful and profoundly disfiguring disease. In communities where filariasis is transmitted, all ages are affected. While the infection may be acquired during childhood its visible manifestations may occur later in life, causing temporary or permanent disability. The disease is caused by three species of thread-like nematode worms, known as filariae – Wuchereria bancrofti, Brugia malayi and Brugia timori. Male worms are about 3–4 centimetres in length, and female worms 8–10 centimetres. The male and female worms together form “nests” in the human lymphatic system.

Filarial infection can cause a variety of clinical manifestations, including lymphoedema of the limbs, genital disease (hydrocele, chylocele, and swelling of the scrotum and penis) and recurrent acute attacks, which are extremely painful and are accompanied by fever. The vast majority of infected people are asymptomatic, but virtually all of them have subclinical lymphatic damage and as many as 40% have kidney damage, with proteinuria and haematuria.

This is likely a case of epididymo-orchitis which usually occurs due to infection with gonorrhoea or chlamydia in this age group (<35 years). Epididymo-orchitis is an acute inflammation of the epididymis and often involves the testis. It is usually caused by bacterial infection which spreads from the urethra or bladder. Amiodarone is a recognised non-infective cause of epididymitis, which resolves on stopping the drug. On examination, tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.

This patient has possible urethral injury based on the history. Urethral catheterisation is contraindicated in this situation.

Up to 10% of male pelvic fractures are associated with urethral or bladder injuries. Urethral injury occurs mainly in males. It has two types.

1.Bulbar rupture:
a. most common
b. mostly associated with straddle-type injury, e.g. from bicycles
c. presentation with a triad of urinary retention, perineal haematoma, and blood at the meatus

2. Membranous rupture:
a. can be extra- or intraperitoneal
b. occurs commonly due to pelvic fracture
c. symptomology may include penile or perineal oedema/haematoma
d. prostate displaced upwards (high-riding prostate)

Ascending urethrogram is carried out in patients of suspected urethral injury. Suprapubic catheter is surgically placed and is indicated in:
1. External genitalia injuries (i.e. the penis and the scrotum)
2. Injury to the urethra caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation.

Lymphovenous anastomosis – Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Causes of lymphoedema:
Primary:
Sporadic, Milroy’s disease, Meige’s disease
Secondary:
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
Thrombophlebitis

Other options given:
Homans operation – Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.

Charles operation – All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.