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radiographic evaluation and exploration are needed in virtually all cases of solid scrotal masses.
Testicular torsion is defined as the twisting of the testis on its spermatic cord with resultant loss of blood
flow and testicular infarction. Commonly misdiagnosed as epididymitis, testis torsion warrants emergent
urological evaluation and possible scrotal exploration. As it is a clinical diagnosis, testicular torsion
should be seriously considered in any male patient aged 12-35 presenting with a sudden onset of pain,
swelling, and elevated testis within the hemiscrotum. A testicular radionuclide scanning, considered the
“gold standard” to reveal the absence of blood flow, or scrotal ultrasonography may assist with the
diagnosis. Torsion will reveal absence of flow on either study but ultrasonography may also reveal
hyperaemia of the epididymis and surrounding tissues. Interestingly, appendix testis or appendix
epididymidis torsion may present in the same manner.
Ultrasound is the generally preferred method of imaging for most scrotal conditions. Infectious disease,
varicoceles, hydroceles, and spermatoceles can be confirmed with ultrasound based on clinical suspicion.
CT or ultrasound in the setting of infection may reveal air within the scrotum or gangrenous tissue. In this
case, Fournier’s gangrene8 may be present and would require emergent débridement to prevent lifethreatening
infection.
Aeromedical considerations
The acute scrotal process precludes aviation duties. Testicular torsion and epididymitis can become
rapidly incapacitating. Consequently, torsion, infection, and malignancy (see section VIII below) are
incompatible with flying duty until they are resolved.Urological consultation in all of these cases is
mandatory to prevent surgery, if possible, and to ensure testicular salvage.
Hydrocele, spermatocele, and hernia disease may be managed conservatively when asymptomatic.
However, all pilots are required to be completely free of those hernias that might give rise to
7 Valsalva manouevre: forced expiratory effort against the closed glottis (“strain”) in order to increase intrathoracic
pressure. After Antonio M. Valsalva, Italian anatomist (1666-1723)
8 Fournier’s gangrene: an acute gangrenous type of necrotizing fasciitis of the scrotum, penis, or perinaeum
involving gram-positive organisms, enteric bacilli, or anaerobes. After Jean Alfred Fournier, French dermatologist
(1832-1914).
ICAO Preliminary Unedited Version — November 2009 III-6-14
incapacitating symptoms during flight, so surgical consultation and remediation of inguinal hernia
disease must be the rule. Especially during flight, because of the decrease in ambient pressure, this
condition may suddenly result in bowel incarceration and strangulation, even when previously
asymptomatic and reducible, causing an aeromedical emergency.
BENIGN PROSTATIC HYPERPLASIA
Disease process
Benign prostatic hyperplasia affects nearly 50 percent of men ages 51-60 and 90 per cent of those over 80
years old. It is characterized by hyperplasia of both prostatic glandular epithelial and stromal cells,
commonly in the central zone of the prostate. Dihydrotestosterone (DHT), converted from plasma
testosterone by the enzyme 5-alpha-reductase, acts as a propagator of this condition. Medicinal therapy
targets this enzyme, thereby decreasing intracellular DHT. Depending on race, most glands are stable
until the fifth decade, when enlargement may occur. Only about 10 percent of men require an operative
cure for their condition.
Clinical features
Obstructive symptoms are predominant but they do not necessarily relate to the size of the prostate on
examination. Prostatic urethral compression is the mechanism of obstruction, and it may occur even in
glands of grossly normal size. Initial symptoms include decreased urinary stream force, hesitancy in
initiation of voiding, post-void dribbling, and a sensation of incomplete emptying. As the degree of
obstruction increases, nocturia, overflow incontinence, urinary retention, and obstructive uropathy may
result. End-stage obstructive cases may result in renal compromise.
Diagnosis
A thorough history and examination is required in any male with lower urinary tract symptoms (LUTS).
Historical identification of haematuria, infection, diabetes, and neurological disease is important. The
international prostate symptom score (IPSS)9 is an important adjunct to the history. Previous urinary
instrumentation, urethral stricture disease, or recent addition of medications may confound the differential
diagnosis. Anticholinergics may impair bladder contractility, and alpha agonists such as pseudoephedrine
may increase outflow resistance.
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Manual of Civil Aviation Medicine 2(2)
