Clinical Q&A - Osteopenia, AF and torsion of testis

Our team of experts answer your questions on osteopenia, AF and cervical polyps.

I admitted a patient urgently because I suspected torsion of the testis, but it turned out to be orchitis. Is there an easy way of telling one from the other?

Torsion can strike men at any age up to their 40s. Men are often sent away from A&E units with missed torsion.

Our policy, in a hospital with a 24-hour imaging service, is that no patient with testis pain leaves until the case has been discussed with the urologist.

The window for catching a torsion is only six hours before the risk of necrosis becomes high. You were right to admit.

MR GORDON MUIR, consultant urologist, King's College Hospital, London

A 70-year-old female patient had a bone density scan five years ago, which reported osteoporosis. She was given a bisphosphonate. A recent bone density scan has classed her as osteopenic. Is this possible?

Osteoporosis and osteopenia are defined according to WHO criteria, which relate an individual's bone mean density (BMD) to the young adult mean.

If the patient was commenced on therapy soon after diagnosis, these findings are not unexpected if the osteoporosis was not severe at onset.

This is because clinical trials of bisphosphonate therapy typically produce increases in BMD of up to 5 per cent at the femoral neck, and even 5-10 per cent at the lumbar spine.

The patient may, of course, also have modified a number of lifestyle factors or discontinued steroid therapy, which would also be relevant.

DR ELAINE DENNISON, MRC environmental epidemiology unit, University of Southampton

Should all patients with a new presentation of AF be referred to a cardiologist for an echocardiogram and possible cardioversion?

AF always has an underlying cause, even if most of the time we cannot easily identify it. So the answer is 'yes, everyone should see a cardiologist'.

As well as looking for a potential remediable cause, the assessment should check left ventricular function with echocardiography.

Patients should also be considered for anticoagulation to reduce the risk of stroke associated with AF.

The patient should be assessed to see whether direct current cardioversion is appropriate.

The decision on cardioversion for AF depends in part on associated cardiac conditions, the patient's general condition and the features of the AF, including its duration and precipitants.

For many patients, accepting the AF and opting for ventricular rate control is the most appropriate choice.

DR ANDREW CLARK, senior lecturer and honorary consultant cardiologist, Castle Hill Hospital, Hull

Cervical polyps are a common finding on routine vaginal examinations or cervical screening. Should I always refer to a gynaecologist?

The decision in each case will depend on the patient's history and clinical features.

Age, symptoms and smear history should be taken into account, as well as the size and appearance of the polyp. After treatments such as laser cone biopsy, the cervix may look like a large sessile polyp, particularly if the treatment was less than six months ago. A tiny pedunculated polyp can be avulsed in the surgery, using polyp or sponge forceps, and then sent for histology. If the patient does not want to be referred to a gynaecologist, it might be possible to monitor the polyp every six to 12 months. This would be reasonable if the patient was asymptomatic, young and does not mind waiting.

However, if the patient is worried, it is better to refer.

MR ALOK ASH, consultant in obstetrics and gynaecology, St Thomas' Hospital, London.

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