Contrast enhanced CT or IVU is useful in elucidating tubular ectasia or medullary calcifications found in
medullary sponge kidney. Other anomalies previously mentioned may require ultrasound, CT, and MRI
to diagnose parenchymal disease in addition to contrast studies such as IVU, retrograde pyelography or
cystography to evaluate the ureters and bladder.
Management
Asymptomatic simple cystic disease requires no further study or treatment. Symptomatic distension of the
renal capsule, obstruction of the collecting system or infection may warrant percutaneous treatment,
sclerosis or even laparoscopic or open operative excision.
The complications of medullary sponge kidney, including calculus formation and infection, require
management. Hypercalciuria associated with the disease induces stone formation, and thus thiazides or
inorganic phosphates are effective for lowering hypercalciuria and limiting stone formation. Phosphate
administration may increase the risk of infectious stone development in the presence of urease-producing
bacteria. Therefore, if phosphates are used, frequent urinary cultures should be performed to ensure
absence of an asymptomatic infection. Long-term antibiotic prophylaxis may be required to prevent these
infections.
Aeromedical considerations
Many of the cystic and congenital abnormalities are disqualifying for aviation duties. Simple cystic
disease is compatible with flight as long as the cysts do not result in mechanical compromise to the
kidney, collecting system or renal vasculature. It is important to differentiate cystic abnormalities from
renal tumours.
Medullary sponge kidney is of aeromedical significance because of the disease complications.
Pyelonephritis and nephrolithiasis are common, with potential sequelae including septicaemia and renal
failure in symptomatic patients. For these reasons, it is disqualifying for aviation duties. Effective use of
the drugs listed above decreases complications and increases the chance of resuming aviation duties.
Autosomal recessive polycystic kidney disease expresses itself early; if an applicant is asymptomatic, the
disease is of little aeromedical importance. Adult polycystic kidney disease may threaten the safety of
flight and so should only be considered with limitation to multicrew operations. Any aeromedical
disposition of an applicant or aviator with polycystic kidney disease should be done in consultation with a
specialist and the medical assessor of the licensing authority.
Although some States require two functioning kidneys for medical certification, an individual may have
no risk of complications in an aviation environment with a single kidney. Normal renal function studies,
absence of symptoms, and no evidence of infectious, obstructive or congenital disease are signs of a good
prognosis. In such cases, unilateral agenesis and hypoplasia are of no clinical significance and are not
at increased risk to interfere with aviation duties.
In summary, symptoms of the above diseases that could impair flying performance include flank pain,
urinary urgency, frequency, dysuria, fever and malaise. Subtle decline of mental clarity and general
health may also occur and will require regular follow-up examinations of those who continue to fly.
SCROTAL PROBLEMS
Disease processes/ clinical features
ICAO Preliminary Unedited Version — November 2009 III-6-13
The scrotum is a loose sac containing the testes, the epididymides, and the spermatic cord.
Dermatological conditions, endocrinopathies, infection, vascular problems, malignancy, and other
diseases may arise in the scrotum and its contents. Testicular examination should reveal a firm, rubbery,
ovoid structure. Diminished testicular size suggests hypogonadism. Elevation of the testis in the
hemiscrotum may indicate torsion or malignancy, especially if palpable masses are present. In the setting
of these findings, the latter diagnosis should be suspected until proven wrong.
Hernias may present as a scrotal finding. Gentle pressure with the physician’s index finger, causing
invagination of the scrotum anterior to the testicle and spermatic cord up to the internal ring, may reveal
this and other pathology. Valsalva manoeuvres7 may assist with this diagnosis, and it may also be useful
in finding a varicocele. This finding is noted by the presence of a dilated, tortuous spermatic vein within
the hemiscrotum. Another diagnostic tool is transillumination: a cystic scrotal mass will transilluminate
whereas a solid one will not pass light.
Diagnosis
The most common physical finding in the testes is a mass. Painless, firm masses that clearly arise from
the testis are malignant until proven otherwise. Solid extratesticular masses tend to be benign but
　
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