24. Scrotal Mass

Question 1

What are the main contents of the scrotum?

Answer 1

Testes
Epididymis
Testicular arteries
Pampiniform plexus

Question 2

What must you immediately consider if the lump is painful?

Answer 2

Testicular torsion

Question 3

List important features of the history of presenting complaint that you must ask about.

Answer 3

Is the lump painful?
How long has the lump been there for?
When did you first notice the lump?
Has the lump got bigger, smaller or stayed the same size?
Is the lump always there?
Are there any other lumps?
Has there been any trauma to the testes?
Does the testis feel heavy?

Question 4

When do inguinal hernias tend to appear in the scrotum?

Answer 4

When intra-abdominal pressure is increased (e.g. when coughing)

Question 5

Describe the variation in size of a varicocoele during the day?

Answer 5

They disappear when the patient lies flat

They will appear when the patient has been standing for a long time

Question 6

List some UTI symptoms that you should ask about.

Answer 6

Dysuria
Polyuria
Suprapubic pain 
Offensive-smelling urine
Urgency
Strangury
Haematuria

Question 7

List an STI symptom that you should ask about.

Answer 7

Urethral discharge

Question 8

What feature of the testis raises suspicion of testicular cancer?

Answer 8

If the testicle feels heavy

Question 9

What is the most likely diagnosis if you can’t get above the swelling?

Answer 9

Inguinoscrotal hernia

Question 10

Why is it important to check whether the mass is separate from the testicle?

Answer 10

It allows you to elicit whether the problem is in the testicle itself, or with other structures within the scrotum

Question 11

What important information about the swelling does transillumination allow you to elicit?

Answer 11

It tells you whether the swelling is caused by a collection of fluid (e.g. a cyst) or a solid mass (e.g. a tumour)

Question 12

What would you suspect if the mass is NOT separate from the testis and does transilluminate?

Answer 12

Hydrocoele

Question 13

What would you suspect if the mass is NOT separate from the testis, does NOT transilluminate and is tender?

Answer 13

Testicular torsion
Orchitis
Epididymo-orchitis
Acute haematocoele

Question 14

What would you suspect if the mass is NOT separate from the testis, does NOT transilluminate and is NOT tender?

Answer 14

Testicular cancer
Chronic haematocoele
Gumma

Question 15

What would you suspect if the mass is separate from the testis and does transilluminate?

Answer 15

Epididymal cyst

Question 16

What would you suspect if the mass is separate from the testis, does NOT transilluminate and is tender?

Answer 16

Acute epididymitis

Torsion of hydatid of Morgagni (appendix testis)

Question 17

What would you suspect if the mass is separate from the testis, does NOT transilluminate and is NOT tender?

Answer 17

TB epididymitis

Post vasectomy sperm granuloma

Question 18

What is the main risk factor for testicular cancer?

Answer 18

Undescended/maldescended testicle

Question 19

What is the term given to the operation that places an undescended testicle in its correct place?

Answer 19

Orchidopexy

Question 20

To which lymph nodes do the testes drain?

Answer 20

Para-aortic lymph nodes

Question 21

To which lymph nodes does the scrotum drain?

Answer 21

Inguinal lymph nodes

Question 22

List some systemic symptoms of malignancy.

Answer 22

Fever
Weight loss
Night sweats

Question 23

What is the investigation of choice for any scrotal mass?

Answer 23

Ultrasound scan

Question 24

What are the main tumour markers for testicular cancer?

Answer 24

a-fetoprotein (AFP)
a-HCG
Lactate dehydrogenase (LDH)

Question 25

Describe the characteristic features of an epididymal cyst.

Answer 25

Distinct from the testis (superior and posterior to it)
Can get above the swelling
Fluctuant and transilluminable
Often multiple or multiocular, and may be bilateral

Question 26

What is the term given to a subtype of epididymal cyst that contains milky fluid?

Answer 26

Spermatocoele

Question 27

Describe what a varicocoele feels like on palpation.

Answer 27

It feels like ‘a bag of worms’

Question 28

What is a varicocoele?

Answer 28

It is made up of dilated, tortuous veins of the pampiniform plexus

Question 29

How do varicocoeles vary in size?

Answer 29

They respond to changes in venous pressure so they can increase in size towards the end of the day (due to venous pooling) or following strenuous exercise
When the patient lies down, the varicocoele will not be palpable

Question 30

What conservative measure can be taken to reduce discomfort caused by varicocoeles?

Answer 30

Scrotal support (e.g. jock strap or tighter pants)

Question 31

If the varicocoele is painful, surgical intervention may be taken. List some treatment options.

Answer 31

Embolisation
Surgical ligation
Sclerotherapy

Question 32

What is a hydrocele?

Answer 32

A collection of fluid within the tunica vaginalis

Question 33

What are the two types of hydrocele?

Answer 33

Primary (idiopathic)

Secondary (to a testicular insult e.g. trauma, infection, cancer)

Question 34

In what age groups do secondary hydroceles tend to occur?

Answer 34

Men ages 20-40 yrs because they are at greatest risk of having one of the initiating pathologies

Question 35

How do you treat hydroceles?

Answer 35

Secondary – treat the cause

Primary – aspirate the fluid or undergo surgery

Question 36

What usually causes epididymo-orchitis?

Answer 36

Acute infections of the testes and epididymis usually arise in the urinary tract or as STIs and ascend via the vas deferens

Question 37

List some investigations for epididymo-orchitis.

Answer 37

Blood cultures – if the patient is septic, it is important to identify the causative organism
HIV test
Urine dipstick – look for signs of UTI (e.g. leucocytes and nitrites)
Urine MC&S – identify the causative organism
Urethral swab and GUM screen