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83. Testicular/scrotal swellings Flashcards

1
Q

History taking testicular/scrotal swelling

A

PC:
Pain - describe pain - A dragging sensation? Throbbing,aching? Severe? worse on standing? does elevating the testicles improve the pain? What were you doing when the pain started? Had you been doing nay sport or exercise before/at the time??
Lump - painful? Tried pressing it in? Constipation? Flatus present? Vomiting?

Have you noticed any breast tissue development?

SHx:
Sexual history

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2
Q

Examination scrotal swellings

A

Inspection:
General inspection
Cough

Palpation:
Light palpation at first → any tenderness
Deeper - Reducible? Can you get above the lump? Can you separate the lump from the testicle?
Features of the lump - hard/soft? Round? regualr/irregualr? size?

Special tests:
Transillumination - hydrocele and large epididymal cyst
Elevation of the testes
Cremasteric reflex

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3
Q

lump/swelling superior and medial to the pubic tubercle, reducible, non-painful

A

inguinal hernia

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4
Q

swollen, tender testis retracted upwards. The skin may be reddened. cremasteric reflex is lost. elevation of the testis does not ease the pain (Prehn’s sign)

A

torsion

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5
Q

soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle, confined to the scrotum, you can get ‘above’ the mass on examination, transilluminates with a pen torch, the testis may be difficult to palpate

A

hydrocele

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6
Q

A scrotal mass that feels like a “bag of worms” More prominent on standing. Disappears when lying down. Asymmetry in testicular size

A

varicocele

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7
Q

Soft round lump separate from the body of the testicle, found posterior to the testicle at the top, May be able to transilluminate

A

epididymal cyst

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8
Q

painless (usually) lump Non-tender (or even reduced sensation) Arising from testicle, Hard, Irregular, Not fluctuant , No transillumination

A

testicular cancer

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9
Q

Investigation testicular swelling

A
  • If torsion suspected - immediate surgical exploration
  • USS to confirm hydrocele/epididymal cyst/to investigate and rule out testicular cancer
  • Doppler for ?varicocele
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10
Q

what is testicular torsion

A

twist of the spermatic cord resulting in testicular ischaemia and necrosis

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11
Q

most common age range and peak incidence torsion

A

peak incidence 13-15 years

most common in males aged between 10 and 30

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12
Q

trigger testicualr torsion

A

triggered by activity, such as playing sports

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13
Q

features testicular torsion

A

pain is usually severe and of sudden onset
the pain may be referred to the lower abdomen
nausea and vomiting may be present
on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
cremasteric reflex is lost
elevation of the testis does not ease the pain (Prehn’s sign)

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14
Q

testicular torsion o/e

A

swollen, tender testis retracted upwards. The skin may be reddened. cremasteric reflex is lost. elevation of the testis does not ease the pain (Prehn’s sign)

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15
Q

plan ?torsion

A

immediate surgical exploration
- if torsion found = bilateral fixation (bialteral orchidoplexy (as ?bellclapper)

USS is useful but dont delay

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16
Q

what type of inguinal hernia is common congenital

A

indirect

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17
Q

what is an indirect inguinal hernia

A

where the peritoneal sac enters the inguinal canal through the deep inguinal ring. (can be congenital)

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18
Q

what type of inguinal hernia is caused by heavy lifting/straining

A

direct inguinal hernia

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19
Q

what is a direct inguinal hernia

A

the peritoneal sac enters the inguinal canal through the posterior wall of the inguinal canal. (acquired due to weakening of musculature)

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20
Q

Management inguinal hernia

A

Treat even if asymptomatic

  • surgical eg mesh repair
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21
Q

complications inguinal hernia repair

A

early: bruising, wound infection
late: chronic pain, recurrence

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22
Q

management paediatric inguinal hernia

A

Under 1 year of age = repair urgently - most risk of strangulation
Over 1 year = elective repair

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23
Q

complications of inguinal hernias

A

Incarceration
Obstruction
Strangulation

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24
Q

what is hernia incarceration

A

Incarceration is where the hernia cannot be reduced back into the proper position (it is irreducible). The bowel is trapped in the herniated position.

Incarceration can lead to obstruction and strangulation of the hernia.

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25
what is hernia obstruction
Obstruction is where a hernia causes a blockage in the passage of faeces through the bowel. Obstruction presents with vomiting, generalised abdominal pain and absolute constipation (not passing faeces or flatus).
26
what is hernia strangulation
Strangulation is where a hernia is non-reducible (it is trapped with the bowel protruding) and the base of the hernia becomes so tight that it cuts off the blood supply, causing ischaemia. This will present with significant pain and tenderness at the hernia site. Strangulation is a surgical emergency. The bowel will die quickly (within hours) if not corrected with surgery. There will also be a mechanical obstruction when this occurs.
27
o/e what is a big part of the risk assessment hernias
size of the neck/defect (narrow or wide) Hernias that have a wide neck are at lower risk of complications
28
indictaion that a hernia is at risk of strangualtion
Episodes of pain in a hernia that was previously asymptomatic Irreducible hernias
29
symptoms of strangulated hernias
Pain Fever Increase in the size of a hernia or erythema of the overlying skin Peritonitic features such as guarding and localised tenderness Bowel obstruction e.g. distension, nausea, vomiting Bowel ischemia e.g. bloody stools
30
bloods strangulated hernia results
Leukocytosis Raised lactate
31
if ?perforation, what scan
erect CXR
32
what is a hydrocele
a collection of fluid within the tunica vaginalis that surrounds the testes
33
features of hydrocele
PC: painless, scrotal swelling o/e: soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle, confined to the scrotum, you can get 'above' the mass on examination, transilluminates with a pen torch
34
types of hydrocele
communicating non-communicating
35
epidemiology communicating hydrocele
newborn males caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
36
causes of hydrocele
Testicular cancer Testicular torsion Epididymo-orchitis Trauma
37
investigation hydrocele
USS to confirm dx and exclude testicular cancer
38
Management hydrocele
rule out serious causes Idiopathic hydroceles may be managed conservatively. Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases.
39
when are infantile hydroceles treated
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
40
define epididymo-orchitis
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling
41
causes epidiymo-orchitis
local spread from: - genital tract (chlamydia, gonnorrhoea) - bladder (e.coli)
42
symptoms epididymo-orchitis
unilateral testicular pain and swelling urethral discharge may be present, but urethritis is often asymptomatic
43
most important ddx epididymo-orchitis
torsion
44
invetsigations epididymo-orchitis
in younger adults assess for sexually transmitted infections (STI) in older adults with a low-risk sexual history send a mid-stream urine (MSU) for microscopy and culture
45
management epididymo-orchitis, suspected enteric organism eg e.coli
oral quinolone for 2 weeks (e.g. ofloxacin)
46
management epididymo-orchitis, suspected sTI
urgent rf to local specialist sti clinic if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
47
what is a varicocele
A varicocele occurs where the veins in the pampiniform plexus become swollen
48
what side do most varicoceles occur on
left - 80-90% due to increased resistance in the left testicular vein
49
serious cause for left sided varicocele
A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma
50
symptoms varicocele
Throbbing/dull pain or discomfort, worse on standing A dragging sensation Sub-fertility or infertility
51
o/e varicocele
A scrotal mass that feels like a “bag of worms” More prominent on standing Disappears when lying down Asymmetry in testicular size if the varicocele has affected the growth of the testicle
52
varicoele that doesnt disappear when lying down...
raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein. These warrant an urgent referral to urology for further investigation.
53
invetsigations varicocele
Ultrasound with Doppler imaging can be used to confirm the diagnosis Semen analysis if there are concerns about fertility Hormonal tests (e.g., FSH and testosterone) if there are concerns about function
54
management varicocele
Uncomplicated cases can be managed conservatively. Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.
55
what is an epididymal cyst
Epididymal cysts occur at the head of the epididymis (at the top of the testicle). A cyst is a fluid-filled sac. An epididymal cyst that contains sperm is called a spermatocele.
56
examination findings epididymal cyst
Soft, round lump Typically at the top of the testicle Associated with the epididymis Separate from the testicle May be able to transilluminate large cysts (appearing separate from the testicle)
57
most common cause of scrotal swellings seen in priamry care
epididymal cyst
58
associated conditions epididymal cyst
polycystic kidney disease cystic fibrosis von Hippel-Lindau syndrome
59
plan ?epididymal cyst
USS if unsure no treatment if in rare case pain or discomfort - removal may be considered.
60
what is cryptochordism
undecended tetsicle
61
bilateral cryptochordism plan?
- review by senior paeds within 24 hours
62
unilateral cryptochordism
- refer at 3 months of age - surgery performed at ~12 months
63
what cells to most testicualr cancers arse from
germ cells Germ cells are cells that produce gametes (sperm in males)
64
two main types of testicular cancers? peak incidence of these?
Seminomas Non-seminomas (mostly teratomas) The peak incidence for teratomas is 25 years and seminomas is 35 years.
65
risk factors testicualr cancer
Undescended testes Male infertility Family history Increased height infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter's syndrome mumps orchitis
66
presentation testicular cancer
The typical presentation is a painless lump on the testicle. Occasionally it can present with testicular pain. The lump will be: Non-tender (or even reduced sensation) Arising from testicle Hard Irregular Not fluctuant No transillumination
67
gynocomastia in testicular cancer, what specific type?
Leydig cell tumour About 2% of patients presenting with gynaecomastia have a testicular tumour.
68
first line invetsigation testicualr cancer
scrotal USS
69
tumour markers for testicualr cancer
Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas) Beta-hCG – may be raised in both teratomas and seminomas Lactate dehydrogenase (LDH) is a very non-specific tumour marker
70
what staging system is used to stage testicualr cancer
Royal Marsden Staging System
71
stages of testicualr cancer
Royal Marsden Staging System: Stage 1 – isolated to the testicle Stage 2 – spread to the retroperitoneal lymph nodes Stage 3 – spread to the lymph nodes above the diaphragm Stage 4 – metastasised to other organs
72
most common places for testicualr cancer to metastesise to
Lymphatics Lungs Liver Brain
73
management of testicualr cancer
depends on stage Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted Chemotherapy Radiotherapy Sperm banking to save sperm for future use, as treatment may cause infertility
74
side effects of treatment testicualr cancer
Infertility Hypogonadism (testosterone replacement may be required) Peripheral neuropathy Hearing loss Lasting kidney, liver or heart damage Increased risk of cancer in the future

Core clinical problems (94 decks)

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