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Core clinical problems > 83. Testicular/scrotal swellings > Flashcards

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
Q

what is hernia obstruction

A

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).

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26
Q

what is hernia strangulation

A

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.

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27
Q

o/e what is a big part of the risk assessment hernias

A

size of the neck/defect (narrow or wide)

Hernias that have a wide neck are at lower risk of complications

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28
Q

indictaion that a hernia is at risk of strangualtion

A

Episodes of pain in a hernia that was previously asymptomatic
Irreducible hernias

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29
Q

symptoms of strangulated hernias

A

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

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30
Q

bloods strangulated hernia results

A

Leukocytosis
Raised lactate

31
Q

if ?perforation, what scan

A

erect CXR

32
Q

what is a hydrocele

A

a collection of fluid within the tunica vaginalis that surrounds the testes

33
Q

features of hydrocele

A

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
Q

types of hydrocele

A

communicating

non-communicating

35
Q

epidemiology communicating hydrocele

A

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
Q

causes of hydrocele

A

Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma

37
Q

investigation hydrocele

A

USS to confirm dx and exclude testicular cancer

38
Q

Management hydrocele

A

rule out serious causes

Idiopathic hydroceles may be managed conservatively. Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases.

39
Q

when are infantile hydroceles treated

A

infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years

40
Q

define epididymo-orchitis

A

Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling

41
Q

causes epidiymo-orchitis

A

local spread from:
- genital tract (chlamydia, gonnorrhoea)
- bladder (e.coli)

42
Q

symptoms epididymo-orchitis

A

unilateral testicular pain and swelling
urethral discharge may be present, but urethritis is often asymptomatic

43
Q

most important ddx epididymo-orchitis

A

torsion

44
Q

invetsigations epididymo-orchitis

A

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
Q

management epididymo-orchitis, suspected enteric organism eg e.coli

A

oral quinolone for 2 weeks (e.g. ofloxacin)

46
Q

management epididymo-orchitis, suspected sTI

A

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
Q

what is a varicocele

A

A varicocele occurs where the veins in the pampiniform plexus become swollen

48
Q

what side do most varicoceles occur on

A

left - 80-90%

due to increased resistance in the left testicular vein

49
Q

serious cause for left sided varicocele

A

A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma

50
Q

symptoms varicocele

A

Throbbing/dull pain or discomfort, worse on standing
A dragging sensation
Sub-fertility or infertility

51
Q

o/e varicocele

A

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
Q

varicoele that doesnt disappear when lying down…

A

raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein. These warrant an urgent referral to urology for further investigation.

53
Q

invetsigations varicocele

A

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
Q

management varicocele

A

Uncomplicated cases can be managed conservatively.

Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.

55
Q

what is an epididymal cyst

A

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
Q

examination findings epididymal cyst

A

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
Q

most common cause of scrotal swellings seen in priamry care

A

epididymal cyst

58
Q

associated conditions epididymal cyst

A

polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome

59
Q

plan ?epididymal cyst

A

USS if unsure

no treatment

if in rare case pain or discomfort - removal may be considered.

60
Q

what is cryptochordism

A

undecended tetsicle

61
Q

bilateral cryptochordism plan?

A
  • review by senior paeds within 24 hours
62
Q

unilateral cryptochordism

A
  • refer at 3 months of age
  • surgery performed at ~12 months
63
Q

what cells to most testicualr cancers arse from

A

germ cells

Germ cells are cells that produce gametes (sperm in males)

64
Q

two main types of testicular cancers? peak incidence of these?

A

Seminomas
Non-seminomas (mostly teratomas)

The peak incidence for teratomas is 25 years and seminomas is 35 years.

65
Q

risk factors testicualr cancer

A

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
Q

presentation testicular cancer

A

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
Q

gynocomastia in testicular cancer, what specific type?

A

Leydig cell tumour

About 2% of patients presenting with gynaecomastia have a testicular tumour.

68
Q

first line invetsigation testicualr cancer

A

scrotal USS

69
Q

tumour markers for testicualr cancer

A

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
Q

what staging system is used to stage testicualr cancer

A

Royal Marsden Staging System

71
Q

stages of testicualr cancer

A

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
Q

most common places for testicualr cancer to metastesise to

A

Lymphatics
Lungs
Liver
Brain

73
Q

management of testicualr cancer

A

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
Q

side effects of treatment testicualr cancer

A

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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