83. Testicular/scrotal swellings Flashcards
History taking testicular/scrotal swelling
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
Examination scrotal swellings
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
lump/swelling superior and medial to the pubic tubercle, reducible, non-painful
inguinal hernia
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)
torsion
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
hydrocele
A scrotal mass that feels like a “bag of worms” More prominent on standing. Disappears when lying down. Asymmetry in testicular size
varicocele
Soft round lump separate from the body of the testicle, found posterior to the testicle at the top, May be able to transilluminate
epididymal cyst
painless (usually) lump Non-tender (or even reduced sensation) Arising from testicle, Hard, Irregular, Not fluctuant , No transillumination
testicular cancer
Investigation testicular swelling
- If torsion suspected - immediate surgical exploration
- USS to confirm hydrocele/epididymal cyst/to investigate and rule out testicular cancer
- Doppler for ?varicocele
what is testicular torsion
twist of the spermatic cord resulting in testicular ischaemia and necrosis
most common age range and peak incidence torsion
peak incidence 13-15 years
most common in males aged between 10 and 30
trigger testicualr torsion
triggered by activity, such as playing sports
features testicular torsion
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)
testicular torsion o/e
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)
plan ?torsion
immediate surgical exploration
- if torsion found = bilateral fixation (bialteral orchidoplexy (as ?bellclapper)
USS is useful but dont delay
what type of inguinal hernia is common congenital
indirect
what is an indirect inguinal hernia
where the peritoneal sac enters the inguinal canal through the deep inguinal ring. (can be congenital)
what type of inguinal hernia is caused by heavy lifting/straining
direct inguinal hernia
what is a direct inguinal hernia
the peritoneal sac enters the inguinal canal through the posterior wall of the inguinal canal. (acquired due to weakening of musculature)
Management inguinal hernia
Treat even if asymptomatic
- surgical eg mesh repair
complications inguinal hernia repair
early: bruising, wound infection
late: chronic pain, recurrence
management paediatric inguinal hernia
Under 1 year of age = repair urgently - most risk of strangulation
Over 1 year = elective repair
complications of inguinal hernias
Incarceration
Obstruction
Strangulation
what is hernia incarceration
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.
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).
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.
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
indictaion that a hernia is at risk of strangualtion
Episodes of pain in a hernia that was previously asymptomatic
Irreducible hernias
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
bloods strangulated hernia results
Leukocytosis
Raised lactate
if ?perforation, what scan
erect CXR
what is a hydrocele
a collection of fluid within the tunica vaginalis that surrounds the testes
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
types of hydrocele
communicating
non-communicating
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
causes of hydrocele
Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma
investigation hydrocele
USS to confirm dx and exclude testicular cancer
Management hydrocele
rule out serious causes
Idiopathic hydroceles may be managed conservatively. Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases.
when are infantile hydroceles treated
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
define epididymo-orchitis
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling
causes epidiymo-orchitis
local spread from:
- genital tract (chlamydia, gonnorrhoea)
- bladder (e.coli)
symptoms epididymo-orchitis
unilateral testicular pain and swelling
urethral discharge may be present, but urethritis is often asymptomatic
most important ddx epididymo-orchitis
torsion
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
management epididymo-orchitis, suspected enteric organism eg e.coli
oral quinolone for 2 weeks (e.g. ofloxacin)
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
what is a varicocele
A varicocele occurs where the veins in the pampiniform plexus become swollen
what side do most varicoceles occur on
left - 80-90%
due to increased resistance in the left testicular vein
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
symptoms varicocele
Throbbing/dull pain or discomfort, worse on standing
A dragging sensation
Sub-fertility or infertility
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
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.
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
management varicocele
Uncomplicated cases can be managed conservatively.
Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.
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.
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)
most common cause of scrotal swellings seen in priamry care
epididymal cyst
associated conditions epididymal cyst
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
plan ?epididymal cyst
USS if unsure
no treatment
if in rare case pain or discomfort - removal may be considered.
what is cryptochordism
undecended tetsicle
bilateral cryptochordism plan?
- review by senior paeds within 24 hours
unilateral cryptochordism
- refer at 3 months of age
- surgery performed at ~12 months
what cells to most testicualr cancers arse from
germ cells
Germ cells are cells that produce gametes (sperm in males)
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.
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
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
gynocomastia in testicular cancer, what specific type?
Leydig cell tumour
About 2% of patients presenting with gynaecomastia have a testicular tumour.
first line invetsigation testicualr cancer
scrotal USS
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
what staging system is used to stage testicualr cancer
Royal Marsden Staging System
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
most common places for testicualr cancer to metastesise to
Lymphatics
Lungs
Liver
Brain
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
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
