Common Presentations of Scrotal and Testicular Disease Flashcards
What is a varicocoele?
Varicose veins of spermatic cord
Part of testis and cord
On which side are varicocoeles more common?
Left
What happens to varicocoeles when you lie down?
Disappear
When should you operate on varicocoeles?
Longstanding dragging pain
Primary infertility
What does sudden onset of a hydrocoele in a young man indicate?
Cancer until proven otherwise
Can you get above a hydrocoele?
No
Can you feel the testis if a hydrocoele is present?
No
What causes primary hydrocoeles?
Unknown
What causes secondary hydrocoeles?
Cancer
Infection
How are hydrocoeles investigated?
Blood markers - Beta HCG - Alpha foetal protein - LDH Ultrasound
What is the treatment for hydrocoeles when cancer is suspected?
Radical orchidectomy > see if blood markers come down
CT to look for lymph nodes - para-aortic
What is a spermatocoele?
Hydrocoele with sperm in it
Are the sperm dead or alive in the spermatocoele?
Usually dead
What colour is the fluid within a spermatocoele?
Whitish
What sort of hydrocoele are spermatocoele usually associated with?
Primary, rather than secondary
What is the demographic in whom testicular torsion occurs?
Young, up to 35
What is the pain associated with testicular torsion?
Acute
Severe
In scrotum, radiating to iliac fossa
What are the associated symptoms with testicular torsion?
Unwell
Mildly febrile
Rapid pulse
Vomiting
What is the position of the testis in testicular torsion?
Elevated
Sometimes horizontal
What does the skin around the testis look like in testicular torsion?
Swollen
Bluish
What is the management for testicular torsion?
Rush to theatre
Try to rescue ischaemic testis
Excise at scrotal raphe (in middle)
Perform orchidopexy on other side = stitch testis on raphe, to stop other side torsioning
How can you tell whether an ischaemic testis can be saved?
20 min after unravelling > make small nick > see if bleeds
If there’s blood, can be saved
If after a long while, and doesn’t bleed, have to remove it
Remove if black in colour
If questionable, can still leave in
Why might you leave in an ischaemic testis?
May be smaller, and won’t produce sperm, but will produce hormone
Are epididymal cysts benign or malignant?
Benign
How are epididymal cysts managed?
Drain > recur
Optimal treatment = epididymectomy, often bilateral
Can you get above an epididymal cyst?
Yes
Can you feel the testis if an epididymal cyst is present?
Yes
What sort of fluid is an epididymal cyst filled with?
Serous
What are the most common cancers of the testis?
Seminoma - less aggressive
Teratoma
What are the rare cancers of the testis?
Leydig cell
Sertoli cell
What are sebaceous cysts of the scrotum?
Sebaceous gland associated with hair follicle blocks > increases in size > becomes cyst
What is the treatment for sebaceous cysts of the scrotum?
Excision
What are the signs and symptoms of epididymo-orchitis?
Severe pain Unilateral swelling Testis - Big - Hard - Red - Very tender
What is the most common organism causing epididymo-orchitis?
E coli
What imaging is done in suspected epididymo-orchitis?
Ultrasound, to make sure not missing testicular cancer
What is the management for epididymo-orchitis?
Elevation
Analgesia
IV Abx
What is Fournier’s gangrene?
Skin of scrotum becomes gangrenous
Goes black and dies
Testis underneath an also die
What causes Fournier’s gangrene?
Usually mix of aerobes and anaerobes
What are the risk factors for Fournier’s gangrene?
Diabetes
Alcohol abuse
What can cause Fournier’s gangrene?
From diverticulum
Perianal abscess
Perforating cancer of anorectum
What is the management for Fournier’s gangrene?
Excision - get rid of all dead skin
Abx against aerobes and anaerobes
After surgery, scrotum heals itself around testis
What are the types of cancers of the penis?
SCC
BCC
Melanoma
What are the investigations for a cancer of the penis?
Biopsy
Examine superficial inguinal nodes
What is the treatment for cancer of the penis?
Excision and full thickness graft
If inguinal nodes involved, chemo- and radiotherapy
If up to corpus cavernosa, amputation
What are the benign intrascrotal lumps?
Hydrocoele Epididymal cyst Varicocoele Benign tumour Idiopathic scrotal oedema
What are the malignant intrascrotal lumps?
Testicular cancer
Lymphoma
Other
What are the investigations of choice for suspected testicular cancer?
Urgent scrotal US
Tumour markers
Why do patients continue to die of testicular cancer if it is a highly curable disease?
Usually due to delay in presentation
What is the clinical syndrome of the acute scrotum?
New onset scrotal pain
+/- swelling
+/- tenderness
+/- erythema
What is the clinical approach to the acute scrotum?
History Focused exam Investigations - Urinalysis - MSU - Urethral swab/first void culture - FBE - US with Doppler
What is the clinical presentation of acute torsion of the spermatic cord?
Acute onset of severe pain \+/- swelling \+/- precipitating event Nausea and vomiting Early presentation
What is the most common cause of acute scrotum in prepubertal boys?
Torsion of testicular appendage
What is the presentation of torsion of testicular appendage?
Localised pain/tenderness in superior pole of testis
Usually less severe pain compared with testicular torsion
Blue dot sign
What is the blue dot sign?
Tender nodule with blue discoloration on upper pole of testis
What is the management for torsion of testicular appendage?
Conservative
- NSAIDs
What are the risk factors for epididymitis or epididymo-orchitis?
IDC
Chronic retention
Structural abnormality
Instrumentation
What are the investigations in suspected epididymitis or epididymo-orchitis?
Urinalysis and MSU
Urethral swab for PCR
Ultrasound
What are the bacterial causes of epididymitis or epididymo-orchitis?
Men <35 - Neisseria gonorrhoeae - Chlamydia trachomatis Men >35 - E coli - Other Gram -ves
What are the viral causes of epididymitis or epididymo-orchitis?
Mumps
Coxsackie
What are the granulomatous causes of epididymitis or epididymo-orchitis?
TB
What are the non-infective causes of epididymitis or epididymo-orchitis?
Behcet’s disease
Amiodarone
Testicular tumour
