Common Presentations of Scrotal and Testicular Disease

Question 1

What is a varicocoele?

Answer 1

Varicose veins of spermatic cord

Part of testis and cord

Question 2

On which side are varicocoeles more common?

Answer 2

Left

Question 3

What happens to varicocoeles when you lie down?

Answer 3

Disappear

Question 4

When should you operate on varicocoeles?

Answer 4

Longstanding dragging pain

Primary infertility

Question 5

What does sudden onset of a hydrocoele in a young man indicate?

Answer 5

Cancer until proven otherwise

Question 6

Can you get above a hydrocoele?

Answer 6

No

Question 7

Can you feel the testis if a hydrocoele is present?

Answer 7

No

Question 8

What causes primary hydrocoeles?

Answer 8

Unknown

Question 9

What causes secondary hydrocoeles?

Answer 9

Cancer

Infection

Question 10

How are hydrocoeles investigated?

Answer 10

Blood markers
- Beta HCG
- Alpha foetal protein
- LDH
Ultrasound

Question 11

What is the treatment for hydrocoeles when cancer is suspected?

Answer 11

Radical orchidectomy > see if blood markers come down

CT to look for lymph nodes - para-aortic

Question 12

What is a spermatocoele?

Answer 12

Hydrocoele with sperm in it

Question 13

Are the sperm dead or alive in the spermatocoele?

Answer 13

Usually dead

Question 14

What colour is the fluid within a spermatocoele?

Answer 14

Whitish

Question 15

What sort of hydrocoele are spermatocoele usually associated with?

Answer 15

Primary, rather than secondary

Question 16

What is the demographic in whom testicular torsion occurs?

Answer 16

Young, up to 35

Question 17

What is the pain associated with testicular torsion?

Answer 17

Acute
Severe
In scrotum, radiating to iliac fossa

Question 18

What are the associated symptoms with testicular torsion?

Answer 18

Unwell
Mildly febrile
Rapid pulse
Vomiting

Question 19

What is the position of the testis in testicular torsion?

Answer 19

Elevated

Sometimes horizontal

Question 20

What does the skin around the testis look like in testicular torsion?

Answer 20

Swollen

Bluish

Question 21

What is the management for testicular torsion?

Answer 21

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

Question 22

How can you tell whether an ischaemic testis can be saved?

Answer 22

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

Question 23

Why might you leave in an ischaemic testis?

Answer 23

May be smaller, and won’t produce sperm, but will produce hormone

Question 24

Are epididymal cysts benign or malignant?

Answer 24

Benign

Question 25

How are epididymal cysts managed?

Answer 25

Drain > recur | Optimal treatment = epididymectomy, often bilateral

Question 26

Can you get above an epididymal cyst?

Answer 26

Yes

Question 27

Can you feel the testis if an epididymal cyst is present?

Answer 27

Yes

Question 28

What sort of fluid is an epididymal cyst filled with?

Answer 28

Serous

Question 29

What are the most common cancers of the testis?

Answer 29

Seminoma - less aggressive | Teratoma

Question 30

What are the rare cancers of the testis?

Answer 30

Leydig cell | Sertoli cell

Question 31

What are sebaceous cysts of the scrotum?

Answer 31

Sebaceous gland associated with hair follicle blocks > increases in size > becomes cyst

Question 32

What is the treatment for sebaceous cysts of the scrotum?

Answer 32

Excision

Question 33

What are the signs and symptoms of epididymo-orchitis?

Answer 33

``` Severe pain Unilateral swelling Testis - Big - Hard - Red - Very tender ```

Question 34

What is the most common organism causing epididymo-orchitis?

Answer 34

E coli

Question 35

What imaging is done in suspected epididymo-orchitis?

Answer 35

Ultrasound, to make sure not missing testicular cancer

Question 36

What is the management for epididymo-orchitis?

Answer 36

Elevation Analgesia IV Abx

Question 37

What is Fournier's gangrene?

Answer 37

Skin of scrotum becomes gangrenous Goes black and dies Testis underneath an also die

Question 38

What causes Fournier's gangrene?

Answer 38

Usually mix of aerobes and anaerobes

Question 39

What are the risk factors for Fournier's gangrene?

Answer 39

Diabetes | Alcohol abuse

Question 40

What can cause Fournier's gangrene?

Answer 40

From diverticulum Perianal abscess Perforating cancer of anorectum

Question 41

What is the management for Fournier's gangrene?

Answer 41

Excision - get rid of all dead skin Abx against aerobes and anaerobes After surgery, scrotum heals itself around testis

Question 42

What are the types of cancers of the penis?

Answer 42

SCC BCC Melanoma

Question 43

What are the investigations for a cancer of the penis?

Answer 43

Biopsy | Examine superficial inguinal nodes

Question 44

What is the treatment for cancer of the penis?

Answer 44

Excision and full thickness graft If inguinal nodes involved, chemo- and radiotherapy If up to corpus cavernosa, amputation

Question 45

What are the benign intrascrotal lumps?

Answer 45

``` Hydrocoele Epididymal cyst Varicocoele Benign tumour Idiopathic scrotal oedema ```

Question 46

What are the malignant intrascrotal lumps?

Answer 46

Testicular cancer Lymphoma Other

Question 47

What are the investigations of choice for suspected testicular cancer?

Answer 47

Urgent scrotal US | Tumour markers

Question 48

Why do patients continue to die of testicular cancer if it is a highly curable disease?

Answer 48

Usually due to delay in presentation

Question 49

What is the clinical syndrome of the acute scrotum?

Answer 49

New onset scrotal pain +/- swelling +/- tenderness +/- erythema

Question 50

What is the clinical approach to the acute scrotum?

Answer 50

``` History Focused exam Investigations - Urinalysis - MSU - Urethral swab/first void culture - FBE - US with Doppler ```

Question 51

What is the clinical presentation of acute torsion of the spermatic cord?

Answer 51

``` Acute onset of severe pain +/- swelling +/- precipitating event Nausea and vomiting Early presentation ```

Question 52

What is the most common cause of acute scrotum in prepubertal boys?

Answer 52

Torsion of testicular appendage

Question 53

What is the presentation of torsion of testicular appendage?

Answer 53

Localised pain/tenderness in superior pole of testis Usually less severe pain compared with testicular torsion Blue dot sign

Question 54

What is the blue dot sign?

Answer 54

Tender nodule with blue discoloration on upper pole of testis

Question 55

What is the management for torsion of testicular appendage?

Answer 55

Conservative | - NSAIDs

Question 56

What are the risk factors for epididymitis or epididymo-orchitis?

Answer 56

IDC Chronic retention Structural abnormality Instrumentation

Question 57

What are the investigations in suspected epididymitis or epididymo-orchitis?

Answer 57

Urinalysis and MSU Urethral swab for PCR Ultrasound

Question 58

What are the bacterial causes of epididymitis or epididymo-orchitis?

Answer 58

``` Men <35 - Neisseria gonorrhoeae - Chlamydia trachomatis Men >35 - E coli - Other Gram -ves ```

Question 59

What are the viral causes of epididymitis or epididymo-orchitis?

Answer 59

Mumps | Coxsackie

Question 60

What are the granulomatous causes of epididymitis or epididymo-orchitis?

Answer 60

TB

Question 61

What are the non-infective causes of epididymitis or epididymo-orchitis?

Answer 61

Behcet's disease Amiodarone Testicular tumour