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MD2 Genitourinary > Common Presentations of Testicular and Scrotal Disease > Flashcards

Common Presentations of Testicular and Scrotal Disease Flashcards

1
Q

DDx for painless scrotal lump

A

INTRASCROTAL
Benign: hydrocele, epididymal cyst, varicocele, benign tumour (uncommon), idiopathic scrotal oedema
Malignant: testicular cancer, lymphoma, other (mets)
EXTRASCROTAL
Inguinal hernia
Ascites
Generalised oedema

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2
Q

What is the relationship between cryptorchidism and testicular cancer?

A

10-30x increased risk of cancer

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3
Q

What are the common sites of metastases for testicular cancer?

A

Retroperitoneal LNs

Chest

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4
Q

What Ix should be performed for a suspected testicular cancer?

A

Urgent scrotal U/S
Tumour markers
If positive, CT chest/abdo/pelvis

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5
Q

What is the prognosis of testicular cancer?

A

Very good; for all persons there is an ~90% chance of cure (highly chemosensitive)
Event stage IV with visceral mets is highly curable, however patients continue to die, usually due to delay in presentation

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6
Q

Describe the clinical syndrome of the acute scrotum

A

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

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7
Q

DDx acute scrotum

A

Appendage torsion: appendix testis, other appendage (epididymis, paradidymis, vas aberrans)
Spermatic cord torsion: intravaginal (acute or intermittent), extravaginal
Epididymitis: infectious, UTI, STI, ?viral, sterile or traumatic
Scrotal oedema/erythema: deeper dermatitis, insect bite or other skin lesion, idiopathic scrotal oedema, early Fournier gangrene
Orchitis: associated with epididymitis with or without abscess, vasculitis (e.g. Henoch-Schonlein purpura), viral illness (e.g. mumps)
Trauma: with haematocoele or scrotal contusion, with testicular rupture
Hernia/hydrocoele: inguinal hernia with or without incarceration, communicating hydrocoele, encysted hydrocoele with or without torsion, associated with acute abdominal pathology (e.g. appendicitis, peritonitis, splenic rupture)
Varicocoele: with pain, with acute rupture or thrombosis
Intrascrotal mass: cystic dysplasia or tumour of testis, epididymal cyst/spermatocoele or tumour, other paratesticular tumours
Other: musculoskeletal pain due to inguinal tendonitis or muscle strain, referred pain (e.g. ureteral calculus or anomaly)
Chronic orchitis

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8
Q

What aspects of Hx are important to elicit in a patient presenting with a scrotal lump?

A 
How did it come to attention?
Precipitating event?
Present for how long?
Pain?
Associated symptoms (UTIs, fevers, cough, SOB, haemoptysis, headaches etc)
PMHx: cryptorchidism, CAH
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9
Q

Describe the important steps in a focussed scrotal exam

A

Inspection: erythema, oedema, transillumination
Palpation: size, shape, position, consistency, tenderness, can you get above it

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10
Q

What general examinations are important in a patient presenting with a scrotal lump?

A

Abdo: masses, hernia, liver and spleen
Lungs: effusion, consolidation
LNs
Neurological

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11
Q

22 year old man presents to his GP with a 1 week Hx of a painless lump in his scrotum
Noticed after a knock playing football; mildly tender initially but not now; no other associated symptoms
Grossly abnormal, rock hard, R sided scrotal swelling; can get above it
Normal epididymis
No normal R testis palpable (all replaced)
Non tender, no transillumination
Atrophic L testis
Fullness in epigastrium
Ix?

A

Testicular U/S
Alpha-fetoprotein
Beta-hCG
LDH

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12
Q

Testicular cancer Mx?

A

Inguinal orchidectomy: mixed NSGCT (non-seminomatous germ cell tumour)
BEP (bleomycin, etoposide, cisplatin): residual mass
Retroperitoneal LN dissection (RPLND): mature teratoma

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13
Q

Ix for the acute scrotum

A 
Urinalysis
MSU
Urethral swab/first void culture
FBE
U/S with Doppler
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14
Q

List 2 predisposing factors for acute torsion of spermatic cord

A

Bell clapper deformity

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15
Q

What is the most commonly affected age group for acute torsion of the spermatic cord?

A

12-18 years

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16
Q

Describe the typical presentation of acute torsion of the spermatic cord

A

Acute onset severe pain +/- swelling, precipitating event
N+V
Early presentation

17
Q

Types of acute torsion of the spermatic cord?

A

Intravaginal

Extravaginal (in neonates)

18
Q

7 possible findings in acute torsion of the spermatic cord

A 
Tender firm testicle
High-riding testicle
Horizontal lie
Absent cremasteric reflex
No pain relief with elevation
Thickened spermatic cord
Epididymis not posterior to testis
19
Q

Ix in acute torsion of the spermatic cord

A

Urinalysis
U/S with Doppler
Exploration

20
Q

Acute torsion of the spermatic cord Mx

A

Fixation +/- dartos pouch

21
Q

To U/S or not to U/S in the case of the acute scrotum?

A 
Probable torsion (or high index of suspicion for torsion): explore
Confident not torsion (or low index of suspicion for torsion): U/S to rule out torsion, establish Dx
22
Q

What is the most common cause of acute scrotum in pre-pubertal boys?

A

Torsion of testicular appendage (appendix testis/epididymis)

23
Q

What is the typical presentation in torsion of testicular appendage?

A

Localised pain/tenderness to superior pole of testis

Usually less severe

24
Q

How is torsion of testicular appendage diagnosed?

A

U/S with Doppler: “blue-dot” sign

25
Q

Mx of torsion of testicular appendage

A

Conservative management (NSAIDs)

26
Q

Typical presentation of epididymitis/epididymo-orchitis

A

Gradually worsening pain (more insidious onset), swelling/tenderness, fever, hydrocoele
?urethritis/discharge, irriative LUTS

27
Q

List 4 risk factors for epididymitis/epididymo-orchitis

A

IDC
Chronic retention
Structural abnormality
Instrumentation

28
Q

Ix for epididymitis/epididymo-orchitis

A

U/A and MSU
Urine/urethral swab for PCR
U/S

29
Q

What are the typical bacterial pathogens responsible for epididymitis/epididymo-orchitis in men 35 years?

A

Men 35 E. coli, other GNBs

30
Q

List 2 viruses which can cause epididymitis/epididymo-orchitis

A

Mumps

Coxsackie

31
Q

List 2 granulomatous causes of epididymitis/epididymo-orchitis

A

TB

BCG

32
Q

List 3 non-infective causes of epididymitis/epididymo-orchitis

A

AI (e.g. Behcet’s)
Drugs (e.g. amiodarone)
Testicular tumour

33
Q

Mx of epididymitis/epididymo-orchitis

A

Elevation
Analgesia
Empiric Abx with GNB and STI coverage

34
Q

What empiric Abx should be used to treat epididymitis/epididymo-orchitis?

A

GNB coverage: trimethoprim/cephalexin/augmentin/norfloxacin x 2/52, OR amp & gent
STI coverage: ceftriaxone 500mg IM OD x 3/7 & azithromycin1g PO stat & doxycycline 100mg BID x 2/52 (or second PO dose of azithromycin at 1/52)

35
Q

How long should the pain and swelling of epididymitis/epididymo-orchitis take to resolve?

A

Pain takes 2-3/7

Swelling takes ~months

36
Q

What does failure of epididymitis/epididymo-orchitis to resolve suggest?

A

Resistance
Complication (U/S to assess)
Tumour (U/S to assess)

37
Q

FU for epididymitis/epididymo-orchitis

A

STI screen and contact tracing, etc

If UTI, refer to urology

38
Q

What complications should be considered in blunt testicular trauma?

A 
Contusion
Fracture
Dislocation
Haematocoele
Urethral injury
Tunica albuginea disrupted
39
Q

Mx for blunt testicular trauma

A

Early exploration (within 72 hours!)

MD2 Genitourinary (1 decks)

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