DrE: Herniae & scrotum Flashcards
Herniae examination: inspection
start: patient standing, fully exposed (umbilicus to knees), chaperoned, examiner kneels at the side of the patient
* ask re pain/reducibility (latter may require the patient to lie down)*
Inspect:
- 6S’s
- Site
- Size
- Shape
- Symmetry
- Surface
- Scars
- Cough impulse
Herniae examination: palpation
- Temperature changes with back of hand
- SEC FFP TR:
- Surface, edges, consistency, fluctuance, fixity (teathered), pulsatile/expansile, transiluminates, reducibility
- Delineate anatomy:
- inguinal herniae = above and medial to pubic tubercle
- femoral herniae = below and lateral to PT
- Direct v indirect:
- pt reduces lump, place 2x finger tips over superficial ring, ask pt to cough ?impulse, remove fingers, ask pt to cough ?impulse
- indirect = contained at superficial ring
- direct = appear lateral to controlled superficial ring
- pt reduces lump, place 2x finger tips over superficial ring, ask pt to cough ?impulse, remove fingers, ask pt to cough ?impulse
- Direct v indirect
- reduce lump and assist in milking inguinal canal from superficial to deep. place 2x fingertips over deep ring, ask pt to cough ?impulse, is impulse is felt?, remove fingers and ask pt to cough
- indirect inguinal heriae = controlled at deep ring
- direct inguinal herniae = reappear medial to controlled deep ring
- reduce lump and assist in milking inguinal canal from superficial to deep. place 2x fingertips over deep ring, ask pt to cough ?impulse, is impulse is felt?, remove fingers and ask pt to cough
Deep ring = 1/2 inch above mid point of inguinal ligament (half way between PT and ASIS)
External/superficial ring = superior to the pubic tubercle
Herniae examination: auscultation
?bowel
incl auscultation of scrotal lump
Herniae examination: completion
- Lymphadenopathy - palpate for inguinal lymphadenopathy
- Contralateral side - ?assoc lesion
- Scrotum - ? assoc lesion
- Abdo exam - full abdo exam
Scrotal examination: inspection
Start: pt standing, fully exposed umbilicus -> knees, chaperone, examiner kneeling at side of patient
ask re pain, ask re reducibility
Inspection:
- 6Ss: site, size, shape, surface, symmetry, scars
- Cough impulse: +ve = indirect inguinal scrotal herniae rather than true scrotal lesion
Scrotal examination: Palpation
- Temperature discrepency with back of hand
- SEC FFP TR : surface, edge, consistency, fluctuance, fixity, pulsatile/expansile, transluminates, reducibility
- Can you get above the lump
- can’t = indirect inguinal scrotal herniae
- continue examination as for a herniae
- can = true scrotal lump
- can’t = indirect inguinal scrotal herniae
- Testicle
- epididymis
- vas deferens
Scrotal examination: xompletion
- lymphadenopathy
- penis and skin of scrotum drain into inguinal nodes
- testes drains into retroperitoneal para aortic nodes
- Examine contralateral side
Can you delinease the hernia relevant anatomy of the inguinal region
- ASIS and PT
- Inguinal ligament - from ASIS to PT
- Deep ring = midpoint of inguinal ligament
- an aperture through transversalis fascia
- Femoral artery = mid-inguinal point, midway between ASIS and Pubic symphysis
- Superficial ring = above PT
- an apertur through external oblique aponeurosis
- Inguinal canal = oblique communication between deep and superficial inguinal rings formed by the arching fibres of the transversus abdominis and internal oblique muscles
What are the borders of the inguinal canal?
- Posterior wall = transversalis fascia
- Anterior wall = external oblique
- Roof = arching fibres of transversus abdominis and internal oblique
- Floor = inguinal ligamant
What are the differntial diagnoses of a groin lump?
lumps and bumps +
- above inguinal ligamanet:
- inguinal hernia
- testicular maldescent
- below inguinal ligament
- femoral hernia
- testicular maldescent
- saphena varix
- femoral artery aneurysm
What are the differential diagnosis of a scrotal lump?
lumps and bumps +
- can’t get above the lump:
- indirect inguinal-scrotal hernia
- congential/infantile hydrocele
- can get above the lump and palpable separately to testis
- epididymal cyst
- epididymitis
- spermatocele
- varicocele
- can get above the lump and palpable with the testis
- haematocoele
- hydrocoele
- orchitis
- torsion
- tumour
What is an inguinal hernia?
abnormal protrusion of abdo contents through inguinal region
Most common groin hernia
Direct: due to acquired weakness in transversalis fascia, increased incidence with age, COPD, obesity, smoking, hernia protrudes directly through weakness in hesselbach’s triangle, without transversing inguinal canal
Indirect: patent processus vaginalis. congenital defect which allows for hernia to transverse deep ring, inguinal canal and superficial ring. If extension into scrotum is observes, indirect inguinoscrotal hernia is present
What are the treatment options for an inguinal hernia?
- conservative:
- truss is a device that may be used to help contain any reducible inguinal hernia within the abdomen, however it is not curative and rarely required
- Medical:
- optimise COPD medication, treat pneumonia (reduce coughing)
- Surgical:
- gold standard, surgical herniotomy & herniorrhaphy, lap or open.
- lichtenstein’s repair - polypropylene mesh to reinforce repair
- shouldice’s repair - if concerns re infection, use 4 later overlappying muscle repair rather than mesh
- gold standard, surgical herniotomy & herniorrhaphy, lap or open.
What is a femoral hernia?
abnormal protrusion through the femoral canal
less common than inguinal hernia
more commonly in females due to stretching of fem canal during pregnancy, or fat regression within the femoral canal after menopause
What are the treatment options for a femoral hernia?
no place for conservative management due to risk of incarceration and strangulation
all femoral herniae should be operated on asap
asymptomatic, reducible femoral herniae may be operated on using a low approach e.g. lockwood’s repair
symptomatic, strangulated femiral herniae may be operated on using a high approach e.g. mc evedy’s repair - this can be easily extended to a laparotomy to resect dead bowel if req
Definition of a herniae
Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position
What herniae do you know of?
- littre’s - containing meckle’s diverticulum
- Maydl’s - containing W shaped loop of bowel such that the middle arem of the W becomes compressed and strangulated
- Richter’s - containing only one side of the bowel wall which may become strangulated
- sliding - part of hernia sac wall is composed of bowel
- epigastric - abnormal protrusion of abdominal contents through epigastric region of linea alba
- herniotomy and herniorrhaphy with repair of lineal alba defect directly/with mesh
- incisional - through weakness of abdo wall at site of previous surgery
- rarely symptomatic, strangulation risk is low, conservative management
- surgical = free mesh repair, lap/open
- spigelian - abnormal protrusion of abdo contents through linea semilunaris.
- open/lap mesh repair due to high risk of strangulation
- umbilical - defect of/near the cicatrix. acquired/congenital. congenital require of congenital defect
- exomphalos - herniation of abdo contents, covered by transparent membrane composed of 3 layers (amniotic/wharton’s jelly/peritoneum). Risk of perf and peritonitis
- Gastroschisis - herniation lateral to cicatrix, without membrane covering. hypothermia/hypovolaemia/sepsis due to eviscerated bowel. NG/Fluid resus/protection of bowel with sterile packs and bags.
- Paraumbilical - defect in lineal alba near umbilicus
- high risk of strangulation, surgical - mayo (herniotomy & herniorrhaphy & suture upper part of rectus over lower part) /reinforced mesh
- Brainstem - due to raised ICP
- Diaphragmatic - hiatus
What is testicular maldescent?
- Retractile - overactive cremasteric reflex, children, Testis appears incompletely descended but may be noticed within the scrotum after a warm bath. treatment = conservative, testis -> less retractile with age
- ectopic - descends to abnormal position after exiting the superficial inguinal ring
- superficial inguinal pouch, perineum, root of penis, femoral canal
- undescended testis - prematurely stops anyway along the normal path as guided by the gubernaculum
What are the complications of undescended testis?
- increased risk of:
- trauma
- torsion
- tumour - 30x risk, commonly seminoma, early orchidoprexy
- infertility
- psychological distress
treatment for undescended testis
- orchidopexy at c.1yr to prevent complications
- undescended testis seen in older children -> short course of hCG/GnRH may help c.15%
What is a hydrocoele?
Scrotal swelling due to fluid accumulation within tunica vaginalis
Primary = persistent processus vaginalis
Secondary = in response to underlying disease e.g. infection torsion, tumour
What types of primary hydrocoeles do you know?
- Vaginal: most common, accumulation of fluid is limited to tunica vaginalis and neither extends to the vas deferens nor communicates with peritoneal cavity
- Infantile: accumulation extends to surround the vas deferens. processus vaginalis is obliterated at the level of the deep ring, NO communication with the peritoneal cavity
- Congenital: accumulation of fluid extends to surround the vas deferens, communication with peritoneal cavity as the processus vaginalis is not obliterated
- Hydrocoele of the cord: RARE, accumulation is limitted to vas deferens only
What treatment options are available for a hydrocoele?
Secondary: resolve with treatment of underlying cause
Treatment options for primary hydrocoeles:
- conservative (until 1 yre)
- reasurance
- scrotal support
- Surgical:
- aspirate: therapeutic and diagnostic
- phenol injection: sclerosing agent, may prevent recurrence
- Lord’s plication: incised and plicated behind the testis
- Jaboulay’s procedure: hydrocoele sac incised, partially excised and remaining tissue is plicated behind the testis
What are epididymitis and orchitis?
epididymitis = inflammation of epididymis
orchitis = inflammation of the testicle
clinical features = acute pain, erythema, oedema + Sx of UTI/Systemic infection
Acute may progress to chronic ?TB
What are the causes of epididymitis and orchitis?
- viral: mumps, infectious mononucleosis (EBV), coxsackie
- Bacteria:
- ascending UTI - e.coli
- STD - chlamydia, TB
Investigations when suspecting epididymitis and orchitis?
- haematology and biochemistry - FBC, U&E, CRP
- Serology: VDRL
- Microbiology:
- swabs - MC&S
- MSU - MC&S
- 3 x early morning urine samples for ZN staining and microscopy ?TB
- Radiology: USS
What are the treatment options for epididymitis and orchitis?
- conservative:
- bed rest & scrotal support
- Medical:
- analgesia, antibiotics e.g. ciprofloxacis/anti-TB regimen
- Surgical: abscess drainage, orchidectomy (if severe)
What are epididymal cysts?
fluid filled swellings of epididymis which are palpated separately from testes
multiple, fluctuant, transilluminate
large persistent cysts may be excised
What is a spermatocoele?
Cystic swelling that contains spermatozoa. commonly found at epididymis and spermatic cord.
clinical features and treatment are similar to epididymal cyst
What is a varicocoele?
A collection of dilated tortuouse veins of the pampiniform plexus
clinically appears as a bag of worms when patient is standing
appearance disappears when the patient is lying
98% are left sides as left testicular vein, (longer) drain directly into left renal vein, where it may be compressed when crossed by the colon
varicocoeles later in adulthood should be Ix for possible invasion of the renal vein by carcinoma
If symptomatic, surgical treatment options include radiological embolisation & lagation of the testicular vein proximal to the deep inguinal ring either open of laparoscopically
what is testicular torsion and why does it occur?
acute condition where the testicle twists around the axis of the spermatic cord
teenagers and young adults, recent Hx of trauma, possibly underlying abnormality
Bell clapper testicular abnormality described tunica vaginalis that doesn’t anchor to the testicle hance allowing free movement of the testicle like the clapper inside a bell
What are the clinical features of testicular torsion?
- acutely hot, painful, tender scrotal swelling, abdo pain, nausea, vomiting
- Cord = shorter and thicker than contralateral side on palpation due to twisting along its axis
- SURGICAL EMERGENCY
- 4-6hrs to salvage
How would you manage a testicular torsion?
- resuscitation
- NBM
- FBC, U&E, G&S
- IV Fluids
- Analgesia
- Consent patient for scrotal exploration +/- bilateral orchidopexx +/- orchidectomy
- Place patient on emergency list
- Inform anaesthetist
What are the differential diagnoses for testicular torsion?
- epididymitis and orchitis
- hydatid of morgagni torsion
- strangulated inguinal hernia
What testicular tumours do you know of?
- Benign:
- leydig cell tumour: benign neoplasm of intersitial leydig cells, may cause precocious puberty due to secretion of testosterone
- sertoli cell tumour: BN of sertoli cells, may cause gynaecomastia due to release of oestrogens
- Malignant:
- seminoma: malignant neoplasm of semineferous tubules with a peak age of 30-40 yrs, c.40% of testicular malignancy, may secrete bHCG (never aFP)
- Teratoma: MN containing elements from all 3 germ layers, multipotent cells that display a wide range of differentiation, 20-30yrs, c.30% of testicular malignancy, may secrete bHCG and aFP
- mixed: MN composed of both seminoma and teratoma, c.20% of testicular malignancy
- Lymphoma/choriocarcinoma/gonadoblastoma: together = remaining 10%
What are the principles of testicular malignancy?
- Painless, hard testicular lump
- sensation of dragging
- secondary hydrocoele
- back pain - para-aortic lymphadenopathy
- respiratory features - lung mets
What staging systems do you know for testicular tumours?
Royal marsden staging
TNM classification
What is the TNM classification for testicular tumours?
- T: tumour spread
- Tx - can’t be assessed
- T0 - no tumour
- Tis - Carcinoma in situ
- T1 - tumour confined to testicle/epididymis
- T2 - tumour confined to testicle/epididymis but with either local invasion of tunica albuguinae, vessels, LN
- T3 - tumour invades stermatic cord
- T4 - tumour invades the scrotum
- N: regional lymphadenopathy
- N0 - none
- N1 - regional <2cm in diameter
- N2 - 2-5cm
- N3 - >5cm
- M: distant metastasis/lymphadenopathy
- M0 - no regional lymphadenopathy
- M1a - lung metastases/distant regional lymphadenopathy
- M1b - other organ metastases
What is the royal marden staging for testicular tumours?
- I : Tx confined to testis
- II: para-aortic lymphadenopathy
- III : supra-diaphragmatic lymphadenopathy
- IV: extra-nodal mets
- L:
- L1 <3 lung mets
- L2 >3 lung mets all lesions <2cm
- L3 >3 lung mets with lesions >2 cm
- H: liver mets
What investigations would you consider for a patient with a suspected testicular malignancy?
- bloods: aFP, bHCG, LDH
- Radiology:
- scrotal USS - tumour assessment
- CXR - lung mets
- CT staging of disease
What happens to aFP and bHCG in testicular tumours?
- seminoma = raised bHCG
- Non-seminoma e.g. teratoma/yolk sack Tx
- raised aFP/bHCG
What are the treatment options for testicular malignancy?
- surgery - orchidectomy via inguinal approach, after clamping the cord, scrotal incision avoided to prevent seeding to scrotal skin that is drained by inguinal LN (not para-aortic)
- Chemotherapy - seminoma/teratoma
- Radiotherapy - seminoma
