Hydrocoele, Varicoele, Testicular Cancer and torsion

Question 1

Define hydrocoele

Answer 1

Describes collection of fluid in tunica vaginalis that surrounds the testes

Question 2

What membrane is the tunica vaginalis part of?

Answer 2

Peritoneal membrane

Question 3

Name and describe 2 subtypes of hydrocoele

Answer 3

Simple - Common in newborns. Fluid trapped in tunica vaginalis. Fluid usually reabsorbed over time and hydrocoele disappears

Communicating - tunica vaginalis is connected to peritoneal cavity via processus vaginalis. This allows fluid to trave from peritoneal cavity to hydrocoele, allowing it to fluctuate in size

Question 4

Give 4 clinical features of hydrocoele

Answer 4

Soft, non-tender swelling around one testicle

Can be in-front or below testicle

Size can fluctuate (depends if simple or communicating)

Transilluminates with light (key feature)

Question 5

Give 3 causes of hydrocoele

Answer 5

Primary hydrocoele - Idiopathic

Secondary hydrocoele - Infection (orchiditis, epididymitis)

Congenital hydrocele

Question 6

What embryological structure does the tunica vaginalis arise from?

Answer 6

Processus vaginalis

Question 7

Give 4 differentials for scrotal swelling

Answer 7

Hydrocoele

Inguinal hernia

Testicular Torsion

Partially descended testes

Question 8

How is hydrocoele diagnosis confirmed?

Answer 8

Ultrasound

Question 9

How are simple hydrocoeles managed?

Answer 9

Usually resolve in 2 years - Give reassurance and follow up

Question 10

How are communicating hydrocoeles managed?

Answer 10

Surgery to remove/ligate connection between peritoneal cavity and hydrocoele (processus vaginalis)

Question 11

Define varicocoele

Answer 11

Describes where veins of the pampiniform plexus become swollen

Question 12

Give 2 complications of varicocoele

Answer 12

Impaired fertility (likely due to disrupting temperature in affected testicle)

Testicular atrophy

Question 13

Where does the pampiniform plexus drain?

Answer 13

Testicular vein

Question 14

Pathophysiologically, how do varicocoele’s form?

Answer 14

Occur due to increased resistance in the testicular vein,

Incompetent valves in testicular vein allow backflow of blood back into pampiniform plexus.

Question 15

Where does the right testicular vein drain into?

Answer 15

Inferior vena cava

Question 16

Where does the left testicular vein drain into?

Answer 16

Left renal vein

Question 17

Where do varicocoeles most commonly arise?

Answer 17

Left side due to increased resistance of left testicular vein

Question 18

What could a left sided varicocoele indicate?

Answer 18

Obstruction of the left testicular vein caused by renal cell carcinoma

Question 19

Give 3 clinical features of varicoele

Answer 19

Throbbing/dull discomfort, worse on standing

A dragging sensation

Sub-fertility/infertility

Question 20

Give 4 examination findings for varicoele

Answer 20

Scrotal mass feels like a “Bag of worms”

More prominent on standing

Disappears when lying down

Asymmetry in testicular size

Question 21

If a varicoele doesn’t disappear when lying down, what may this indicate?

Answer 21

Retroperitoneal tumour obstructing drainage of renal vein.

Warrants urgent referral to urology

Question 22

Name 3 investigations important to conduct when investigating varicoele

Answer 22

Ultrasound with Doppler imaging (confirms diagnosis)

Semen analysis (if concerns about fertility)

Hormonal tests (FSH/LH if concerns about function)

Question 23

How are varicocoeles managed?

Answer 23

Uncomplicated - Conservative management

Pain, testicular atrophy or infertility - Surgery or endovascular embolization

Question 24

Define testicular torsion

Answer 24

Describes twisting of the spermatic cord with rotation of the testicle, resulting in ischaemia and necrosis.

Is a urological emergency

Question 25

Give 3 symptoms of testicular torsion

Answer 25

Acute onset severe unilateral testicular pain Lower abdominal pain and vomiting Triggered by activity (i.e playing sports)

Question 26

Give 5 examination findings for testicular torsion

Answer 26

Firm swollen testicle Elevated/retracted testicle Absent cremasteric reflex Abnormal testicular lie (horizontal) Rotation (epididymis is not in normal posterior position)

Question 27

Name 2 causes of testicular torsion

Answer 27

Activity (sport) Bell-Clapper Deformity (fixation between the testicle and tunica vaginalis is absent)

Question 28

What deformity is associated with testicular torsion?

Answer 28

Bell-clapper deformity

Question 29

Describe how the Bell-Clapper Deformity causes testicular torsion (3)

Answer 29

Describes where fixation between testicle and tunica vaginalis is absent. testicle hangs in horizontal position instead of typical vertical position. This makes it able to rotate within the tunica vaginalis, twisting the spermatic cord.

Question 30

How is testicular torsion diagnosed? What will this show?

Answer 30

Scrotal Ultrasound Shows whirlpool sign (spiral appearance of spermatic cord and blood vessels)

Question 31

Give 2 surgical options to treat testicular torsion

Answer 31

Surgical exploration; Orchidoplexy (correcting position of testicles and fixing them in place. Orchidectomy (removing testicle - if surgery is delayed or there is necrosis)

Question 32

How may testicular cancer present?

Answer 32

Painless hard nodule on one testicle

Question 33

What type of cancer are 95% of testicular cancers?

Answer 33

Germ cell tumours

Question 34

Name 2 types of germ cell tumours

Answer 34

Seminomas Non-seminomas (embryonal, yolk sac, teratoma and choriocarcinoma)

Question 35

Give 4 risk factors for testicular cancer

Answer 35

Undescended testicles Male infertility Positive family history Increased height

Question 36

Give 4 clinical features of testicular cancer

Answer 36

Painless, non-tender lump Hard lump Irregular No transillumination

Question 37

What type of testicular cancer can present with gynaechomastia?

Answer 37

Leydig cell tumour (non-germ cell)

Question 38

What investigation confirms diagnosis of testicular cancer?

Answer 38

Scrotal ultrasound

Question 39

What imaging tool is used to stage testicular cancer?

Answer 39

Staging CT Scan

Question 40

Give 3 biochemical tumour markers for testicular cancer

Answer 40

Alpha fetoprotein - May be raised in teratomas Beta hCG - May be raised in teratomas/seminomas Lactate dehydrogenase (LDH) - Non-specific

Question 41

What system is used to stage testicular cancer?

Answer 41

Royal Marsden Staging System

Question 42

Describe the Royal Marsden Staging System for staging Testicular Cancer

Answer 42

Stage 1 - Isolated to testicle Stage 2 - Spread to the retroperitoneal lymph nodes Stage 3 - Spread to the lymph nodes above the diaphragm Stage 4 - Metastasized to other organs

Question 43

Name 4 common places for testicular cancer to metastasize

Answer 43

Lymphatics Lungs Liver brain

Question 44

How is testicular cancer managed? (5)

Answer 44

MDT meeting Surgery - Radical orchidectomy Chemotherapy/radiotherapy Sperm banking Follow up - Monitor tumour markers, CT or CXR

Question 45

Give 4 complications of the treatment for testicular cancer

Answer 45

Infertility Hypogonadism (testosterone replacement may be required) Peripheral neuropathy Hearing loss