Lumps in the Groin and Scrotum

Question 1

Diagnosing Scrotal Masses

Answer 1

• Can you get above the mass? – if no then inguinoscrotal hernia or a hydrocele extending proximally.

Is it separate from the testes, is it a cystic or a solid (fluctuant) and does it transilluminate:

• If separate, cystic (flutuant) transilluminates = epidermal cyst.
• If testicular, cystic (fluctuant) and transilluminates = hydrocele.
• If separate, solid and does not transilluminate = epididymitis, varicocele or spermatocoele.
• If testicular, solid and does not transilluminate = tumour, orchitis or haematocele.

Question 2

Epididymal Cyst

Answer 2

Usually develop in adulthood and contain clear or milky (spermatocele) fluid. They usually lie above and behind the testis. Epididymal cysts should only be removed if symptomatic.

Question 3

Hydrocoele

Answer 3

There is fluid within the tunica vaginalis (the serous covering of the testes).

The cause can be primary – idiopathic or associated with a patent processus vaginalis (typically resolves during 1st year of life) or secondary – to a tumour, infection or trauma.

They can resolve spontaneously or be managed by aspiration or surgery – plicating (folding) the tunica vaginalis (Lord’s repair) or inverting the sac.

Question 4

Epididymitis and Orchitis - Causes and Investigation

Answer 4

Causes are chlamydia, E coli, mumps, gonorrhoea or TB.

It usually presents with a sudden onset tender swelling, dysuria, sweats and a fever.

Investigations – take a urine sample, look for urethral discharge and consider an STI screen. Warn the patient that the symptoms may worsen before they improve.

Question 5

Epididymitis and Orchitis - Management

Answer 5

If <35 years give 100mg Doxycycline BD for 10 days (covers chlamydia) and think about treating sexual partners.

If >35 years it is often associated with UTI so give 300mg Ciprofloxacin BD for 10 days.

Also give analgesia, bed rest, scrotal support or abscess drainage.

Question 6

Varicocoele

Answer 6

Dilated veins of the pampiniform plexus and the left side is more commonly affected. They are often visible as distended scrotal blood vessels that feel like a bag of worms and the patient may complain of a dull ache.

It is associated with subfertility perhaps because the pampiniform plexus is normally involved in cooling the testes so spermatogenesis is affected.

Repair is via surgery or embolisation but appears to have little effect on subsequent pregnancy rates.

Question 7

Haematocoele

Answer 7

Blood in the tunica vaginalis following trauma which may require drainage or excision.

Question 8

Malignancy - Types

Answer 8

The commonest malignancy found in men aged between 15-44 years of age.

Types – seminoma (30-65 years), teratoma (20-30 years) or tumours of sertoli cells (produce oestrogen), tumours of leydig cells (produce androgens) or lymphoma.

10% of testicular tumours occur in undescended testicles and a contralateral tumour is found in 5%.

Question 9

Malignancy - Presentation

Answer 9

Painless testicular lump, haematospermia, secondary hydrocele, pain, dyspnoea (due to lung metastases), abdominal mass (lymphadenopathy) or effects of hormones.

Question 10

Risk Factors

Answer 10

An undescended testicle, a hernia in infancy or infertility.

Question 11

Malignancy - Staging

Answer 11

• 1 – no evidence of metastases
• 2 – infradiaphragmatic node involvement (spread is via para-aortic nodes).
• 3 – supradiaphragmatic node involvement.
• 4 – lung involvement.

Question 12

Malignancy - Investigations

Answer 12

Chest x-ray and CT for staging and tumour markers – αFP and β-HCG.

Question 13

Malignancy - Management

Answer 13

Orchidectomy – via a groin incision to allow the cord to be clamped before mobilisation, to prevent seeding of the scrotal skin and to allow the incision to be within the radiotherapy field.

For seminoma’s give radiotherapy to the groin and abdominal lymph nodes and for teratoma’s give chemotherapy e.g. bleomycin, etoposide and cisplatin are given.

Question 14

Malignancy - Prognosis

Answer 14

5 year survival is 96-100% for stage 1 and 55-75% for stage 4.

Reoccurrence is likely to occur within 18-24 months so CT and tumour markers are repeated every 6 weeks initially.

Question 15

Torsion - Presentation

Answer 15

Occurs between 12-27 years – sudden onset pain in one testes which makes walking uncomfortable, abdominal pain, nausea and vomiting.

Signs – there is inflammation of one testis – tender, hot and swollen and the testis may lie high and transversely.

Question 16

Torsion - Differential

Answer 16

Epididymo-orchitis (older patient with symptoms of a UTI), tumour, trauma, acute hydrocele or idiopathic scrotal oedema (there are no signs of inflammation).

Question 17

Torsion - Investigation and Management

Answer 17

• Investigations – Doppler ultrasound demonstrates a lack of blood flow to the testis.
• Management – get consent for orchidectomy and a bilateral fixation (orchidopexy). The testis is untwisted and if its colour looks good it is returned to the scrotum and both testes are fixed.

Question 18

Abnormal Testes

Answer 18

• Cryptorchidism – complete absence of the testicle from the scrotum.
• Retractile testis – the genitalia are normally developed but there is an excessive cremasteric reflex. The testicle is often found at the external inguinal ring. Management is reassurance.
• Maldescended testis – may be found anywhere along the normal path of descent.
• Ectopic testis – most commonly found in the superior inguinal pouch (anterior to the external oblique aponeuroses) but may also be abdominal, perineal, penile or in femoral triangle.

Question 19

Undescended Testes - Complications

Answer 19

Infertility, increased risk of malignancy (risk remains after surgery), testicular trauma and torsion and associated with hernias and urinary tract abnormalities.