Pathology of the Scrotum and Foreskin Flashcards
Where do the testicular veins drain?
Left testicular veins drains into renal vein
Right testicular veins drains into IVC
What is the lymphatic drainage of the testes?
Para-aortic nodes
Hydrocele
A hydrocele is a type of swelling in the scrotum that occurs when fluid collects in the tunica intima. Hydrocele is common in newborns and usually disappears without treatment by age 1 caused by a patent processus vaginalis.
What can cause hydroceles in boys and older men?
Older boys and adult men can develop a hydrocele due to inflammation or injury within the scrotum.
How are hydroceles diagnosed?
History
Examination - cystic, able to get above swelling.
Ultrasound
Transilluminable
Epididymal cyst / Spermatocele
An epididymal cyst is a fluid-filled sac which grows at the top end of the testicle - arising from the epididymal ducts.
What are the symptoms of an epididymal cyst?
Painless
Cystic and transilluminant
Usually separate from the testes.
How are epididymal cysts diagnosed?
Ultrasound scan
Varicocele?
Varicocele is an enlargement of the veins within the scrotum. A varicocele is similar to a varicose vein you might see in your leg.
Where do the varicoceles form?
Pampiniform plexus
Pampiniform plexus
The pampiniform plexus is a loose network of small veins found within the male spermatic cord.
What are the symptoms of varicocele?
Feels like a bag of worms (disappears when lying down).
Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility.
What are the three main causes of testicular swelling?
Torsion
Acute Epididymo-orchitis/epididymitis
Torsion of testicular appendix
How is hydrocele treated?
Aspirated if unfit for surgery
Why are varicoceles most commonly found in the left testes?
Found most commonly in the left testes due to increased pressure in the left testicular vein as it drains into the left renal vein.
Indirect inguinal hernias
Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring due to failure to close the embryonic processus vaginalis.
What is the difference between a direct and indirect inguinal hernia?
Symptoms of both include groin pain, which can be severe.
Direct inguinal hernias are often caused by age-related stress and weakened muscles in the inguinal canal.
Indirect inguinal hernias are caused by a persistent opening that does not close during fetal development.
How do tumours of the testes present?
Often in 20-40yr old men
Painless lump
Not separate from the testes
Describe testicular torsion.
Most common in 20-40yr old men
Testes rotates around it’s vascular base leading to acute pain.
What are the clinical symptoms of testicular torsion?
Sudden onset of severe testicular pain
Abdominal pain and vomiting
Retraction of testes into bell clapper position
Swollen, tender erythematous scrotum.
What is the surgical management of testicular torsion?
Testes are sutured to tunica vaginalis to prevent further torsion - known as orchiopexy.
Epididymitis
Infection of the epididymis
What is the cause of epididymitis?
Due to chlamydia - 2 week course of doxycycline may be given.
What are the symptoms of epididymitis?
Scrotal discomfort
Scrotal swelling
Pain during micturition
Orchitis and it’s cause
Infection of the testes
- commonly has a viral cause such as MUMPS.
Epididymo-orchitis
When epididymitis spreads to the testes.
> has a gradual onset causing a dull ache/pain.
Lymphocele
Collection of lymphatic fluid
Describe how a lymphocele may form.
Following femoral artery surgery in groin.
Disruption of local lymphatics causing a collection of lymphatic fluid forming a lump.
Ectopic testes
Testes not present in scrotum
Saphena varix
A saphena varix is a dilatation at the top of the long saphenous vein due to valvular incompetence. It may reach the size of a golf ball or larger. The varix is: soft and compressible. disappears immediately on lying down.
How is testicular torsion diagnosed?
A Doppler ultrasound
Doppler ultrasound
A Doppler ultrasound is a test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins.
What are the two ways testicular tumours are classified?
Germ cell tumours (90%)
Non-germ cell tumours (10%)
Priaprism
Involuntary persistent erection unrelated to sexual stimulation.
What are the complications of priaprism?
Hypoxic damage
Erectile dysfunction
Corporeal fibrosis - loss of penile length
Prostatitis
Prostate gland inflammation usually caused by gram negative bacterial infection.
Rotation of the testes around the spermatic cord may cause what?
Testicular torsion
Erythematous
Redness of the skin due to increased bloodflow - occurs in infections and inflammation.
Cryptorchidism
The absence of one or both testes in the scrotum - missing testes are located in the inguinal canal.
What are hypospadias and epispadias?
Abnormal urethral openings on the penis:
Hypospadias - ventrally
Epispadias - dorsally
What are the different types of germ cell tumours?
Seminomas Non-seminomas GCT Embryonal carcinoma Choriocarcinoma Teratoma
What are the different types of sex cord / gonadal stromal tumours?
Sertoli cells tumour
Leydig cells tumour
Granulosa cell tumour
Which testicular tumour produces beta-hCG?
Non-seminomas GCT
Outline the histology of teratomas.
Contains many tissue types e.g hair, teeth, neurons etc
Outline the histology of leydig cells tumour
Reinke crystals
What are the signs and symptoms of testicular tumours?
Painless mass on testes Lower abdominal pain / heaviness Previously atrophied testis increases in size Gynecomastia Metastasis
Gynecomastia
Enlarged / swelling of breast tissue in men - commonly caused by raised oestrogen levels.
How are testicular tumours diagnosed?
Biopsy Chest x-ray - for pulmonary metastasis CT scan MRI Ultrasound
How do seminoma and NSGCT present on ultrasounds?
Seminoma: Smooth echogenic mass
NSGCT: No defined borders appears as calcified cystic masses.
What are risk factors of testicular tumours?
Cryptorchidism Previous testicular tumour Family history White individuals Congenital abnormalities - hypospadias/inguinal hernias Infection - mumps causing orchitis
What are the main serum tumour makers in testicular cancer?
Alpha fetoprotein
Normal AFP
Beta-hCG
Lactate dehydrogenase
Alphafetoprotein is commonly associated with what testicular tumour?
Yolk sac tumours
What is the general treatment for testicular tumours?
Counselling - discussing sperm retrieval and storage as well as prosthesis for cosmetic reasons.
Orchidectomy
Subsequent treatment depends on histology and staging.
Orchidectomy
Removal of one or both testicles
What does the prepuce (foreskin) do?
Covers and protects the glans penis and urethral
meatus.
Balanoposthitis
Balanoposthitis is inflammation of the head of
the penis and the foreskin”
What are the symptoms of balanoposthitis?
Redness, swelling and soreness around the head of the penis or foreskin A thick discharge under the foreskin A rash on the penis Itchiness An unpleasant odour Pain when urinating
What are some of the causes of balanoposthitis?
Irritation caused by smegma Thrush Bacterial infection (streptococcal) STI's Playing with foreskin Skin conditions e.g eczema
When is thrush a more common cause of balanoposthitis?
More common in people with diabetes or people who have recently taken antibiotics.
What STI’s can cause balanoposthitis?
Gonorrhoea
Herpes
Syphilis
Phimosis
Is a condition where the foreskin is too tight to be pulled
back over the head of the penis.
What can cause phimosis?
Common causes are : chronic and recurrent posthitis,
eczema, psoriasis, lichen planus and lichen sclerosis.
What is the presentation of phimosis?
Can present with pain due to recurrent tearing and scarring, pin hole meatus and difficulty urinating, sexual problem.
Paraphimosis
When the foreskin cannot be returned to its original
position after being retracted.
What are the complications of paraphimosis?
Consequence – pain, swelling and restricted blood flow to the glans. A tight constriction ring is formed. In extreme cases the penile head may become gangrenous.
Testicular cancer most commonly metastasises where?
Lungs
Physiological phimosis
Where the foreskin does not retract - completely normal in boys under 7 years old.
A 60 year old man presents with a right sided scrotal swelling. On examination there is a soft swelling in the right hemi-scrotum, you can get above it, the testis is not palpable separate from it. It trans illuminates. The most likely pathology is:
Hydrocele
At a well baby check you examine a 3 week old baby boy. You notice that the foreskin appears hooded and the urethral meatus is eccentrically placed on the ventral aspect of the glans. The most likely developmental abnormality is:
Hypospadias
