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Year 3 Renal & Urology > Scrotal lumps > Flashcards

Scrotal lumps Flashcards

1
Q

What is the anatomy of the testis?

A

.

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2
Q

What is the superior anatomy of the testis?

A

.

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3
Q

What is the vasculature of the testis?

A

Supplied by the testicular arteries which arise directly from the abdominal aorta. They are drained by the pampiniform plexus which drains into the IVC and left renal vein via the testicular vein.

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4
Q

What is epididymitis?

A

Inflammation of the epididymis.

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5
Q

What are the types of epididymitis? (x2)

A

Acute and chronic

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6
Q

What is the cause of epididymitis? (x5) In younger and older men?

A

Bacterial infection from gonorrhoea, chlamydia, E. coli, mumps, TB (rare). In men under 35, it is most often due to STIs; in men over 35, it is most often due to G-ve enteric organisms that cause UTIs.

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7
Q

What is the epidemiology of epididymitis: Incidence? Age?

A

1 in 150 visits; occurs in ages 16-30, 51-70.

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8
Q

What are the symptoms of epididymitis? (x5)

A

Pain in the back of the testicles (insidious), swelling of the testicle, burning with urination, frequent urination. Fever.

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9
Q

What are the signs of epididymitis? (x5)

A

Cremasteric reflex is preserved, distinguishing this from testicular torsion. Painful point tenderness, palpation may reveal an indurated (hardened) epididymitis. Prehn’s sign - lifting the testis up over the symphysis relieves pain. 1st catch urine sample to look for urethral discharge.

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10
Q

What are the investigations for epididymitis? (x3)

A

Generally made on the basis of symptoms. 1st catch urine sample may show discharge. Doppler USS demonstrates areas of increased blood flow, which would differentiate epididymitis from testicular torsion which is associated with decreased blood flow.

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11
Q

What are the complications of epididymitis? (x7)

A

Abscess, testicular infarction, orchitis, infertility, hypogonadism, sepsis, hydrocele.

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12
Q

How is epididymitis managed? (x4)

A

Antibiotics if infection is suspected. Analgesics. Elevating the testis alleviates pain. Epididymectomy indicated only in acute cases when there is discharge of pus.

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13
Q

What is orchitis?

A

Inflammation of the testes.

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14
Q

What are the causes of orchitis?

A

Can be related to epididymitis infection which has spread to the testicles (called epididymo-orchitis). Same causes as epididymitis.

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15
Q

What are the symptoms of orchitis? (x6)

A

Haematospermia, haematuria, pain, visible swelling of testicles, inguinal lymphadenopathy. Prehn’s sign positive.

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16
Q

What are the signs of orchitis?

A

Redness, warmth, painful point tenderness.

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17
Q

What are the complications of orchitis? (x7)

A

Damage to blood vessels of the spermatic cord in ischaemia orchitis. Testicular atrophy. Infertility. Sepsis. Hypogonadism. Testicular cancer. Hydrocele.

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18
Q

What are the investigations for orchitis? (x3)

A

Blood (ESR high), urine (blood), USS.

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19
Q

How is orchitis managed? (x2)

A

Antibiotics and NSAIDs to relieve pain.

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20
Q

What is testicular torsion?

A

Twisting (torsion) of the spermatic cord causing occlusion of the testicular blood vessels and the viability of the testis is compromised.

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21
Q

What is the clinical importance of recognising testicular torsion? Timescale?

A

Recognise the condition before its cardinal signs and symptoms manifest, as prompt surgery saves the testicles. Performed in less than 6 hours means salvage rate is 90-100%; performed over 24 hours post-presentation means salvage rate is 0-10%,

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22
Q

What is the aetiology of testicular torsion?

A

Lax tissues surrounding the testis enable them to move around the scrotum, hence a twisting may occur.

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23
Q

What are the risk factors for testicular torsion? (x4)

A

Tumour, trauma, cold temperature, congenital malformation (bell-clapper deformity where testis inadequately attached to the scrotum allowing freer movement)

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24
Q

What are the symptoms of testicular torsion? (x5)

A

Sudden onset of pain unilaterally, uncomfortable to walk, abdominal pain, N&V, quite often with a history of previous, brief episodes of similar pain due to torsion but with spontaneous resolution.

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25
Q

What are the signs of testicular torsion? (x4)

A

Inflammation of one testis – tender, hot, swollen. Testis may lie high and transversely. Cannot elicit the cremasteric reflex. Lifting the testis up over the symphysis increases pain, whereas in epididymitis, this usually relieves pain – Prehn’s sign negative.

26
Q

What are the complications of testicular torsion? (x3)

A

Testicular infarction, infertility (even when the other testicle is not affected), reperfusion injury.

27
Q

What is the physiology of infertility in testicular torsion?

A

Following injury to the testicle, the body’s immune system is activated to clean up damaged cells. In the process, this creates anti-testicular cell antibodies that cross the blood-testis barrier and damage both testicles.

28
Q

What are the types of testicular torsion? (x3)

A

Intravaginal and extravaginal torsion (torsion occurring inside and outside the tunica vaginalis respectively). Intermittent testicular torsion (chronic variant of torsion characterised by intermittent scrotal pain, followed by eventual spontaneous detorsion and resolution of pain).

29
Q

What is the tunica vaginalis?

A

The tunica vaginalis is the pouch of serous membrane that covers the testes. It is derived from the vaginal process of the peritoneum

30
Q

What are the investigations for testicular torsion?

A

Usually done on clinical findings. USS when diagnosis in unclear – duplex shows reduced blood flow.

31
Q

How is testicular torsion managed? (x2)

A

Twisting is done SURGICALLY, outwards towards the thigh (as torsion often occurs because the testicle twists towards the midline). Removal of the testis occurs in cases of infarction, to prevent necrosis. AND ANALGESICS, usually opioids.

32
Q

What is the prognosis of testicular torsion?

A

Generally good with rapid treatment. About 40% require removal of the testicle from infarction.

33
Q

What is the epidemiology of testicular torsion: Incidence? Age?

A

1 in 15 000 per year; under 25 years old.

34
Q

What is the definition of testicular cancer?

A

Cancer develops in the testicles.

35
Q

What are the causes of testicular cancer? (x7)

A

Undescended testis (cryptorchidism), FHx, inguinal hernias (in infancy), Klinefelter syndrome, mumps, orchitis, infertility.

36
Q

What is the mechanism of testicular cancer?

A

Most testicular germ cells have too many chromosomes (hence Klinefelter syndrome risk factor (XXY)). An isochromosome 12p is present in about 80% of testicular cancers.

37
Q

What are the symptoms of testicular cancer? (x6)

A

o Lump in testis

o Sharp pain/dull ache in lower abdomen/scrotum in some

o Describing ‘heaviness’ in the scrotum

o Breast enlargement from hormonal effects of beta-hCG

o Lower back pain from lymphadenopathy.

o Dyspnoea from lung mets.

38
Q

What are the complications of testicular cancer? (x2)

A

Infertility from treatment. Hydrocele.

39
Q

What are the types of testicular cancer? (x4)

A

Most common type is germ cell tumour; divided into seminomas (seminiferous tubule) and nonseminomas. Other types include sex-cord stromal tumours and lymphomas.

40
Q

What are the investigations for testicular cancer? (x4)

A

o USS (determine character of lump e.g. cystic or solid, uniform, poorly defined)

o Blood tests (tumour markers – alpha-fetoprotein, beta-hCG, LDH-1). Also good for monitoring treatment

o CXR allow staging

o CT scan used to evaluate full extent of disease (CT scan).

41
Q

How is biopsy performed for testicular cancer?

A

Obtained from inguinal orchiectomy (excision of whole testis and attached structures; epididymis and spermatic cord). A biopsy should not be performed as it raises the risk of spreading cancer cells into the scrotum.

42
Q

What is the epidemiology of testicular cancer: Incidence? How common? Proportion of deaths?

A

2000 annual incidence in UK, 16th most common cancer in men, accounting for 1% of deaths.

43
Q

How is testicular cancer staged?

A
  1. No evidence of metastasis
  2. Infradiaphragmatic node involvement (spread via the para-aortic nodes, NOT inguinal nodes)
  3. Supradiaphragmatic node involvement
  4. Lung involvement (haematogenous (carried by blood))
44
Q

What is a varicocele?

A

Abnormal enlargement of the pampiniform venous plexus in the scrotum (drains blood from the testicles via the spermatic cord and inguinal canal).

45
Q

What is the epidemiology of varicocele: Prevalence? Trend?

A

Occurs in 15-20% of all men. Increasing incidence with age.

46
Q

What are the causes of varicocele? (x3)

A

Anatomical; three theories – (1) vein on the left side connects to the larger outflowing vein at a right angle which tends to fail, (2) valves fail, (3) excessive pressure in upstream arteries created by nutcracker syndrome.

47
Q

What is nutcracker syndrome?

A

Vein compression disorder when the abdominal aorta or SMA squeezes the left renal vein.

48
Q

What are the symptoms of varicocele? (x3)

A

Soft lumps and mostly on the left side, pain and heaviness in the scrotum.

49
Q

What are the complications of varicocele?

A

Infertility (theories include that varicocele damaged sperm via excess heat caused by blood pooling and oxidative stress on sperm).

50
Q

What are the investigations for varicocele?

A

Confirmed on scrotal USS which will show dilation of the pampiniform plexus.

51
Q

What is hydrocele?

A

Serous fluid accumulation within the tunica vaginalis.

52
Q

What is primary and secondary hydrocele?

A

Primary: associated with a patent processus vaginalis, which typically resolves during the first year of life; Secondary: to testis tumour, trauma, infection.

53
Q

What is the epidemiology of primary and secondary hydrocele: Age? Where?

A

In first year of life, or in elderly. More prevalent in hot countries.

54
Q

What is the differential epidemiology of primary and secondary hydrocele?

A

Primary is more common and usually in younger men.

55
Q

What are the causes of hydrocele? (x1 and x3)

A

Impaired reabsorption in primary; chronic infection (mosquito-borne parasites of Africa and South-East Asia), trauma and trauma in secondary.

56
Q

What are the symptoms? (x3)

A

Often asymptomatic. Painless, enlarged testis, feeling of ‘heaviness’ in scrotum,

57
Q

How do the symptoms differ between primary and secondary hydroceles?

A

Primary are usually larger.

58
Q

What are the signs of primary hydroceles? (x5)

A

Testis cannot usually be felt, transillumination (shining light through sac; indicates presence of fluid; differentiates it from tumour), fluctuant, impulse on coughing is negative, non-reducible (latter two signs differentiate it from hernia).

59
Q

What are the investigations for hydrocele?

A

Done on examination, and USS to visualise the cause or for diagnosing complications (duplex USS).

60
Q

How can you differentiate between scrotal masses on examination: Three questions?

A

o Can you get above? Is it separate from the testis? Cystic or solid?

o Cannot get above: hernia or hydrocele extending proximally.

o Separate and cystic: epididymal cyst

o Separate and solid: epididymitis/varicocele

o Testicular and cystic: hydrocele

o Testicular and solid: tumour, orchitis.

61
Q

How do scrotal masses differ anatomically?

A

.

Year 3 Renal & Urology (10 decks)

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