Scrotal lumps

Question 1

Inspection of the lump 6 S’s

Answer 1

Site
Size
Shape
Symmetry
Skin change
Scars

Question 2

Palpating the lump (CAMPFIRE)

Answer 2

Consistency
Attachments
Mobility
Pulsation

Fluctuation
Irreducibility
Regional lymph nodes
Edge

Also:
Tenderness
Temperature
Transillumination

Question 3

Investigations

Answer 3

USS - first line

Blood test - tumour markers e.g. beta HCG, AFP, LDH

Question 4

Biopsy

Answer 4

Biopsy is not warranted for the diagnosis of testicular cancer (due to risk of seeding cancer)

Question 5

Scrotal lumps

Answer 5

Hydrocoele
Varicocoele
Epididymal Cysts
Epididymitis
Inguinal hernia 
Testicular tumour

Question 6

Hydrocoele

Answer 6

Abnormal collection of peritoneal fluid in the tunica vaginalis

• painless fluctuant swelling
• transilluminate
• between 20-40yrs - undergo urgent ultrasound scan

Question 7

Causes of hydrocoele

Answer 7

Primary

Secondary - trauma, infection or malignancy

Question 8

Varicocoele

Answer 8

Abnormal dilatation of the pampiniform venous plexus within the spermatic cord

• bag of worms
• dragging sensation
• may disappear on lying flat
• commonly on left

Question 9

Complications of varicocoeles

Answer 9

Infertility

Testicular atrophy

Question 10

Red flags for varicocele

Answer 10

Acute onset
Right-sided
Remain when lying flat

Investigated urgently

Question 11

Mx of varicocele

Answer 11

Infertility - semen analysis

Mx:
Asymptomatic varicocoeles with no red flags - no treatment

Surgical:

• embolisation
• open or laparoscopic approach for ligation of the spermatic veins

Question 12

Epididymal Cysts

Answer 12

Benign fluid-filled sacs arising from the epididymis

• smooth fluctuant nodule
• separate from the testis
• transilluminate
• can have multiple
• seen in middle aged men
• Do not require treatment
• Surgery if large and painful

Question 13

Epididymitis

Answer 13

Inflammation of the epididymis commonly due to bacteria - STI or enteric

• unilateral acute onset scrotal pain
• may have associated swelling, erythematous overlying skin, and systemic symptoms such as fever
• tender epididymis
• Prehn’s sign

Question 14

Prehn’s sign

Answer 14

pain may be relieved on elevation of the testis

Question 15

Mx of epididymitis

Answer 15

Oral antibiotics and analgesia

Question 16

Testicular Tumours

Answer 16

Painless lump arising from the testis

• firm irregular mass
• does not transilluminate

Ix: urgent ultrasound scan
Bloods - tumour markers

Question 17

Mx of testicular tumours

Answer 17

High index of suspicion - radical inguinal orchidectomy

Adjuvant chemotherapy

Question 18

Testicular Torsion

Answer 18

Twisting of the testis on the spermatic cord causing ischaemia.

• sudden-onset
• very severe
• unilateral scrotal pain
• associated nausea or vomiting
• ‘Bell-clapper’ deformity
• affected testis is usually extremely tender, raised, and swollen
• loss of cremasteric reflex

Question 19

Mx of testicular Torsion

Answer 19

Surgical emergency - fixation of both testes within 6 hours

Question 20

Benign Testicular Lesions

Answer 20

Leydig cell tumours
Sertoli cell tumours
Lipomas
Fibromas

Question 21

Orchitis

Answer 21

Inflammation of the testis commonly caused by mumps

Tx - rest and analgesia

Rare complication:
Intra-testicular abscess - requires drainage

Question 22

Investigations for scrotal pain

Answer 22

Urine dipstick - urinalysis + MCS

Urethral swab STI

Routine bloods

USS of scrotum

Question 23

Henoch-Schoenlein Purpura

Answer 23

IgA-mediated small vessel vasculitis

Commonly affects the skin, mucous membranes, and kidneys.

Triad:

• purpuric rash on limbs
• arthritis
• abdominal pain