Scrotal Lumps Flashcards
Inspection of lump - 6 Sās
- Site
- Size
- Shape
- Symmetry
- Skin changes
- Scars
Palpation of lump - CAMPFIRE
- Consistency
- Attachments
- Mobility
- Pulsation
- Fluctuation
- Irreducibility
- Regional lymph nodes
- Edge
+ tenderness, temperature and transillumination
1st line investigation for scrotal lump
USS scrotum
Diagnosing testicular cancer, what is after USS?
- Biopsy = NO due to risk of seeding cancer
- Instead clinical diagnosis, USS and histopathological exam following orchidectomy
- Bloods for testicular tumours markers should be sent if suspect cancer
Testicular cancer tumour markers
- Alpha fetoprotein (AFP)
- Beta human chorionic gonadotrophin (b-HCG)
- Lactate dehydrogenase (LDH) - but this is not specific to testicular cancer, will be high when rapidly dividing cells present so any cancer really with high tumour burden
Two classifications of scrotal lumps
- testicular
- Extra-testicular
Extra-testicular differentials for scrotal lump
- Hydrocele
- Varicocele
- Epididymal cyst
- Epididymitis
- Inguinal hernia
Testicular differentals for scrotal lumps
- Testicular tumour
- Testicular torsion
- Benign testicular lesions
- Orchitis
What is hydrocele?
- Abnormal collection of peritoneal fluid
- Between parietal and visceral layers of tunica vaginalis (envelops testes)
Presentation of hydrocele
- Painless fluctuant swelling - ocassionally can grow large and cause discomfort while sitting/walking
- Transilluminates
- Uni or bilateral
- Can also form in spermatic cord and is differential for groin lump
What is congenital hydrocele?
- Affects 3% male neonates
- Generally regresses spontaneously by 1-2yrs old
- No treatment typically needed - caused by patient processus vaginalis, may need ligation to stop recurrence
Older male hydroceles causes
- Primary - idiopathic
- Secondary - infection, trauma, malignancy
- Those aged 20-40yrs OR if testes cannot be palpated should have urgent USS scan
Transillumination - what is it?
- Shine pen torch from behind scrotal lump
- Observe whether light travels through
- Assess whether mass is fluid filled or not - fluid transilluminates, solid wont
- Hydroceles and epididymal cysts will transilluminate usually
What is varicocele?
- Abnormal dilatation of pampiniform venous plexus within spermatic cord
- Bag of worms appearance
Presentation of varicoceles
- Lump
- Feel like bag of worms
- Dragging sensation
- May disappear when lay flat - examine lying down, standing and while performing valsalva
Where are most varicoceles located and why?
- Left
- Spermatic vein drains directly into left renal vein (compared to IVC on R)
Consequence of varicocele
- Can cause infertility and testicular atrophy
- Increases intra-scrotal temperature - impaired flow, stasis of warm venous blood
- So men should undergo semen analysis if varicocele and fertility issues ā> refer to urology if abnormal
Red flag signs varicocele
- Acute onset
- Right sided
- Remain when lying flat
Investigate these urgently - also examine abdo with all varicoceles incase of renal tumour
Treatment of varicocele
- If asymptomatic with no red flags - no treatment
- Surgical - embolisation by interventional radiologist or open/laparascopic ligation of spermatic veins
What are epididymal cysts?
- Benign fluid filled sacs
- Arising from epididymis
- AKA spermatoceles
Presentation of epididymal cyst
- Smooth, fluctuant nodule
- Above and seperate from testes
- Transilluminates
- Often multiple
Management epididymal cyst
- No treatment
- In rare cases if very large/painful may need surgery - avoid in younger men as may lead to infertility
Inguinal hernia as scrotal lump
- Can pass into scrotum via external inguinal ring (superficial)
- Entering inguinal canal initially via internal (deep) inguinal ring (indirect) or through Hesslebachs triangle (direct)
- Run alongside spermatic cord when in scrotum
Examination of scrotal inguinal hernia
- Cannot get above - cannot palpate its superior surface
- Cough can exacerbate swelling
- Can disappear when lay flat
- Assess for strangulation or incarceration
Examination for testicular cancer
- Firm
- Irregular mass
- No transillumination
Deformity associated with testicular torsion
- Bell clapper deformity - high attachment of tunica vaginalis allowing rotation
What can form following orchitis?
- Intra-testicular abscess
- RARE though
- Will require drainage and occasionally orchidectomy
