Scrotal lumps Flashcards
What should you ask about in the history of a scrotal lump?
Time of onset, associated symptoms such as pain, previous episodes
What should inspection of the lump include?
The 6Ss
Site, size, shape symmetry, skin changes, scars
When palpating the lump what should be commented on?
Tenderness, temperature, transillumination
CAMPFIRE
Consistency, attachments, mobility, pulsation, fluctuation, irreducibility, regional lymph nodes and edge
Also palpate the testis, epididymis and vas deferens
What investigations would you do for someone with a scrotal lump?
Ultrasound scan of the scrotum
blood tests and further imaging
Why would you not take a biopsy for testicular cancer?
seeding
How is a diagnosis of testicular cancer made?
clinical features, ultrasound, histopathological examination of the testis after a orchidectomy
What blood tests are done for testicular cancer?
testicular tumour markers- lactate dehydrogenase (LDH), alpha fetoprotein (AFP) and beta-human chorionic gonadotrophin (beta hCG)
How would you assess for widespread pulmonary metastasis in testicular cancer?
Chest radiograph
How would you assess for metastasis of the para-aortic lymph nodes and further?
CT Scan of the chest- abdomen- pelvis
How can scrotal lumps be classified?
Testicular or extra-testicular
What are the extra-testicular scrotal lumps?
Hydrocoele Varicocoele Epididymal cyst Epididymitis Inguinal hernia
What are the testicular scrotal lumps?
Testicular tumours
Orchitis
Testicular torsion
What is a hydrocoele?
Abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis
What are the clinical features of a hydrocoele?
Painless
Fluctuant swelling
transilluminates
Unilateral or bilateral
What is a congenital hydrocoele?
effects up to 3% of male neonates and regress spontaneously by 1 or 2 years old, in infants they are caused by patent processes vaginalis which required ligation to stop recurrence
What transilluminates?
Fluid, solids will not
What can cause hydrocoeles in older males?
trauma, infection, malignancy
What is a varicocoele?
abnormal dilatation of the pampiniform venous plexus
What does a varicocoele look like?
A bag of worms with a dragging sensation that may disappear when lying flat
In what positions should you examine a varicocoele?
Standing up, lying down and valsalva manoeuvre
Which side do varicocoeles usually present?
The left side as drains directly into the left renal vein rather than the inferior vena cava
What are the complications of a varicocoele?
infertility, testicular atrophy due to increase in intra-scrotal temperature so should get a seman analysis
What are the red flag signs with a varicocoele?
acute onset, ride sided or remain when lying flat, should examine abdomen as may be due to renal tumour
What is the management?
If asymptomatic then no treatment needed, or ligation of spermatic veins and embolisation
What is an eididymal cyst?
benign fluid filled sacs arising from the epididymis
How do epididymal cysts present?
smooth fluctuant nodule found above and separate from the testis that will transilluminate, ca be multiple
What is the treatment for epididymal cysts?
usually do not need treatment as no association with malignancy and rarely have symptoms, operating may cause infertility
What is epididymitis?
Inflammation of the epididymis
What is the presentation of epididymitis?
unilateral acute onset scrotal pain, associated swelling, redness, fever, tender and pain which is received by elevation of the testis (prehns sign)
What is the treatment of Epididymitis?
usually bacterial in origin e.g. STI or enteric organisms so oral antibiotics and analgesia will help
How do inguinal hernias pass into the scrotum?
External ring
How can you examine an inguinal hernia?
you cannot get above an inguinal hernia within the scrotum (can not palpate its superior surface) , a cough may exacerbate the swelling, may disappear when lying flat
How would testicular cancer present?
Painless lump arising from the testis
Firm irregular mass that does not transilluminate
How would you diagnose testicular cancer?
urgent ultrasound scan and tumour markers
How is testicular cancer treated?
Radical inguinal orchidectomy and chemotherapy- 90% five year survival rate
What is orchitis?
inflammation of the testis
What causes orchitis?
usually mumps
what is orchitis usually paired with?
Epididymitis
Epididymo-orchitis
What is a complication of orchitis?
Intra- testicular abscess
What is testicular torsion?
Twisting of the testis on the spermatic cord causing ischaemia
How does testicular torsion present?
Sudden onset very severe unilateral scrotal pain with nausea and vomiting, tender, raised and swollen testis with a loss of cremasteric reflex
What increases incidence of testicular torsion?
Bell clapper deformity
high attachment of tunica vaginalis allowing rotation
What is the treatment for testicular torsion?
surgical emergency so scrotal exploration and fixation must occur, salvage rates decline after 6 hours
What are some examples of benign testicular lesions?
Leydig cell tumours, sertoli cell tumours and lipomas or fibromas
