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CCE Lectures/Workshops > Scrotal Lumps > Flashcards

Scrotal Lumps Flashcards

1
Q

How should a testicular mass be approached?

A

Assumed testicular cancer until proven otherwise

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2
Q

In a patient with acute, tender enlargement of the testis, what should be assumed until proved otherwise?

A

Testicular torsion

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3
Q

What are the differentials for scrotal swelling with minimal pain?

A
  • Inguinal hernias
  • Hydrocoele
  • Varicocoele
  • Testicular tumours
  • Epididymal cyst (spermatocoele)
  • Idiopathic scrotal oedema
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4
Q

What are the differentials for scrotal pain?

A
  • Testicular torsion
  • Epididymo-orchitis
  • Strangulated hernia
  • Torsion of hytadid of Morgagni
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5
Q

What are the differentials for groin swellings?

A
  • Inguinal hernia
  • Lymphadenopathy
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6
Q

Describe idiopathic scrotal oedema

A

Occurs in children, either bilateral or unilateral

Sudden onset

Minimal tenderness

Testicles normal on examination

Resolves spontaneously

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7
Q

What is a varicocoele?

What features of the history may indicate a varicocoele?

How does it appear on examination?

How is it diagnosed?

A

= Abnormal dilation of the internal spermatic veins and/or pampiniform plexus that drain blood from the testes

History

  • Painless testicular mass

Examination:

  • Seperate from testis
  • 90% left sided (if right sided be suspicious of right sided retroperitoneal or pelvic compressive mass)
  • Solid
  • May feel like a ‘bag of worms’
  • More prominent on standing/valsalva manoeuvre

Diagnosis:

  • Clinical examination primary form of diagnosis
  • USS may be used to confirm diagnosis or detect sub-clinical varicocoeles
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8
Q

When should abdominal imaging be requested for a suspected varicocoele?

A

If sudden onset and bilateral

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9
Q

How are varicocoeles managed?

A
  • Sub clinical or grade I: reassurance
  • Grade II or III (<20% size difference or symmetrical testes): Observation
  • Grade II or III (asymmetrical): surgery (open repair, or 2nd line laparoscopic repair)
  • Embolisation if it affects sperm quality or causes testicular atrophy
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10
Q

What are hydrocoeles?

What features in the clinical history could suggest a hydrocoele?

How should a hydrocoele appear on examination?

How would a suspected hydrocoele be investigated?

A

Abnormal serous fluid that occurs between the layers of the tunica vaginalis that surrounds the testis or along the spermatic cord.

History:

  • Testicular mass
  • Previous trauma, infection, testicular torsion, testicular tumour or varicocoele.
  • Enlargement of scrotal mass following physical activity
  • Variation in size throughout the day

Examination:

  • Scrotal mass: soft if the communication is large, tense if it is small.
  • May extend into inguinal canal
  • Visible on trans-illumination
  • Testicular and cystic
  • Fluctuant
  • Able to get above swelling

Investigations:

  • Rarely need imaging, clinical diagnosis usually sufficient
  • USS can be used to confirm but usually not necessary
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11
Q

Who are hydrocoeles common in?

A

Common in male infants and new-borns; often self resolve in the first few years of life.

May occur in adult men secondary to trauma, infection, testicular torsion, testicular tumour or varicocoele.

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12
Q

Describe the management of hydrocoeles

A

Surgery if significant bother

  • Children:
    • <2 years: observation
    • 2-11 years: surgery. Excision of hydrocoele or drainage.
  • Adolescents:
    • If idiopathic: surgery
    • If post varicocoelectomy: observation +/- aspiration 1st line
    • 2nd line: surgery
  • Adults:
    • 1st line: observation (if without discomfort or infection)
    • 2nd line: surgery or aspiration and sclerotherapy (if large/uncomfortable)
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13
Q

What is testicular torsion?

What features of the clinical history could indicate possible torsion?

A

=Urological emergency caused by the twisting of the testicle on the spermatic cord. Causes construction of the vascular supply and time-sensitive ischaemia and/or necrosis of the testicular tissue.

History:

  • Sudden onset, severe testicular pain
    • Can be intermittent (torsion which untwists intermittently)
    • No relief upon elevation of the testicle
    • May have abdominal pain (T12)
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14
Q

How does testicular torsion appear on examination?

How is it investigated?

A

Examination:

  • Scrotal swelling or oedema with worsens with time
  • Scrotal erythema and skin changes with late presentation
  • Reactive hydrocoele may develop with time
  • High riding affected testicle
  • Horizontal lie of affected testicle
  • Absent cremasteric reflex on affected side

Investigations:

  • USS: Grey scale or doppler (power or colour)
  • Exploration <6 hours
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15
Q

Describe the management of testicular torsion

A
  • Non-neonate:
    • 1st line: emergency scrotal exploration under urology
    • Analgesia and anti-emetics: morphine sulphate and ondansetron
    • 2nd line: Manual de-torsion followed by scrotal exploration
  • Neonate with torsion at birth: 1st line: initial stabilisation +/- semi-elective scrotal exploration
  • Neonate with normal testes at birth and subsequent torsion: 1st line: emergency scrotal exploration
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16
Q

What are the possible complications of testicular torsion?

How quickly must testes with suspected torsion undergo exploration?

A

<6 hours exploration

Complications:

  • Infarction of affected testicle
  • Loss of fertility + psychological implications
  • Impaired pubertal development if occurring in child (if bilateral torsion occurs)
17
Q

What features of the clinical history may indicate possible testicular cancer?

What are the risk factors?

A

History:

  • Testicular mass (usually painless)

Risk factors:

  • Cryptorchidism
  • +ve FHx or personal Hx
  • Testicular atrophy
  • White ethnicity
  • Age 20-40 years (if older males more likely to be metastasis from other cancers, i.e. lymphoma)
  • HIV infection
  • More likely with history of testicular maldescent
18
Q

How would a testicular tumour appear on examination?

A
  • Testicular mass, usually painless (>85%), may be bilateral
  • Testicular and solid, irregular
  • Not trans-illuminated, but may have reactive hydrocoeles around them which can be trans-illuminated.
19
Q

What is an epididymal cyst?

Describe the features of the clinical history that might suggest an epididymal cyst

How may an epididymal cyst appear on examination?

Describe the management

A

Cyst related to epididymis and testis can be palpated separately.

History

  • Scrotal swelling
  • Can be painful
  • Sometimes consequence of varicectomy

Examination

  • Scrotal mass that can be trans-illuminated
  • Can be palpated separate to the testis, lying posterior and superior to it.

Investigations

  • Scrotal USS can assist diagnosis

Management

  • None unless causes cosmetic embarrassment/pain
20
Q

What is epididymo-orchitis?

What features of the history may suggest this?

What are the risk factors?

A

= Inflammation of the epididymis causing pain and swelling

History:

  • Unilateral pain, onset over several hours
  • Swelling, unilateral, symptoms <6 weeks duration

Risk factors:

  • Multiple sexual partners
  • Sexual partners infected with Chlamydia trachomatis, Neisseria gonorrhoeae, and/or Mycoplasma genitalium.
  • History of anal intercourse
  • Age >19 years (any age after puberty)
  • History of viral infection
  • Infection or contact with tuberculosis
  • Previous bladder outflow obstruction
  • Previous instrumentation of urinary tract
  • Predisposition to infection in urinary tract (obstruction, DM)
21
Q

How would epididymo-orchitis appear on examination?

What investigations are used? What are the expected results?

A

Examination:

  • Tenderness
  • Hot, erythematous swollen hemi-scrotum (diffuse enlargement of the testis)
  • Scrotal skin changes

Investigations:

  • Gram staining of urethral secretions: detect urethritis and/or gonococcal infection
  • Urine dipstick test: if +ve f or WBC, suggests urethritis and/or lower UTI
  • MSU: isolate causative organism
  • Urine sample for NAAT for chlamydia & gonorrhoea infections
  • Urethral swab: required for culture for N. gonorrhoeae
  • Consider HIV testing as those HIV +ve at risk of other STIs.
22
Q

Describe the management of epididymo-orchitis

A
  • If bacterial cause: antibiotic therapy
  • Idiopathic or viral: analgesia
  • Tuberculous: Anti-tuberculous antibiotics
  • Amiodarone induced: dose reduction or discontinuation of drug
23
Q

Describe torsion of hydatid of morgagni

A

Anatomically a small cyst (a remnant of the Wolfian duct) torsion.

Occurs in children

Sudden severe pain

Maximum tenderness over upper pole of testis and ‘blue dot sign’

Conservative management with analgesia.

24
Q

Describe the pathophysiology of testicular cancer

A

All germ cell tumours are believed to start developing during fetal development and to progress through a non-invasive stage called intratubular germ cell neoplasia unclassified (carcinoma in situ). This condition is thought to be a precancerous lesion that will eventually lead to malignant growth. Congenital abnormalities leading to distorted differentiation of germ cells and arrest of normal development of the primordial germ cell are considered to be an important aetiological factor for testicular cancer as well. Environmental factors (trauma, hormones, and atrophy) and genetic predisposition (gain of the chromosomal arm 12p) are also thought to play a role in the development of the disease. A combination of these factors is thought to be the leading cause of this condition.

Teratomas are most common in young men, but the incidence of seminomas rises with age and becomes the most common testicular tumour in the over 60s.

25
Q

How are suspected testicular cancers investigated?

Describe the management

A

Investigations:

  • Testicular USS primary test, near 100% sensitivity
  • Testicular tumour markers (alpha fetoprotein, beta-HCG, LDH)
  • CT chest abdo pelvis to assess metastases (may show enlarged retroperitoneal lymph nodes)
  • Serum beta hCG: elevated in nearly all cases of choriocarcinoma

Management:

  • Radical (inguinal) orchiectomy (usually curative in early stages) + surveillance
  • Seminoma: + chemo and radiotherapy if stage I locally invasive or not locally invasive
  • Non-seminoma: + chemo and radiotherapy + retroperitoneal lymph node dissection
  • Sperm storage

CCE Lectures/Workshops (9 decks)

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