Scrotal Lumps Flashcards
What is the first line investigation for scrotal lumps?
USS scrotum
What are the differentials for a scrotal lump?
Extra-testicular:
- hydrocele
- varicocele
- epididymal cyst
- epididymitis
- inguinal hernia
Testicular:
- testicular cancer
- benign tumours
- testicular torsion
- orchitis
What are the benign testicular tumours?
Leydig cell tumours
Sertoli cell tumours
Lipomas
Fibromas
What are the clinical features of a hydrocele?
Painless fluctuant swelling that will transilluminate
Unilateral or bilateral
Can grow very large –> discomfort
What are the causes of hydroceles?
Congenital (usually regress spontaneously) Idiopathic Secondary to: - trauma - infection - malignancy
How is a hydrocele investigated?
If aged 20-40 or if testis cannot be palpated:
–> urgent USS
Which scrotal lumps classically transilluminate?
Hydrocele
Large epididymal cysts
What is a varicocele?
Abnormal dilatation of the pampiniform venous plexus within the spermatic cord
What are the clinical features of a varicocele?
Lump, feels like a bag of worms, or a dragging sensation
May disappear on lying flat
90% on the LEFT side
Red flag signs:
- acute onset
- right sided
- remains when lying flat
What is the management for varicoceles?
Asymptomatic with no alarm features:
- no treatment required
Alarm features:
- embolisation by interventional radiologist
- ligation of the spermatic veins
What are the complications associated with varicoceles?
Infertility + testicular atrophy
What are the clinical features of epididymal cysts?
Benign fluid-filled sacs arising from the epididymis Smooth fluctuant nodule Found above and separate from the testis Transilluminate Often multiple
What is the management for epididymal cysts?
No treatment required
unless very large or painful - rare
How might an inguinal hernia present in the scrotum?
Passes via the external inguinal ring
Runs alongside the spermatic cord
What are the examination features of an inguinal hernia in the scrotum?
You cannot ‘get above’ the lump (cannot palpate superior surface)
Cough may exacerbate the swelling
May disappear on lying flat
Must assess for strangulation or obstruction
When might orchitis present in the absence of epididymitis?
Mumps is the main cause
- preceded with history of parotid swelling
What are the usual causes of epididymitis?
Local extension of infection from urinary tract:
- STIs in males < 35 (chlamydia, gonorrhoea)
- enteric organisms from UTI in males > 35 (often secondary to bladder outflow obstruction due to BPH)
What are the clinical features of epididymitis?
Unilateral scrotal pain + swelling
May be fever + rigors
Features associated with cause e.g. UTI, STI
On examination:
- red, swollen + tender
- may be associated hydrocele
- Prehn’s sign positive
- cremasteric reflex intact
What is Prehn’s sign?
Scrotum elevated by the examiner –> relieves pain
Which investigations should be done for epididymitis?
Urinalysis + culture
STI tests
Routine bloods +/- cultures
US Doppler –> increased blood flow
What is the management for epididymitis?
Appropriate antibiotic therapy
Analgesia
Abstain from sexual activity until antibiotic course complete
What are the clinical features of testicular torsion?
Sudden onset severe unilateral testicular pain
Referred abdominal pain
Associated nausea and vomiting
On examination:
- testis in high position with horizontal lie
- absent cremasteric reflex
- negative Prehn’s sign
How is testicular torsion diagnosed?
Clinical diagnosis –> straight to theatre for surgical exploration
US doppler can show compromised blood flow
How is testicular torsion managed?
Surgical emergency
- -> 4-6 hour window from symptoms onset to salvage testis
- bilateral orchidopexy (untwisted and both testis fixed to scrotum)
- if non-viable –> orchidectomy
How are testicular tumours classified?
Germ cell (95%) - usually malignant
- seminomas
- non-seminomatous (yolk sac, choriocarcinoma, embryonal + teratoma)
Non-germ cell (5%) - usually benign
- leydig cell
- sertoli cell
What are the risk factors for testicular cancer?
Cryptorchidism (undescended testes)
Family or personal history
Kleinfelter’s syndrome
What are the clinical features of testicular cancer?
Unilateral painless testicular lump
Irregular, firm, fixed mass, does not transilluminate
If metastases:
- weight loss
- back pain (retroperitoneal spread)
- dyspnoea (lung mets)
How is testicular cancer diagnosed?
Tumour markers + imaging alone
–> DO NOT do biopsy (might cause seeding of cancer)
Which tumour markers are associated with testicular cancer?
beta-HCG
AFP
LDH
Which types of imaging are used for investigation testicular cancer?
Scrotal USS for initial assessment
CT with contrast for staging
How is testicular cancer staged?
Royal Marsden Classification: I - confined to testes II - lymph nodes below diaphragm III - lymph nodes above + below diaphragm IV - extralymphatic spread
How is testicular cancer managed?
Inguinal radical orchidectomy (testes + spermatic cord)
+/- chemo/RT
Pre-treatment fertility assessment + cryopreservation
