Scrotal Lumps

Question 1

What is the first line investigation for scrotal lumps?

Answer 1

USS scrotum

Question 2

What are the differentials for a scrotal lump?

Answer 2

Extra-testicular:

• hydrocele
• varicocele
• epididymal cyst
• epididymitis
• inguinal hernia

Testicular:

• testicular cancer
• benign tumours
• testicular torsion
• orchitis

Question 3

What are the benign testicular tumours?

Answer 3

Leydig cell tumours
Sertoli cell tumours
Lipomas
Fibromas

Question 4

What are the clinical features of a hydrocele?

Answer 4

Painless fluctuant swelling that will transilluminate
Unilateral or bilateral
Can grow very large –> discomfort

Question 5

What are the causes of hydroceles?

Answer 5

Congenital (usually regress spontaneously)
Idiopathic
Secondary to:
- trauma
- infection
- malignancy

Question 6

How is a hydrocele investigated?

Answer 6

If aged 20-40 or if testis cannot be palpated:

–> urgent USS

Question 7

Which scrotal lumps classically transilluminate?

Answer 7

Hydrocele

Large epididymal cysts

Question 8

What is a varicocele?

Answer 8

Abnormal dilatation of the pampiniform venous plexus within the spermatic cord

Question 9

What are the clinical features of a varicocele?

Answer 9

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

Question 10

What is the management for varicoceles?

Answer 10

Asymptomatic with no alarm features:
- no treatment required

Alarm features:

• embolisation by interventional radiologist
• ligation of the spermatic veins

Question 11

What are the complications associated with varicoceles?

Answer 11

Infertility + testicular atrophy

Question 12

What are the clinical features of epididymal cysts?

Answer 12

Benign fluid-filled sacs arising from the epididymis 
Smooth fluctuant nodule
Found above and separate from the testis
Transilluminate
Often multiple

Question 13

What is the management for epididymal cysts?

Answer 13

No treatment required

unless very large or painful - rare

Question 14

How might an inguinal hernia present in the scrotum?

Answer 14

Passes via the external inguinal ring

Runs alongside the spermatic cord

Question 15

What are the examination features of an inguinal hernia in the scrotum?

Answer 15

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

Question 16

When might orchitis present in the absence of epididymitis?

Answer 16

Mumps is the main cause

- preceded with history of parotid swelling

Question 17

What are the usual causes of epididymitis?

Answer 17

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)

Question 18

What are the clinical features of epididymitis?

Answer 18

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

Question 19

What is Prehn’s sign?

Answer 19

Scrotum elevated by the examiner –> relieves pain

Question 20

Which investigations should be done for epididymitis?

Answer 20

Urinalysis + culture
STI tests
Routine bloods +/- cultures
US Doppler –> increased blood flow

Question 21

What is the management for epididymitis?

Answer 21

Appropriate antibiotic therapy
Analgesia
Abstain from sexual activity until antibiotic course complete

Question 22

What are the clinical features of testicular torsion?

Answer 22

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

Question 23

How is testicular torsion diagnosed?

Answer 23

Clinical diagnosis –> straight to theatre for surgical exploration
US doppler can show compromised blood flow

Question 24

How is testicular torsion managed?

Answer 24

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

Question 25

How are testicular tumours classified?

Answer 25

Germ cell (95%) - usually malignant

• seminomas
• non-seminomatous (yolk sac, choriocarcinoma, embryonal + teratoma)

Non-germ cell (5%) - usually benign

• leydig cell
• sertoli cell

Question 26

What are the risk factors for testicular cancer?

Answer 26

Cryptorchidism (undescended testes)
Family or personal history
Kleinfelter’s syndrome

Question 27

What are the clinical features of testicular cancer?

Answer 27

Unilateral painless testicular lump
Irregular, firm, fixed mass, does not transilluminate

If metastases:

• weight loss
• back pain (retroperitoneal spread)
• dyspnoea (lung mets)

Question 28

How is testicular cancer diagnosed?

Answer 28

Tumour markers + imaging alone

–> DO NOT do biopsy (might cause seeding of cancer)

Question 29

Which tumour markers are associated with testicular cancer?

Answer 29

beta-HCG
AFP
LDH

Question 30

Which types of imaging are used for investigation testicular cancer?

Answer 30

Scrotal USS for initial assessment

CT with contrast for staging

Question 31

How is testicular cancer staged?

Answer 31

Royal Marsden Classification:
I - confined to testes
II - lymph nodes below diaphragm
III - lymph nodes above + below diaphragm
IV - extralymphatic spread

Question 32

How is testicular cancer managed?

Answer 32

Inguinal radical orchidectomy (testes + spermatic cord)
+/- chemo/RT

Pre-treatment fertility assessment + cryopreservation