Scrotal mass (oxford clin cases) Flashcards
What is a swollen and tender scrotum until proven otherwise?
Testicular torsion
What questions would you want to ask in the history if someone presents with a scrotal lump? Explain why you’d ask them
How long has the lump been there- a cancer will not usually suddenly arise
Is the lump always there- inguinal hernias can slide into the scrotum and may only be present after intra abdominal pressure increases
Is the lump painful- torsion, abscess etc are likely to be painful but malignancy is not
Does the lump feel heavy- as malignancy is not painful you can use this feature to point you towards a diagnosis if other clinical features are present
Are there any other lumps anywhere in the body
Are there any associated symptoms- UTI (dysuria, suprapubic pain, new nocturia, cloudy urine, urgency, smelly urine), STI (fever, rash, purulent discharge)
How did the patient first notice the lump
Has the lump gotten bigger, smaller or stayed the same in size
What 4 things must you keep in mind when examining the testes? How will this help you narrow your differentials
Can you get above the mass- if the answer is no and it extends into the suprapubic regions its likely an inguinal hernia
Does it transilluminate when you shine a torch through it- if yes its likely a cyst of oedema (fluid)
Is it tender or hard- if its hard its more likely cancer, if tender more likely torsion
Can you palpate the testes separate from the lump- feel for the epididymis, spermatic cord and testis and if you can’t feel them note which ones you can’t feel
What is the biggest risk factor for a testicular tumor?
Undescended or maldescended testes
What lymph nodes do the tests vs the scrotal skin drain to?
Testes= para aortic nodes
Scrotal skin= inguinal nodes
If you suspect the mass is cancer, what else do you need to check for and how should you do this?
Metasteses- palpate lymph nodes
Para aortic and supra clavicular nodes as this is where the testes drain
If the scrotal skin is involved eh there is erythema, puckering etc then palpate the inguinal nodes too
What is the first line investigation for a suspected testicular cancer?
Ultrasound of both testes
What imaging and investigations might you do for a suspected testicular cancer?
First line ultrasound of both testes
Tumor markers
Imaging to allow staging- chest x ray and CT chest/abdomen/pelvis
What imaging is done to stage testicular cancer?
Chest x ray
CT chest/abdomen/pelvis
What tumors might doctors test for when testicular cancer is confirmed/suspected?
AFP
Beta HCG
LDH
What characteristics in the history/ examination/ patient description will point to a diagnosis of variocele?
Feels like a ‘bag of worms’
Worse at the end of the day or after exercise
Disappears when they lie down
Can get above the lump
Doesn’t usually arise suddenly but develop and grow over time
How is variocele managed?
Reassure the patient that this is a normal and common condition and not to worry
Wearing tight/ compressive clothing may be helpful (like varicose veins)
Can be embolized/ surgically ligated if problematic
What is hydrocele?
A collection of fluid in the tunica vaginalis ie around the testis
How do you differentiate hydrocele from epididymal cyst?
Hydrocele= testis not palpable
Epididymal cyst= testis palpable
What features in history/ examination/ patient description point to a diagnosis if hydrocele?
Transilluminable Testis not palpable May be very large There may a history of infection/ trauma/ cancer Non tender
