Scrotal Mass/Pathology

Question 1

Testicles begin descending into the scrotum, being pulled by the gubernaculum and via the inguinal canal around the 3rd trimester of pregnancy. Why does the scrotum not remain in the abdomen where they start from?

1 - not sufficient room
2 - must be below the penis
3 - too warm for sperm to survive
4 - vas deferens may become blocked

Answer 1

3 - too warm for sperm to survive
- sperm cannot survive at body temperature

Question 2

As the scrotum begins to descend via the inguinal canal, a peritoneum out pouching is formed called what?

1 - vas deferens
2 - process vaginalis
3 - tunica vaginalis
4 - spermatic cord

Answer 2

2 - process vaginalis
- once descended the process vaginalis closes

Question 3

Once the testicles have descended via the inguinal ligament into the scrotum the out pouching of the peritoneum closes. However, each testicle remains covered by an extension of the peritoneum. What is this out pouching called?

1 - vas deferens
2 - epididymis
3 - tunica vaginalis
4 - spermatic cord

Answer 3

3 - tunica vaginalis
- BUT this does not cover the epididymis or the spermatic cord
- the spermatic cord contains vas deferens, blood vessels, lymphatics and nerves

Question 4

When we examine the scrotum we need to assess if we can get above or below the mass. Which of the following pathologies can you NOT get above when performing an examination of a patient?

1 - epididymal cyst
2 - hydrocoele
3 - testicular tumour
4 - inguinal hernia
5 - varicose veins

Answer 4

4 - inguinal hernia

Question 5

When examining the testicles, which of the following would be classed as separate from the testicle?

1 - epididymal cyst
2 - varicocele
3 - testicular tumour
4 - all of the above

Answer 5

1 - epididymal cyst
- this is located on the epididymis

Question 6

What is the number 1 imaging choice for the scrotum?

1 - MRI
2 - CT
3 - ultrasound
4 - X-ray

Answer 6

3 - ultrasound

Question 7

Is testicular torsion dangerous?

Answer 7

• yes
• medical emergency and one of the most common causes if acute scrotal pain in young men <18 y/o

Question 8

Which of the following is NOT typically an acute sign of testicular torsion?

1 - acute onset of severe pain
2 - haematuria
3 - nausea and vomiting
4 - none of the above

Answer 8

2 - haematuria
- history of trauma is a common cause and must be explored

Question 9

In testicular torsion we can have a bell clapper deformity. Is this intra or extravaginal torsion?

Answer 9

• intravaginal torsion
• this is because this is twisting of the testicles including the tunica vaginalis

Question 10

Which age group is testicular torsion most common in?

1 - 1-10
2 - 10-20
3 - 20-30
4 - 30-40

Answer 10

2 - 10-20

Question 11

To diagnose and assess the risk of testicular torsion in a patient we have to use the TWIST score (Testicular Workup for Ischamia and Suspected Torsion). Which of the following variables is NOT included in this scoring system?

1 - Swelling
2 - Haematuria
3 - Hard Testicle
4 - Absent cremaster
5 - Nausea or vomiting
6 - High riding testicle

Answer 11

2 - Haematuria

Scores:
- 0-2 low risk = discharge
- 2-4 intermediate risk = ultrasound
- 5-7 high risk = investigate

Question 12

Prehns sign can be used to distinguish between testicular torsion and epididymitis. What is Prehns sign?

1 - pain increases when elevating the testicles
2 - pain is high upon palpations
3 - TWIST score >3 without tenderness
4 - all of the above

Answer 12

1 - pain increases when elevating the testicles
- this is a NEGATIVE prehns sign
- in epididymitis pain is relieved when elevating the testicles

Question 13

The cremaster reflex is when you stroke the inner thigh close to the scrotum. When stroking the inner thigh the cremaster muscle to contracts and pulls the testicle on that side upwards. Is this reflex present in testicular torsion?

Answer 13

• no

Question 14

Epididymo-orchitis is a differential for testicular torsion, where the epididymis and/or testicle becomes inflamed, most likely due to an infection. Which of the following suggest Epididymo-orchitis over testicular torsion?

1 - age (older in Epididymo-orchitis)
2 - onset is slower
3 - signs of infection
4 - all of the above

Answer 14

4 - all of the above

Question 15

Fournier’s gangrene is a differential for testicular torsion, where there is an acute necrotic infection of the scrotum; penis; or perineum. Which patient group is this most common in?

1 - 10-20 y/o
2 - diabetics
3 - elderly
4 - females

Answer 15

2 - diabetics
- immunosuppressed increases the risk