Scrotal masses (module 5) Flashcards
three arteries contained in the spermatic cord
testicular artery
Cremasteric artery
artery of the ductus deferens
three nerves contained in the spermatic cord
genital branch of genitofemoral nerve
ilioinguinal nerve
autonomic nerves
three structures in the spermatic cord that aren’t arteries or nerves
pampiniform plexus of testicular veins
lymphatics
processus vaginalis (where present)
what is present in the spermatic cord
3 arteries (testicular, cremasteric, artery of the ductus deferens)
3 nerves (genital branch of the genitofemoral nerve, ilioinguinal nerve, autonomic nerves)
3 other structures (pampiniform plexus of the testiuclar veins, lymphatics, processes vaginalis)
what does the darts muscle do
retracts the testis if it is cold or during sexual arousal
the testis develop as
an out pouching of the abdominal wall
tunica vaginalis
produces small amounts of fluid
derived from a peritoneal out pouching called processus vaginalis
mostly regresses
high fusion of tunica vaginalis
means the testicles lie loose (bell clapper configuration)
bell clapper configuration of the testes
tend to be high riding with a horizontal lie
prone to twisting (torsion)
if present, the condition is bilateral
hydrocoele
excess fluid in the tunica vaginalis
may be congenital or acquired (infection/trauma/tumour)
function of the scrotum
allows testicles to be kept at a lower temperature than within the body
receives rich blood supply
where does the scrotum get its blood supply
from multiple vessels including the external and internal pudendals
the scrotum is prone to
large haematomas with trauma and surgical procedures due to rich blood supply and lax and capacious tissues
from where do the testicles receive their blood supply
testicular artery (from aorta)
cremasteric artery (from inferior epigastric)
artery of the ductus deferens (from a branch of internal iliac artery)
what happens if one of the arterial blood supplies to the testes is compromised
it is often possible to sacrifice one or more testicular vessels with the testis remaining viable
where do the lymphatics of the testes drain to
drain along the spermatic cord and back along the gonadal vessels to nodes alongside the great vessels of the abdomen
basically they drain to the retroperitoneum
where would testicular cancer typically spread to
spreads to retroperitoneal nodes
three main cell types of the testes
spermatogonia
leydig cells (produce testosterone)
Sertoli cells
the tunica vaginalis is applied to
the front of the testes
the tunica vaginalis contains
a little fluid
when the tunica vaginalis produces excessive fluid this is called
a hydrocoele
is a scrotal mass a frequent presentation
yes
commonest cause of scrotal lumps
hydrocoeles
epididymal cysts
varicocoeles
most serious causes of scrotal lumps
testiuclar cancer
incarcerated inguinal hernia
not to be missed!
causes of scrotal mass where the cause is within the testis
testicualr tumour
epididymo-orchitis/abscess
causes of scrotal mass where the cause is within the epididymis
epididymal cyst
causes of scrotal mass where the cause is outside testes/epididymis
varicocoele
spermatocoele
hydrocoele
causes of scrotal mass that extend above the scrotum
hernia
determining the cause of a scrotal mass based on its location
varicocoele is caused by
dilated pampiniform veins of the testis
how common are varicocoeles
up to 15% of the population
80% occur on the left side
which side do varicocoeles generally occur on
left
what damage can a varococoele do
may produce warming of the testes
can reduce quality, mobility and number of sperm
can reduce testicular growth in certain cases
occasionally symptomatic
hernia is caused by
weakness/deficiency of the anterior abdominal wall
may be congenital or acquired
epididymal cyst
usually asymptomatic and almost always benign
spermatocoele
retention cyst of epididymis containing sperm
common after vasectomy
usually asymptomatic
approach to determining the cause of a scrotal mass
most scrotal masses can be discriminated on physical examination
U/S is indicated to confirm diagnosis and exclude malignancy - an extension of clinical examination
diagnosis that are made more likely if pain is present
torted cyst/torted testes
infected epididymal cyst
epididymo-orchitis/abscess
infected hydrocoele (pyocoele)
incarcerated hernia
what is made more likely if you can’t palpate above the lump?
inguinal hernia
what diagnosis is made more likely if the mass in compressible and collapsable when supine?
varicocoele
is often described and feeling like a bag of worms
what diagnosis is made more likely if the mass transluminates
hydrocoele
epididymal cyst (Chinese lantern appearance)
inguinoscortal ultrasound
highly sensitive, specific and reliable and reproducible
should be performed to confirm diagnosis and exclude malignancy
what should you exclude before diagnosing hydrocoele
- testicular cancer
- infection/abscess
- trauma/rupture of testes
when diagnosing varicocoele it is important to
measure the size of the testes
check the kidney for tumour as kidney tumours occasionally cause varicocoeles
when diagnosing testicualr tumours it is also important to
check tumour markers
arrange CT chest/abdomen.pelvis for mets or nodes
should you aspirate a hydrocoele
aspiration is rarely indicated as
risks infection
collection rapidly recurs
how should you treat a hydrocoele
surgery eg. hydrocoelectomy with plication and/or eversion of tunica vaginalis are used most commonly
recurrence rate is low
post-operative haematoma is a common complication
common complication of surgery to treat hydrocoele
haematoma
when is treatment needed for varicocoele
if symptomatic
if there is reduction of testicular growth
the role of varococoele repair to treat male factor infertility is contentious
epididymal cyst and spermatocoele treatment
treatment rarely indicated unless very large
Excision risks injuring testicular blood supply/causing vas injury (this can lead to chronic scrotal pain, or vas injury can lead to obstruction of sperm transit)
treatment of hernia
emergency repair indicated if strngulated/incarcerated
elective repair (open or laparoscopic) offered if reducible
serious diagnoses not to be missed include
testicular torsion
testicular tumour
strangulated/incarcerated inguinal hernia
