Scrotal pain/swelling Flashcards
ΔΔ groin lump?
• Femoral/inguinal hernias
(can’t get above the lump, bowel sounds over it, reducible)
• Lymph nodes
• Psoas abscess (back pain, limp, swinging temperature)
• Lipoma of spermatic cord
• Saphena varix (dilated varicose vein at sapheno-femoral junction which reduces on lying flat/has +ve cough impulse)
• Femoral artery aneurysm
• Hydrocele/varicocele
ΔΔ scrotal lump?
• Tumour (until proven otherwise!) • Femoral/inguinal hernias (can't get above the lump, bowel sounds over it, reducible) • Seperate from testes: - hydrocele, varicocele (reduces on lying flat) • Epididymal: - cyst - spermatocele - epididymo-orchitis • Incompletely descended testes
important Ex point for distinguishing inguinoscrotal hernia from cord/testicular lump?
- cannot get above a hernia/will have no upper border
* also cough impulse +ve, reducible, bowel sounds present
how to examine a lump?
SSS CCCC TTTT PS
site, size, shape
colour, contour (edge), consistency, compressibility (fluctuance)
temperature, tenderness, tethering, transilluminance
pulsatility, spread (regional lymph nodes)
Hx: baby or elderly gent with smooth, transilluminable lump anteroinferior to the testicle, which you CAN get above? (if large underlying testicle not palpable)
hydrocele
(1’ patent tunica vaginalis)
(2’ to tumour)
Ix hydrocele?
US (if uncertain or pt aged 20-40 ΔΔ tumour)
Tx hydrocele?
- drainage
* curative surgery (Lord’s/Jaboulay’s repair)
Hx: patient with tender, tense lump which doesn’t transilluminate, following being kicked in the balls?
haematocele
Ix haematocele?
Tx?
US (ΔΔ torsion, tumour)
may need surgical exploration +/- drainage
Hx: young patient comes in with a left scrotum which feels like a bag of worms, and is more prominent on standing, starting to cause a little pain?
Tx?
varicocele
(usually ASx, but just feels like a bag of worms)
Tx - ligation if pain, but surgery doesn’t improve fertility
Hx: patient has a fluctuant, transilluminable lump attached to testis but feels like a clearly seperate structure - no pain?
epididymal cyst
Asx, no Tx
Hx: sexually active young patient with swollen, painful epididymis/testis, +/- UTI Sx, urethral discharge?
epididymo-orchitis
isolated orchitis is rare. what is main cause?
mumps
common causes of epididymo-orchitis?
chlamydia/gonorrhoea
E.coli if older
mumps
Hx that would make you think mumps causing epididymo-orchitis?
parotitis 1 wk ago
high fever, headache, V
Ix epididymo-orchitis?
BEDSIDE:
• first catch urine dip, MC+S +/- nucleic acid testing of urethral swabs
BLOODS:
• +/- HIV test
• mumps IgM/IgG if suspected
IMAGING:
• doppler US (ΔΔ epididymo-orchitis vs torsion)
Tx epididymo-orchitis?
- start Abx on clinical suspicion
- STI? doxycycline 10 days + IM ceftriaxone
- E.coli? ciprofloxacin 10 days
- bed rest and scrotal elevation
Hx: 13 year old boy has sudden onset unilateral scrotal pain, which is making walking uncomfortable, with associated abdo pain, N, V, and a swollen, red, tender hemiscrotum with the right testis lying higher and transverse, with no cremasteric reflex?
testicular torsion
surgery!
risk factor for torsion?
undescended testis
previous torsion on contralateral side (hence both sides fixed at orchidopexy)
Ix torsion?
surgical exploration without delay if any suspicion, detorsion (<6 hrs) and fixation with suture (orchidopexy) of both sides
(+/- doppler US, urinalysis)
ΔΔ scrotal lumps?
- epididymal cyst
- hernia
- varicocele
- hydrocele
- haematocele
- germ cell tumour
ΔΔ testicular pain/swelling?
- epididymo-orchitis
- torsion
- leukaemia or lymphoma infiltration
- germ cell tumour
Hx: 30 yr old patient comes in with painless solid unilateral lump, or testicular enlargement, +/- secondary hydrocele?
Ex: firm lump which you CAN get above, which DOESN’T transilluminate?
testicular germ cell tumour
- 20 percent have scrotal pain or dragging sensation
- 5 percent have gynaecomastia if B-hCG producing
- +/- back ache (para-aortic lymph node spread)
- +/- ureteric obstruction
- +/- weight loss, fatigue
- +/- long mets (SOB, SVC obstruction)
what kind of germ cell tumour is commoner:
<30?
>30?
teratoma
seminoma
risk factors for germ cell CA?
- FHx
- cryptorchidism (undescended)
- Klinefelter’s
- atrophy (post mumps)
Ix germ cell tumour?
BLOODS: "BAL" • B-hCG • AFP • LDH (very specific if both B-hCG and AFP elevated)
IMAGING:
• scrotal US
• CXR (bilateral hilar lymphadenopathy or cannon-ball mets)
• orchiectomy
tumour markers in GCT?
“BAL”:
• B-hCG
• AFP
• LDH
(very specific if both B-hCG and AFP elevated)
(should return to normal post-surgery)
(LDH measures “bulk” of the disease and rapidity of growth)
diagnosis of germ cell tumour?
staging?
- orchiectomy (NOT biopsy) and histology
- CT-CAP
- CT brain if lung mets
Tx germ cell tumour?
• orchiectomy, prosthesis
• biopsy contralateral
+/- radio, carboplatin, “BEP” chemo
complications/prognosis germ cell tumour?
- fertility issues - sperm storage
* 95 percent survive 5 years
ΔΔ acute, tender swollen testis?
- torsion until proven otherwise
- epididymo-orchitis
- trauma
Ex a scrotal mass:
1) can’t get above it
2) seperate and cystic
3) seperate and solid
4) testicular and cystic
5) testicular and solid
1) hernia
2) epididymal cyst
3) epididitis, or varicocele
4) hydrocele
5) tumour, haematocele, orchitis (US)
