Scrotal pain/swelling

Question 1

ΔΔ groin lump?

Answer 1

• 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

Question 2

ΔΔ scrotal lump?

Answer 2

• 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

Question 3

important Ex point for distinguishing inguinoscrotal hernia from cord/testicular lump?

Answer 3

• cannot get above a hernia/will have no upper border

* also cough impulse +ve, reducible, bowel sounds present

Question 4

how to examine a lump?

Answer 4

SSS CCCC TTTT PS

site, size, shape

colour, contour (edge), consistency, compressibility (fluctuance)

temperature, tenderness, tethering, transilluminance

pulsatility, spread (regional lymph nodes)

Question 5

Hx: baby or elderly gent with smooth, transilluminable lump anteroinferior to the testicle, which you CAN get above? (if large underlying testicle not palpable)

Answer 5

hydrocele
(1’ patent tunica vaginalis)
(2’ to tumour)

Question 6

Ix hydrocele?

Answer 6

US (if uncertain or pt aged 20-40 ΔΔ tumour)

Question 7

Tx hydrocele?

Answer 7

• drainage

* curative surgery (Lord’s/Jaboulay’s repair)

Question 8

Hx: patient with tender, tense lump which doesn’t transilluminate, following being kicked in the balls?

Answer 8

haematocele

Question 9

Ix haematocele?

Tx?

Answer 9

US (ΔΔ torsion, tumour)

may need surgical exploration +/- drainage

Question 10

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?

Answer 10

varicocele
(usually ASx, but just feels like a bag of worms)

Tx - ligation if pain, but surgery doesn’t improve fertility

Question 11

Hx: patient has a fluctuant, transilluminable lump attached to testis but feels like a clearly seperate structure - no pain?

Answer 11

epididymal cyst

Asx, no Tx

Question 12

Hx: sexually active young patient with swollen, painful epididymis/testis, +/- UTI Sx, urethral discharge?

Answer 12

epididymo-orchitis

Question 13

isolated orchitis is rare. what is main cause?

Answer 13

mumps

Question 14

common causes of epididymo-orchitis?

Answer 14

chlamydia/gonorrhoea
E.coli if older
mumps

Question 15

Hx that would make you think mumps causing epididymo-orchitis?

Answer 15

parotitis 1 wk ago

high fever, headache, V

Question 16

Ix epididymo-orchitis?

Answer 16

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)

Question 17

Tx epididymo-orchitis?

Answer 17

• start Abx on clinical suspicion
• STI? doxycycline 10 days + IM ceftriaxone
• E.coli? ciprofloxacin 10 days
• bed rest and scrotal elevation

Question 18

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?

Answer 18

testicular torsion

surgery!

Question 19

risk factor for torsion?

Answer 19

undescended testis

previous torsion on contralateral side (hence both sides fixed at orchidopexy)

Question 20

Ix torsion?

Answer 20

surgical exploration without delay if any suspicion, detorsion (<6 hrs) and fixation with suture (orchidopexy) of both sides
(+/- doppler US, urinalysis)

Question 21

ΔΔ scrotal lumps?

Answer 21

• epididymal cyst
• hernia
• varicocele
• hydrocele
• haematocele
• germ cell tumour

Question 22

ΔΔ testicular pain/swelling?

Answer 22

• epididymo-orchitis
• torsion
• leukaemia or lymphoma infiltration
• germ cell tumour

Question 23

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?

Answer 23

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)

Question 24

what kind of germ cell tumour is commoner:
<30?
>30?

Answer 24

teratoma

seminoma

Question 25

risk factors for germ cell CA?

Answer 25

• FHx
• cryptorchidism (undescended)
• Klinefelter’s
• atrophy (post mumps)

Question 26

Ix germ cell tumour?

Answer 26

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

Question 27

tumour markers in GCT?

Answer 27

“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)

Question 28

diagnosis of germ cell tumour?

staging?

Answer 28

• orchiectomy (NOT biopsy) and histology
• CT-CAP
• CT brain if lung mets

Question 29

Tx germ cell tumour?

Answer 29

• orchiectomy, prosthesis
• biopsy contralateral
+/- radio, carboplatin, “BEP” chemo

Question 30

complications/prognosis germ cell tumour?

Answer 30

• fertility issues - sperm storage

* 95 percent survive 5 years

Question 31

ΔΔ acute, tender swollen testis?

Answer 31

• torsion until proven otherwise
• epididymo-orchitis
• trauma

Question 32

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

Answer 32

1) hernia
2) epididymal cyst
3) epididitis, or varicocele
4) hydrocele
5) tumour, haematocele, orchitis (US)