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Scrotal Swellings Flashcards

1
Q

List the key causes of scrotal or testicular lumps

A
  • Epididymo-orchitis
  • Testicular torsion
  • Hydrocele
  • Varicocele
  • Epididymal cyst
  • Testicular cancer
  • Inguinal hernia
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2
Q

What is Epididymo-orchitis?

A

Inflammation of the epididymis and testicle

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3
Q

Where are sperm stored and matured?

A

Epididymis

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4
Q

Where does the epididymis drain?

A

Into the vas deferens

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5
Q
A
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6
Q

List 4 causes of Epididymo-orchitis

A
  1. E. coli
  2. Chlamydia trachomatis
  3. Neisseria gonorrhoea
  4. Mumps
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7
Q

In what clinical scenario must we consider mumps?

A
  1. In patients with parotid gland swelling and orchitis
  2. Mumps tends only to affect the testicle, sparing the epididymis
  3. It can also cause pancreatitis
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8
Q

How does Epididymo-orchitis present?

A

Gradual onset (minutes to hours) with unilateral:

  • Pain in testes
  • Tenderness on palpation
  • Swelling
  • Dragging or heavy sensation
  • Urethral discharge (if STI related)
  • Systemic symptoms ie. fever, potentially sepsis
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9
Q

Key differential for epididymo-orchitis?

A

Testicular torsion

Both present with acute onset of pain in one testicle. If in doubt, treat as torsion

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10
Q

List 3 features of epididymo-orchitis which make a sexually transmitted organism more likely

A
  1. Age under 35
  2. Increased number of sexual partners in the last 12 months
  3. Discharge from the urethra
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11
Q

List 4 investigations for suspected epididymo-orchitis

A
  1. Urine MC & S
  2. Chlamydia and gonorrhoea NAAT testing on a first pass urine
  3. Charcoal swab of discharge for gonorrhoea
  4. Saliva swap for PCR testing for mumps, if suspected
  5. Serum antibodies for mumps, if suspected
  6. Ultrasound to assess for torsion or tumours
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12
Q

Management of epididymo-orchitis

A
  1. If acutely unwell or septic - admit for IV antibiotics
  2. If high risk of STI - urgent referral to GUM clinic for assessment and treatment.
  3. If low risk of STI offer Ofloxacin for 14 days
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13
Q

What are Quinolones

A

Powerful broad-spectrum antibiotics that have excellent gram negative cover

Often used for UTIs, pyelonephritis, epididymo-orchitis and prostatitis

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14
Q

2 examples of Quinolone antibiotics

A

Ofloxacin, levofloxacin and ciprofloxacin

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15
Q

List 2 important side effects of quinolones

A
  1. Tendon damage and tendon rupture ie. Achilles tendon
  2. Lower seizure threshold (caution in patients with epilepsy)
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16
Q

List 2 complications of Epididymo-orchitis

A
  1. Chronic pain
  2. Chronic epididymitis
  3. Testicular atrophy
  4. Sub-fertility or infertility
  5. Scrotal abscess
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17
Q

What is Testicular Torsion?

A

Twisting of the spermatic cord with rotation of the testicle - urological emergency

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18
Q

Why is testicular torsion a urological emergency?

A

Delay in treatment increases risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility

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19
Q

Typical age affected by torsion

A

Typical a teenage boy - but can be any age

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20
Q

Trigger for testicular torsion?

A

Activity, such as playing sports

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21
Q

Presentation of testicular torsion

A

Acute rapid onset of unilateral testicular pain, may be associated with abdominal pain and vomiting

Sometimes abdo pain is the only symptom in boys, so examination to exclude torsion is essential

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22
Q

List 4 exam findings of testicular torsion

A
  1. Firm swollen testicle
  2. Elevated (retracted) testicle
  3. Absent cremasteric reflex
  4. Abnormal testicular lie (often horizontal)
  5. Rotation, so epididymis is not in normal posterior position
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23
Q

What is a bell-clapper deformity?

A

One of the causes of testicular torsion

  • Normally testicle is fixed posteriorly to the tunica vaginalis (vertical)
  • A bell-clapper deformity is where fixation is absent, so testicle hangs in a horizontal position (prone to rotation)
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24
Q

Management of testicular torsion

A
  1. Nil by mouth
  2. Analgesia
  3. Urgent senior urology assessment
  4. Surgical exploration of the scrotum
  5. Orchiopexy or orchidectomy
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25
What is an Orchiopexy vs Orchidectomy
Orchiopexy - correcting the position of the testicles and fixing them in place Orchidectomy - removing the testicle, if the surgery is delayed or there is necrosis
26
What investigation will confirm testicular torsion? Why is this not always done?
A scrotal ultrasound But any investigation that will delay the patient going to theatre for treatment is not recommended.
27
Characteristic findings of USS in torsion?
The whirlpool sign, a spiral appearance to the spermatic cord and blood vessels
27
What is a hydrocele?
A collection of fluid within the tunica vaginalis that surrounds the testes
28
List 4 examination findings of a hydrocele
* Testicle palpable within the hydrocele * Soft, fluctuant and may be large * Irreducible and has no bowel sounds * Transilluminated
29
What is the tunica vaginalis Where does it embryologically derive from?
A sealed pouch of membrane that surrounds the testes Originally it is part of the peritoneal membrane. During the development it becomes separated from this and remains in the scrotum
30
How can we distinguish a hydrocele from a hernia
Hydrocele is Irreducible and has no bowel sounds
31
How do hydroceles usually present?
Painless and present with a soft scrotal swelling
32
List 4 causes of a hydrocele
1. Idiopathic 2. Testicular cancer 3. Testicular torsion 4. Epididymo-orchitis 5. Trauma
33
Management of a hydrocele?
* **USS** (to exclude serious causes eg. cancer) * Idiopathic hydroceles managed conservatively * Surgery, aspiration or sclerotherapy for large or symptomatic cases
34
What is a Varicocele?
Where the veins in the pampiniform plexus become swollen
35
List 2 consequences of an untreated varicocele
1. Impaired fertility, due to temperature disruption in the affected testicle 2. Testicular atrophy, reducing the size and function of the testicle
36
What is the pampiniform plexus?
A venous plexus found in the spermatic cord that drains the testes Plays a role in regulating the temperature of blood entering the testes by absorbing heat from the nearby testicular artery
37
The pampiniform plexus drains into the \_\_\_\_\_\_\_\_
Testicular vein
38
Pathophysiology of a varicocele?
Result of increased resistance in the testicular vein Incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus
39
Compare drainage of the R vs L testicular vein
1. Right drains directly into the IVC 2. Left drains into the Left renal vein
40
Do most varicoceles occur on the left or the right?
Left due to increased resistance in the left testicular vein
41
What important ddx may cause a left-sided varicocele
A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma
42
How doe varicoceles present?
1. Throbbing/dull pain or discomfort, worse on standing 2. A dragging sensation 3. Sub-fertility or infertility
43
List 4 examination findings of a varicocele
1. Scrotal mass that feels like a “bag of worms” 2. More prominent on standing 3. Disappears when lying down 4. Asymmetry in testicular size if growth of the testicle is affected
44
If a varicocele does not disappear when lying flat, what must we be concerned about?
Retroperitoneal tumours obstructing the drainage of the renal vein Urgent referral to urology
45
Investigations for a varicocele
1. **Ultrasound with Doppler imaging** can be used to confirm the diagnosis 2. Semen analysis if there are concerns about fertility 3. Hormonal tests (e.g., FSH and testosterone) if there are concerns about function
46
Management of a varicocele
Uncomplicated cases can be managed conservatively If there is pain, testicular atrophy or infertility - Surgery or Endovascular embolisation
47
What is an Epididymal cyst?
A fluid-filled sac located at the head of the epididymis
48
What is a spermatocele?
Same as an epididymal cyst but contains sperm
49
Presentation of Epididymal cysts
Most cases are asymptomatic Patients may have felt a lump, or it may be found incidentally on USS for another indication
50
Examination findings of an Epididymal cysts?
Soft, round lump associated with the epididymis (separate from testicle) May be able to transilluminate if large
51
Management of Epididymal cysts
Usually, they are entirely harmless and are not associated with infertility or cancer Removal considered if they cause pain or discomfort
52
What cells do testicular cancer arise from?
Germ cells
53
In what age group are testicular cancers most common?
Younger men between 15 and 35 years
54
What are the 2 types of testicular cancers?
1. Seminomas 2. Non-seminomas (mostly teratomas)
55
List 4 risk factors for testicular cancers
1. Undescended testes 2. Male infertility 3. Family history 4. Increased height
56
How do testicular cancers present?
Typically a painless lump on the testicle which is * Non-tender * Arising from testicle * Hard * Irregular * Not fluctuant * No transillumination
57
Which testicular tumour may present with gynaecomastia?
Leydig cell tumour (rare)
58
Initial and diagnostic investigation for testicular tumours?
**Scrotal ultrasound** Staging CT scan can be used to look for areas of spread and to stage the cancer
59
List 3 tumour markers for testicular cancer
1. **Alpha-fetoprotein** – may be raised in teratomas 2. **Beta-hCG** – may be raised in teratomas and seminomas 3. **Lactate dehydrogenase** (**LDH**) very non-specific tumour marker
60
Staging system for testicular cancer?
Royal Marsden Staging System * Stage 1 – isolated to the testicle * Stage 2 – spread to the retroperitoneal lymph nodes * Stage 3 – spread to the lymph nodes above the diaphragm * Stage 4 – metastasised to other organs
61
List the 4 common sites of metastasis for testicular cancer
* Lymphatics * Lungs * Liver * Brain
62
Management of testicular cancer?
Guided by a MDT, treatment can involve: * Surgery (radical orchidectomy) – prosthesis can be inserted * Chemotherapy * Radiotherapy * Sperm banking as treatment may cause infertility
63
List 4 long term side effects of testicular cancer treatment
1. Infertility 2. Hypogonadism (testosterone replacement may be required) 3. Peripheral neuropathy 4. Hearing loss 5. Lasting kidney, liver or heart damage 6. Increased risk of cancer in the future
64
Prognosis of testicular cancer?
* GOOD for early testicular cancer (90% cure rate) * Metastatic disease is also often curable * Seminomas have a slightly better prognosis than non-seminomas

Peri-op (22 decks)

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