Scrotal Swellings Flashcards
List the key causes of scrotal or testicular lumps
- Epididymo-orchitis
- Testicular torsion
- Hydrocele
- Varicocele
- Epididymal cyst
- Testicular cancer
- Inguinal hernia
What is Epididymo-orchitis?
Inflammation of the epididymis and testicle
Where are sperm stored and matured?
Epididymis
Where does the epididymis drain?
Into the vas deferens
List 4 causes of Epididymo-orchitis
- E. coli
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Mumps
In what clinical scenario must we consider mumps?
- In patients with parotid gland swelling and orchitis
- Mumps tends only to affect the testicle, sparing the epididymis
- It can also cause pancreatitis
How does Epididymo-orchitis present?
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
Key differential for epididymo-orchitis?
Testicular torsion
Both present with acute onset of pain in one testicle. If in doubt, treat as torsion
List 3 features of epididymo-orchitis which make a sexually transmitted organism more likely
- Age under 35
- Increased number of sexual partners in the last 12 months
- Discharge from the urethra
List 4 investigations for suspected epididymo-orchitis
- Urine MC & S
- Chlamydia and gonorrhoea NAAT testing on a first pass urine
- Charcoal swab of discharge for gonorrhoea
- Saliva swap for PCR testing for mumps, if suspected
- Serum antibodies for mumps, if suspected
- Ultrasound to assess for torsion or tumours
Management of epididymo-orchitis
- If acutely unwell or septic - admit for IV antibiotics
- If high risk of STI - urgent referral to GUM clinic for assessment and treatment.
- If low risk of STI offer Ofloxacin for 14 days
What are Quinolones
Powerful broad-spectrum antibiotics that have excellent gram negative cover
Often used for UTIs, pyelonephritis, epididymo-orchitis and prostatitis
2 examples of Quinolone antibiotics
Ofloxacin, levofloxacin and ciprofloxacin
List 2 important side effects of quinolones
- Tendon damage and tendon rupture ie. Achilles tendon
- Lower seizure threshold (caution in patients with epilepsy)
List 2 complications of Epididymo-orchitis
- Chronic pain
- Chronic epididymitis
- Testicular atrophy
- Sub-fertility or infertility
- Scrotal abscess
What is Testicular Torsion?
Twisting of the spermatic cord with rotation of the testicle - urological emergency
Why is testicular torsion a urological emergency?
Delay in treatment increases risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility
Typical age affected by torsion
Typical a teenage boy - but can be any age
Trigger for testicular torsion?
Activity, such as playing sports
Presentation of testicular torsion
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
List 4 exam findings of testicular torsion
- Firm swollen testicle
- Elevated (retracted) testicle
- Absent cremasteric reflex
- Abnormal testicular lie (often horizontal)
- Rotation, so epididymis is not in normal posterior position
What is a bell-clapper deformity?
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)
Management of testicular torsion
- Nil by mouth
- Analgesia
- Urgent senior urology assessment
- Surgical exploration of the scrotum
- Orchiopexy or orchidectomy
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
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.
Characteristic findings of USS in torsion?
The whirlpool sign, a spiral appearance to the spermatic cord and blood vessels
What is a hydrocele?
A collection of fluid within the tunica vaginalis that surrounds the testes
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
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
How can we distinguish a hydrocele from a hernia
Hydrocele is Irreducible and has no bowel sounds
How do hydroceles usually present?
Painless and present with a soft scrotal swelling
List 4 causes of a hydrocele
- Idiopathic
- Testicular cancer
- Testicular torsion
- Epididymo-orchitis
- Trauma
Management of a hydrocele?
- USS (to exclude serious causes eg. cancer)
- Idiopathic hydroceles managed conservatively
- Surgery, aspiration or sclerotherapy for large or symptomatic cases
What is a Varicocele?
Where the veins in the pampiniform plexus become swollen
List 2 consequences of an untreated varicocele
- Impaired fertility, due to temperature disruption in the affected testicle
- Testicular atrophy, reducing the size and function of the testicle
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
The pampiniform plexus drains into the ________
Testicular vein
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
Compare drainage of the R vs L testicular vein
- Right drains directly into the IVC
- Left drains into the Left renal vein
Do most varicoceles occur on the left or the right?
Left due to increased resistance in the left testicular vein
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
How doe varicoceles present?
- Throbbing/dull pain or discomfort, worse on standing
- A dragging sensation
- Sub-fertility or infertility
List 4 examination findings of a varicocele
- Scrotal mass that feels like a “bag of worms”
- More prominent on standing
- Disappears when lying down
- Asymmetry in testicular size if growth of the testicle is affected
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
Investigations for a varicocele
- Ultrasound with Doppler imaging can be used to confirm the diagnosis
- Semen analysis if there are concerns about fertility
- Hormonal tests (e.g., FSH and testosterone) if there are concerns about function
Management of a varicocele
Uncomplicated cases can be managed conservatively
If there is pain, testicular atrophy or infertility - Surgery or Endovascular embolisation
What is an Epididymal cyst?
A fluid-filled sac located at the head of the epididymis
What is a spermatocele?
Same as an epididymal cyst but contains sperm
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
Examination findings of an Epididymal cysts?
Soft, round lump associated with the epididymis (separate from testicle)
May be able to transilluminate if large
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
What cells do testicular cancer arise from?
Germ cells
In what age group are testicular cancers most common?
Younger men between 15 and 35 years
What are the 2 types of testicular cancers?
- Seminomas
- Non-seminomas (mostly teratomas)
List 4 risk factors for testicular cancers
- Undescended testes
- Male infertility
- Family history
- Increased height
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
Which testicular tumour may present with gynaecomastia?
Leydig cell tumour (rare)
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
List 3 tumour markers for testicular cancer
- Alpha-fetoprotein – may be raised in teratomas
- Beta-hCG – may be raised in teratomas and seminomas
- Lactate dehydrogenase (LDH) very non-specific tumour marker
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
List the 4 common sites of metastasis for testicular cancer
- Lymphatics
- Lungs
- Liver
- Brain
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
List 4 long term side effects of testicular cancer treatment
- Infertility
- Hypogonadism (testosterone replacement may be required)
- Peripheral neuropathy
- Hearing loss
- Lasting kidney, liver or heart damage
- Increased risk of cancer in the future
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
