Scrotum pathology Flashcards
What are complications of cryptorchidism?
-Testicular cancer, with a 40 fold increased risk
-Infertility.
What is the most common location of an undescended testis?
70% in the inguinal canal, under external oblique
What contributes to the aetiology of an undescended testicle?
-Low birth weight, premature birth
-positive family history
-Down syndrome
-Increased abdominal pressure (gastroschisis)
In a neonate with cryptorchidism what management option would you recommend?
Management is normally withheld until 6 months of age to allow the testicle to descend spontaneously
After 6 months, spontaneous descent is rare
The child should have an
orchidoplexy, where the testis is mobilized and then fixed in a dependent position in the scrotum.
Does orchidoplexy reduce the risk of infertility and testicular cancer?
Orchidoplexy is thought to reduce the risk of both infertility and testicular cancer; however, it does not reduce either to normal levels.
A major benefit of the testes new location in the
scrotum is the facilitation of self-examination, allowing earlier detection of a suspicious lump
Would the surgical management differ for a 20 year old with a unilateral undescended testis?
Yes. The recommendation would be to offer an orchidectomy, as the risk of testicular cancer is high.
What are the different types of testicular cancer?
95% of testicular tumours are germ cell tumours
-divided into pure seminomas and
nonseminomatous germ cell tumours
-second group is subdivided into teratomas,
choriocarcinomas, yolk sac tumours and mixed germ cell tumours.
What is the peak age for teratomas and seminomas?
Teratomas have a peak incidence between the ages of 20-30
Seminomas have a peak incidence between the ages of 30-40
What are the risk factors for testicular tumours>
Cryptoorchidism
Fhx
Contralateral testicular tumour
Klinefeltr’s syndrome, downs
Caucasian ethnicity
From your examination you suspect testicular cancer. What tumour markers might be useful?
The tumour markers for teratomas include:
beta-HCG (Human chorionic gonadotrophin)
AFP
The tumour markers for seminomas include:
Placental alk phos
Sometimes beta-HCG
Both: LDH marker for tumour volume and necrosis
In what other cancer could you find high AFP levels?
Hepatocellular carcinoma (HCC) may also have high AFP levels
What initial imaging would you arrange?
A scrotal ultrasound
How would you manage a patient with suspected testicular cancer both clinically and on ultrasound?
-Surgical work up: bloods and staging CTTAP
-biopsy not done as risks seeding tumour
-MDT discussion
-Management stage dependent: usually orchidectomy +/- lymph node dissection +/- chemo/radiotherapy
Is radiotherapy effective for testicular tumours?
Radiotherapy is used in the management of seminomas, but not for nonseminomatous germ
cell tumours.
What is the overall prognosis of testicular cancer?
Prognosis depends on tumour stage. 5-year survival ranges from 92-94% for patients with
good prognostic features to 50% for patients with poor prognostic features
What follow up investigations are used to monitor for possible recurrence?
Both:
-Regular clinic
-Regular tumour markers (beta hcg, ldh, ((AFP))
Seminomas:
-Regular clinic review for 10 yrs
-placental ALP, Beta-HCG and LDH monitoring
-abdominal and pelvic CT scan repeated
every 6 months for the first 5 years, then annually.
Nonseminomas are monitored in similar way
-with regular clinic
-beta-HCG, LDH, AFP, CEA
-6-12 monthly CT abdo pelvis.
What is metastasis?
Metastasis is the survival and growth of cells at a site distant from their primary origin.
Where do testicular tumours metastasise to?
Testicular cancers tend to metastasis to the lung, colon bladder and pancreas
What are differential diagnoses for groin swellings?
Above inguinal ligament
-inguinal hernia
-Undescended testis
-encysted hydrocele/lipoma of cord
-Iliac node
Below inguinal ligament
-femoral hernia
-lymph node
-Saphena varix
-femoral aneurysm
-psoas abscess
Differential diagnosis for scrotal swelling
Extra testicular
-Inguinal hernia
-Hydrocele
-Varicocele
Intra-testicular
-Testicular tumour
-Epididymo-orchitis
-Testicular torsion
What are the characteristic features of a varicocele>
Bag of worms
Heaviness/dragging sensation
Renal symptoms if left sided: compression of left renal vein (left spermatic vein opens at sharp angle into left renal vein, right opens into IVC)
What are the characteristic features of testicular torsion>
Horizontal lie
Absent cremasteric reflex
What are the characteristic features of epididymo-orchitis
Pain
Swelling
Elevation relieves pain
Raised CRP/white cells
What organisms commonly cause epididymo-orchitis?
Male <35: chlamydia, gonorrhea
Male >35: enteric organism from uti e.g. e.coli, klebsiella, proteus
