Surgery: Scrotal lumps Flashcards
Name some of the benign scrotal lumps
- Hydrocele
- Varicocele
- Epidiymal cyst
- Spermatocele
- Abscess
- Orchitis/Epidiymitis
Red flag features for varicocele (3)
- acute onset
- right-sided
- remain when lying flat
What to ask about in the history in a patient presenting with a scrotal lump? (3)
- clarify time of onset
- associated symptoms (especially pain)
- previous episodes
What does the inspection of a scrotal lump should include (6)?
“6 S’s” → describing:
- Site
- Size
- Shape
- Symmetry
- Skin changes
- any Scars present
What to comment on in lump palpation? (11)
comment on 3T CAMPFIRE:
- Tenderness, Temperature, Transillumination
- Consistency
- Attachments
- Mobility
- Pulsation
- Fluctuation
- Irreducibility
- Regional lymph nodes
- Edge
Investigations of scrotal lumps
- ultrasound scan of the scrotum → the first-line
If cancer is suspected:
- blood tests: lactate dehydrogenase (LDH), alpha-fetoprotein (AFP), and beta-human chorionic gonadotrophin (beta-hCG)
- further imaging may be warranted, depending on the suspected underlying cause (CXR, CT
What blood-tests to perform if a testicular cancer is suspected?
- lactate dehydrogenase (LDH)
- alpha-fetoprotein (AFP)
- beta-human chorionic gonadotrophin (beta-hCG)
What imaging and why to perform if testicular cancer is suspected? (3)
- USS → in any suspicious testicular mass
- CXR → to assess for widespread pulmonary metastasis
- CT scan → chest-abdomen-pelvis to look for metastases in confirmed cancer cases → will assess for para-aortic lymph nodes spread
Do we do a biopsy in suspected testicular cancers?
NO! → due to risk of seeding cancer
Hydrocele
- what is this
- what layers does it involve
- abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis enveloping the testis
A typical presentation of hydrocele
- painless fluctuant swelling
- transilluminate
- either unilateral or bilateral
- occasionally they can grow very large and cause discomfort when sitting and walking
When do we consider surgical management of a hydrocele?
If they grow very large and cause discomfort on sitting, walking etc.
Management of congenital hydrocele
- affect up to 3% of male neonates
- regress spontaneously by one or two years of age
- No treatment is typically needed
- In infants, they can be caused by a patent processus vaginalis requiring ligation to stop recurrence
Causes of hydrocele in an adult
- primary → idiopathic
- secondary → trauma, infection, or malignancy
In which cases to perform an urgent USS when a patient presents with hydrocele?
- aged between 20-40yrs
OR
- where the testis cannot be palpated
What is the principle behind transillumination?
The technique helps to assess whether a mass is fluid-filled or not:
- the fluid will transilluminate
- solid masses will not
*Hydrocoeles and large epididymal cysts will classically transilluminate
What is varicocele?
- abnormal dilatation of the pampiniform venous plexus within the spermatic cord
Presentation of varicocele
A lump described as:
- feeling like a “bag of worms”
- with a “dragging sensation”
- may disappear on lying flat
What position do we examine the patient with varicocele?
- lying down
- standing up
- whilst performing a valsava manoeuvre
What side and why are the varicoceles commonly found?
90% of varicoceles are found on the left side as the spermatic vein drains directly into the left renal vein
(compared to the inferior vena cava on the right)
Possible complications of varicocele
infertility and testicular atrophy → increasing the intra-scrotal temperature
*men who have a varicocele and fertility issues should undergo semen analysis, with referral to a urology specialist if abnormal
Do we need to treat varicoceles?
Asymptomatic varicoceles with no alarming features generally need no treatment
Possible surgical management of varicocele
Surgical management includes:
- embolisation → by an interventional radiologist
- surgical approaches → open or laparoscopic approach for ligation of the spermatic veins
Do we examine the abdomen in a patient presenting with varicocele?
The abdomen should always be examined → to exclude a renal tumour as the cause of a varicocele (albeit rare)
What’s that?
An ultrasound demonstrating the dilated venous plexus of the varicocele
(A) without Doppler
(B) with Doppler
What’s that?
Ultrasound showing hydrocele
Pathophysiology of epididymal cyst
Epididymal cysts aka spermatoceles
- benign fluid-filled sacs arising from the epididymis
Features of epididymal cyst (on examination)
- smooth fluctuant nodule
- found above and separate from the testis
- transilluminate
- often multiple
Management of epididymal cyst
Usually, no treatment is required:
- rarely cause symptoms
- have no association to malignancy
In rare instances, if they are very large or painful → surgery may be required
Best to avoid surgery in younger men → may lead to infertility
What’s epididymitis? (pathophysiology and cause)
- inflammation of the epididymis
- bacterial in origin → either STI-related organisms in sexually active younger males or enteric organisms in older males
Symptoms of epididymitis
- swelling
- erythematous overlying skin
- systemic symptoms e.g.fever
What can be seen on examination in epididymitis?
- tender
- pain may be relieved on elevation of the testis = Prehn’s sign
Treatment of epididymitis
Antibiotics and analgesia
- if the organism is unknown: ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
- further investigations following treatment are recommended to exclude any underlying structural abnormalities
Orchitis
- what is this
- cause
Orchitis → inflammation of the testis
- the main cause → the mumps virus, which often is preceded with a history of parotid swelling
Treatment of orchitis
- rest and analgesia
- rarely an intra-testicular abscess may form requiring drainage and occasionally orchidectomy
- *Cases of epididymo-orchitis should be treated as per epididymitis*
- if the organism is unknown → ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
What’s testicular torsion? (pathophysiology)
- twist of the spermatic cord resulting in testicular ischaemia and necrosis
- most common in males aged between 10 and 30 (peak incidence 13-15 years)
Presentation of testicular torsion
- pain is usually severe and of sudden onset
- the pain may be referred to the lower abdomen
- nausea and vomiting may be present
- on examination there is usually a swollen, tender testis retracted upwards. The skin may be reddened
- cremasteric reflex is lost and elevation of the testis does not ease the pain
Management of testicular torsion
- scrotal exploration and fixation of both testes ⇒ to prevent irreversible testicular damage
- should be done within 6-hours following onset of pain
- both testis should be fixed as the condition of bell clapper testis is often bilateral
What age group a testicular cancer is common in?
20-40 years old
What type of tumour the majority of testicular cancers are?
Around 95% of cases of testicular cancer are germ-cell tumours
Types of germ-cell tumours (2)
Seminomas and non-seminomas
Types of non-seminomas germ cell tumours? (4)
- Teratoma
- Yolk sac tumour
- Choriocarcinoma
- Mixed germ cell tumours (10%)
Primary testicular tumours could be categorised into (2)
- germ cell tumours (GCT) (95%) → usually malignant
- non-germ cell tumours (NGCTs) (5%) → usually benign
Non- germ cell tumours could be categorised into (2)
Leydig cell tumors and Sertoli cell tumors
What Leydig and Sertoli cell tumours secrete?
- Leydig → androgen
- Sertoli → oestrogen
*both tumours are usually benign
Risk factors for testicular cancer
- Cryptorchidism
- Infertility
- Family history
- Klinefelter’s syndrome
- Mumps orchitis
Features/presentation of testicular cancer
- A painless lump is the most common presenting symptom
- Pain may also be present in a minority of men
- Other possible features include hydrocele, gynaecomastia
- Metastatic disease can present with: anorexia weight loss, back pain, thoracic symptoms related to nodal or visceral mets etc
Diagnosis of testicular cancer is made by (2)
- imaging
- tumour marker
biopsy cannot be done!
Investigations in suspected testicular cancer
- USS
- blood test (α-FP, β-HCG, LDH)
Seminoma is characteristic of what age group of a patient?
- occur in all age groups, but if an older man develops testicular cancer, it is more likely to be seminoma
- Seminomas, in general, aren’t as aggressive as nonseminomas
Non-seminoma occurs in what age group?
•Nonseminoma - tumors tend to develop earlier in life and grow and spread rapidly.
*Several different types of nonseminoma tumors exist, including choriocarcinoma, embryonal carcinoma, teratoma and yolk sac tumor.
Management of testicular cancer
- Orchidectomy (Inguinal approach)
- Chemotherapy and radiotherapy may be given depending on staging
- Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection
Prognosis of testicular cancer
Prognosis is generally excellent
- 5 year survival for seminomas is around 95% if Stage I
- 5 year survival for teratomas is around 85% if Stage I
What’s that?
Seminoma of the testes
Staging of testicular cancer
What’s Bell’s Clapper deformity?
Causes of epididymo- orchitis
–Sexually active & < 35
- Gonorrhoea
- Chlamydia
–Children & men > 35
•E.Coli
Investigations for epidydymo-orchitis
- Bloods
- UDT & MSSU
- Urethral swabs
- Urine Chlamydia and Gonorrhoea
- Scrotal USS (can be done as o/p)
Antibiotics for epididymo- orchitis
- in >35 y old
- in <35 y old
- Antibiotics
- >35: Ciprofloxacin 500mg bd (14 days)
- <35 or STI Suspected:
- Doxycycline 100mg bd (14 days to cover chlamydia) & ask to visit GUM clinic for contact tracing etc.
How to differentiate between torsion and infection?
Differentials for acute scrotal pain
Pathology within scrotum
- Torsion of testis
- Torsion of testicular appendage
- Epididymo-orchitis
- Testicular Tumour
Referred Pain
•Ureteric Colic
