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Y4 CBLs > Surgery: Scrotal lumps > Flashcards

Surgery: Scrotal lumps Flashcards

1
Q

Name some of the benign scrotal lumps

A
  • Hydrocele
  • Varicocele
  • Epidiymal cyst
  • Spermatocele
  • Abscess
  • Orchitis/Epidiymitis
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2
Q

Red flag features for varicocele (3)

A
  • acute onset
  • right-sided
  • remain when lying flat
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3
Q

What to ask about in the history in a patient presenting with a scrotal lump? (3)

A
  • clarify time of onset
  • associated symptoms (especially pain)
  • previous episodes
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4
Q

What does the inspection of a scrotal lump should include (6)?

A

“6 S’s” → describing:

  • Site
  • Size
  • Shape
  • Symmetry
  • Skin changes
  • any Scars present
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5
Q

What to comment on in lump palpation? (11)

A

comment on 3T CAMPFIRE:

  • Tenderness, Temperature, Transillumination
  • Consistency
  • Attachments
  • Mobility
  • Pulsation
  • Fluctuation
  • Irreducibility
  • Regional lymph nodes
  • Edge
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6
Q

Investigations of scrotal lumps

A
  • 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
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7
Q

What blood-tests to perform if a testicular cancer is suspected?

A
  • lactate dehydrogenase (LDH)
  • alpha-fetoprotein (AFP)
  • beta-human chorionic gonadotrophin (beta-hCG)
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8
Q

What imaging and why to perform if testicular cancer is suspected? (3)

A
  • 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
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9
Q

Do we do a biopsy in suspected testicular cancers?

A

NO! → due to risk of seeding cancer

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10
Q

Hydrocele

  • what is this
  • what layers does it involve
A
  • abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis enveloping the testis
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11
Q

A typical presentation of hydrocele

A
  • painless fluctuant swelling
  • transilluminate
  • either unilateral or bilateral
  • occasionally they can grow very large and cause discomfort when sitting and walking
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12
Q

When do we consider surgical management of a hydrocele?

A

If they grow very large and cause discomfort on sitting, walking etc.

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13
Q

Management of congenital hydrocele

A
  • 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
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14
Q

Causes of hydrocele in an adult

A
  • primary → idiopathic
  • secondary → trauma, infection, or malignancy
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15
Q

In which cases to perform an urgent USS when a patient presents with hydrocele?

A
  • aged between 20-40yrs

OR

  • where the testis cannot be palpated
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16
Q

What is the principle behind transillumination?

A

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

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17
Q

What is varicocele?

A
  • abnormal dilatation of the pampiniform venous plexus within the spermatic cord
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18
Q

Presentation of varicocele

A

A lump described as:

  • feeling like a “bag of worms”
  • with a “dragging sensation”
  • may disappear on lying flat
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19
Q

What position do we examine the patient with varicocele?

A
  • lying down
  • standing up
  • whilst performing a valsava manoeuvre
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20
Q

What side and why are the varicoceles commonly found?

A

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)

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21
Q

Possible complications of varicocele

A

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

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22
Q

Do we need to treat varicoceles?

A

Asymptomatic varicoceles with no alarming features generally need no treatment

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23
Q

Possible surgical management of varicocele

A

Surgical management includes:

  • embolisation → by an interventional radiologist
  • surgical approaches → open or laparoscopic approach for ligation of the spermatic veins
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24
Q

Do we examine the abdomen in a patient presenting with varicocele?

A

The abdomen should always be examined → to exclude a renal tumour as the cause of a varicocele (albeit rare)

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25
Q

What’s that?

A

An ultrasound demonstrating the dilated venous plexus of the varicocele

(A) without Doppler

(B) with Doppler

26
Q

What’s that?

A

Ultrasound showing hydrocele

27
Q

Pathophysiology of epididymal cyst

A

Epididymal cysts aka spermatoceles

  • benign fluid-filled sacs arising from the epididymis
28
Q

Features of epididymal cyst (on examination)

A
  • smooth fluctuant nodule
  • found above and separate from the testis
  • transilluminate
  • often multiple
29
Q

Management of epididymal cyst

A

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

30
Q

What’s epididymitis? (pathophysiology and cause)

A
  • inflammation of the epididymis
  • bacterial in origin → either STI-related organisms in sexually active younger males or enteric organisms in older males
31
Q

Symptoms of epididymitis

A
  • swelling
  • erythematous overlying skin
  • systemic symptoms e.g.fever
32
Q

What can be seen on examination in epididymitis?

A
  • tender
  • pain may be relieved on elevation of the testis = Prehn’s sign
33
Q

Treatment of epididymitis

A

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
34
Q

Orchitis

  • what is this
  • cause
A

Orchitis → inflammation of the testis

  • the main cause → the mumps virus, which often is preceded with a history of parotid swelling
35
Q

Treatment of orchitis

A
  • 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
36
Q

What’s testicular torsion? (pathophysiology)

A
  • 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)
37
Q

Presentation of testicular torsion

A
  • 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
38
Q

Management of testicular torsion

A
  • 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
39
Q

What age group a testicular cancer is common in?

A

20-40 years old

40
Q

What type of tumour the majority of testicular cancers are?

A

Around 95% of cases of testicular cancer are germ-cell tumours

41
Q

Types of germ-cell tumours (2)

A

Seminomas and non-seminomas

42
Q

Types of non-seminomas germ cell tumours? (4)

A
  • Teratoma
  • Yolk sac tumour
  • Choriocarcinoma
  • Mixed germ cell tumours (10%)
43
Q

Primary testicular tumours could be categorised into (2)

A
  • germ cell tumours (GCT) (95%) → usually malignant
  • non-germ cell tumours (NGCTs) (5%) → usually benign
44
Q

Non- germ cell tumours could be categorised into (2)

A

Leydig cell tumors and Sertoli cell tumors

45
Q

What Leydig and Sertoli cell tumours secrete?

A
  • Leydig → androgen
  • Sertoli → oestrogen

*both tumours are usually benign

46
Q

Risk factors for testicular cancer

A
  • Cryptorchidism
  • Infertility
  • Family history
  • Klinefelter’s syndrome
  • Mumps orchitis
47
Q

Features/presentation of testicular cancer

A
  • 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
48
Q

Diagnosis of testicular cancer is made by (2)

A
  • imaging
  • tumour marker

biopsy cannot be done!

49
Q

Investigations in suspected testicular cancer

A
  • USS
  • blood test (α-FP, β-HCG, LDH)
50
Q

Seminoma is characteristic of what age group of a patient?

A
  • 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
51
Q

Non-seminoma occurs in what age group?

A

•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.

52
Q

Management of testicular cancer

A
  • Orchidectomy (Inguinal approach)
  • Chemotherapy and radiotherapy may be given depending on staging
  • Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection
53
Q

Prognosis of testicular cancer

A

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
54
Q

What’s that?

A

Seminoma of the testes

55
Q

Staging of testicular cancer

A
56
Q

What’s Bell’s Clapper deformity?

A
57
Q

Causes of epididymo- orchitis

A

–Sexually active & < 35

  • Gonorrhoea
  • Chlamydia

–Children & men > 35

•E.Coli

58
Q

Investigations for epidydymo-orchitis

A
  • Bloods
  • UDT & MSSU
  • Urethral swabs
  • Urine Chlamydia and Gonorrhoea
  • Scrotal USS (can be done as o/p)
59
Q

Antibiotics for epididymo- orchitis

  • in >35 y old
  • in <35 y old
A
  • 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.
60
Q

How to differentiate between torsion and infection?

A
61
Q

Differentials for acute scrotal pain

A

Pathology within scrotum

  • Torsion of testis
  • Torsion of testicular appendage
  • Epididymo-orchitis
  • Testicular Tumour

Referred Pain

•Ureteric Colic

Y4 CBLs (32 decks)

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