Testicles Flashcards
Testicular Torsion
• Usually secondary to exertion or minor trauma
• tunica vaginalis invests whole of testicle
- therefore free-hanging testicle can twist on
its mesentery
Presentation of testicular torsion
- Sudden onset severe pain in one testis
- May have lower abdominal pain (testis supplied by T10)
- Associated with N/V
- May be Hx of previous testicular pain or torsion
Examination of testicular torsion
- Inflammation of one testis: hot, swollen, extremely tender
* Testis rides high and lies transversely
Mx of testicular torsion
Mx • Surgical emergency - 4-6h window from onset of pain to salvage testis • Inform senior • NBM • IV access - Analgesia - Bloods: FBC, U+E, G+S, clotting
• Surgery
- Consent for possible orchidectomy
- Bilateral orchidopexy: suture testes to scrotum
Epididymal Cyst
- Develop in adulthood
- Contain clear or milky (spermatocele) fluid
- Lie above and behind testis
- Remove if symptomatic
Varicocele
- Dilated veins of pampiniform plexus
- Presentation
- Feel like bag of worms in the scrotum
- May be visible dilated veins
- ↓ size on lying down
- Dull ache
• Mx
- Conservative: scrotal support
- Surgical: clipping the testicular vein (open or
lap)
Pathology of varicocele
Pathology
Primary: Left side commoner: drain into left renal vein
Secondary: left renal tumour has tracked down renal vein → testicular vein obstruction.
Hydrocele
• Collection of serous fluid within tunica vaginalis
• Primary- patent processus vaginalis
- Commoner, larger, tense, younger men
• Secondary
- Tumour, trauma, infection
- Smaller, less tense
• Ix
- USS testicle to exclude tumour
Mx of hydrocele
- May resolve spontaneously
• Surgery:
- Lord’s Repair: fold the sac
- Jaboulay’s Repair: eversion of the sac
• Aspiration
- Usually recur so not 1st line.
- Send fluid for cytology and MC+S
Epididymo-Orchitis aetiology
Local extension of infection
- STI: Chlamydia, gonorrhoea
- Ascending UTI: E. coli
- Mumps
Presentation of epididymo-orchitis
- Sudden onset unilateral tender swelling
- Dysuria
- Sweats, fever
Examination of epididymo-orchitis
• Tender, red, warm, swollen testis and epididymis
- Elevating testicle may relieve pain - Prehn’s sign
• Secondary hydrocele
• Urethral discharge
Investigations for epididymo-orchitis
- Blood: FBC, CRP
- first-void urine NAAT - STI
- Urine: dip, MC+S (first void)
- Urethral swab and STI screen
- USS: exclude abscess
Mx of epididymo-orchitis
- Bed rest
- Analgesia
- Scrotal support
• Abx:
- Enteric organisms – Ofloxacin 14 days
- STI organisms – Ceftriaxone IM single dose and Doxycycline PO 10 - 14 days
• Drain abscess if present
Testicular tumours pathology
Germ Cell: 95% • Seminoma 40% - ↑ βhCG - ↑ placental ALP - metastasise late
• Non-seminoma
- Mixed - commonest NSGCT
- Teratoma
- Yolk Sac
- Choriocarcinoma - ↑↑ βhCG
Sex-cord Stromal 5% (benign)
• Leydig Cell
- May secrete androgens or oestrogens
• Sertoli Cell
- Mostly benign
- May secrete oestrogens
Teratoma
- Arise from all 3 germ layers
- Common and benign in children
- Rare and malignant in adults: 15-30yrs
- Secrete βhCG and/or AFP
- Chemosensitive
Ix for testicular tumours
• Tumour markers - monitoring • Scrotum USS - initial • Staging - CXR - CT chest, abdomen, pelvis (CAP) • Biopsy not done due to seeding risk
Tumour markers
- ↑AFP and ↑hCG in 90% of teratomas
- ↑hCG in 15% of seminomas
- Normal AFP in pure seminomas
- LDH - marker of tumour volume
Mx of testicular tumours
• If both testes are abnormal, semen can be
cryopreserved
Seminomas
• Stage 1-2: inguinal orchidectomy + radiotherapy
• Stage 3-4: as above + chemo (BEP)
Non-seminomas:
• Stage 1: inguinal orchidectomy + surveillance
• Stage 2: orchidectomy + chemo + para-aortic LN
dissection
• Stage 3: orchidectomy + chemo
Testicular Ca follow up
Close f/up to detect relapse
• Typically w/i 18-24mo
• Repeat CT scanning and tumour markers
Intercourse with epididymitis
Refrain during abx course
Complications of epididymitis
Reactive hydrocele
Abscess formation
Testicular infarction
Epididymitis causative organism
Enteric > 35 yo:
- E. Coli
- P. Aeruginosa
- K. Pneumonia
STI < 35 yo :
- N. gonorrhoeae
- Chlamydia trachomatis
Non-seminoma GCT behaviour
Metastasise early
Worse prognosis
Non-seminoma GCTs
- Mixed - commonest NSGCT
- Teratoma
- Yolk Sac
- Choriocarcinoma - ↑↑ βhCG
Risk factors for testicular cancers
Cryptorchidism - undescended testes
Previous testicular malignancy
FHx
Kleinfelter’s syndrome
Clinical features of testicular cancer
- Unilateral painless testicular lump
- irregular, firm, fixed
- does not transilluminate
- Metastasise -weight loss, back pain, dyspnoea
Which medication can cause scrotal gangrene
Dapagliflozin - SGLT2 - rare
