Testicles

Question 1

What are some important identifiers on examination and their differentials?

Answer 1

Cannot get above – inguinal hernia or proximally extending hydrocele

Separate and cystic – epididymal cyst

Separate and solid – epididymitis, varicocele

Testicular and cystic – hydrocele

Testicular and solid – tumour, haematocele, granuloma, orchitis – USS to differentiate

Question 2

What are epididymal cysts and how do you manage them?

Answer 2

Usually develop in adulthood

Contain clear or milky fluid

Lie above and behind the testes

Remove if symptomatic

Question 3

What is a hydrocoele?

Answer 3

Fluid within tuinca vaginalis

Question 4

What is the difference between a primary and secondary hydrocoele?

Answer 4

Primary - associated with patent processus vaginalis (developmental outpouching of parietal peritoneum); more common, larger, most commonly occurs in younger men; can resolve spontaneously

Secondary - to a testis tumour, trauma, infection

Question 5

How do you treat a hydrocoele?

Answer 5

Aspirate ± repetition of such

Corrective surgery if primary

Treat cause if secondary

Question 6

What is a varicocele and how do you treat one?

Answer 6

Dilated veins of pampiniform plexus

Left side more commonly affected
Visible distended scrotal vessels - ‘bag of worms’
Dull ache

Surgical repair

Question 7

What is a spermatocoele?

Answer 7

Build-up of fluid in the spermatic cord

Question 8

What are epididymitis and orchitis and what causes them?

Answer 8

Inflammation of epdidymis or testis

STI/UTI ie Chlamydia, E.coli, N.gonorrhoea; TB

Trauma, urine in the epididymis

Question 9

How do epididymitis and orchitis present?

Answer 9

Sudden onset tender swelling
Dysuria
Sweats, fever

Question 10

How do you investigate epididymitis and orchitis?

Answer 10

1st catch urine sample
Urethral discharge? swab and culture
STI screen

Question 11

How do you treat epididymitis and orchitis?

Answer 11

Doxycycline – Chlamydia
If gonorrhoea – add ceftriaxone
Use Abx for 2-4wks

Analgesia, drainage – if necessary

Treat partners too

Question 12

What is testicular torsion?

Answer 12

Mechanical twisting of the spermatic cord → cuts off testicles blood supply/ischemia

Question 13

What are some risk factors for testicular torsion?

Answer 13

Most common just after birth and during and after puberty (up to 30yrs)

Risk factors

• Larger testicle (due to normal variation or tumour)
• Congenital malformation called processus vaginalis (bell-clapper deformity)
  i) Accounts for most cases
  ii) Testicle is inadequately fixed to the scrotum and so is free floating
• Trauma (rare), most occur spontaneously

Question 14

How does testicular torsion present?

Answer 14

Severe, rapid onset testicular/groin pain and tenderness
N+V
Erythema and swelling of testicle
Testicle may be higher than normal

Question 15

How do you investigate torsion?

Answer 15

Clinical examination

Doppler USS - may demonstrate lack of blood flow to testis

Question 16

How do you treat torsion?

Answer 16

Surgical emergency

If surgery <6hrs = 90%+ salvage; >24hrs = <10%

Realignment of testis + fixation of both testes to scrotum to prevent recurrence (orchidopexy)

Potential need for orchidectomy

Question 17

What is the epidemiology of testicular cancer?

Answer 17

Commonest malignancy in men aged 15-44

10% occur in undescended testes, even after orchidopexy (moving of undescended testicle to scrotum and fixing in place)

Other risk factors – infant hernia, infertility

Question 18

What are the common cell lines involved?

Answer 18

Seminoma 55% (30-65yrs)

Non-seminomatous germ cell tumours – 33%

Mixed germ cell tumour – 12%

Lymphoma

Contralateral tumour found in 5%

Question 19

How does testicular cancer present?

Answer 19

Painless testicle lump – typically found after trauma/infection
± haemospermia, secondary hydrocele
Pain
Dyspnoea (lung mets) Abdominal mass (enlarged nodes)
Effects of secreted hormones – i.e. excess androgens

Question 20

What are metastases rates?

Answer 20

25% of seminomas and 50% of NSGCTs present with metastases

abdominal lymph nodes, lung, liver, bone, brain

Question 21

How do you investigate testicular cancer?

Answer 21

Excision biopsy – diagnostic

CXR/CT/MRI – staging

α-FP and ß-hCG – are useful tumour markers and can be used for monitoring of treatment

Question 22

How do you treat testicular cancer?

Answer 22

Radical orchidectomy

Seminomas are sensitive to radiotherapy
i) Seminoma – radio+orchidectomy = 95% curative

NSGCT ± mets
i) Bleomycin + etoposide + cisplatin

Self examination is necessary to reduce late presentation