testicular pathology

Question 1

what is testicular torsion?

Answer 1

Testicular torsion is a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue

Question 2

what anatomical variation can increase risk of testicular torison ?

Answer 2

bell clapper testicle

Question 3

what are the S&S of testicular torsion?

Answer 3

• Sudden onset of moderate to severe, constant, unilateral scrotal pain, often with nausea, vomiting, and abdominal pain.
• May have been preceding episodes of intermittent pain that suddenly resolved.
• The testis is globally tender, high in the scrotum, may have a transverse axis, and be slightly enlarged. If it is infarcted, scrotal wall oedema and tenderness may be present. Absence of ipsilateral cremasteric reflex is the most reliable sign.

Question 4

what are the InV for testicular torsion?

Answer 4

Doppler US - absent or decreased blood flow in the affected testicle; decreased flow velocity in the intra-testicular arteries, increased resistive indices in the intra-testicular arteries

Grey-Scale US - presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downwards perpendicular to the spermatic cord).

Question 5

how is testicular torsion managed?

Answer 5

Testicular torsion is a surgical emergency with a 4-6hrs window from the onset of symptoms to salvage the testis before significant ischaemic therefore urgent surgical exploration of the testis is needed

suitable strong analgesia and anti-emetics pre-operatively, and made nil by mouth with maintenance fluids prescribed.

If torsion is confirmed intra-operatively, the cord and testis will be untwisted and both testicles fixed to the scrotum, termed bilateral orchidopexy (prevent further any further torsion episodes).

In cases where the testis is non-viable, an orchidectomy may be warranted; prosthesis can be inserted at time of surgery or at a later date, at the patient request.

Question 6

what is epididymitis?

Answer 6

Acute epididymitis is inflammation of the epididymis characterised by scrotal pain and swelling of less than 6 weeks’ duration

It may be associated with irritative lower urinary tract symptoms, urethral discharge, and fever. It is usually unilateral

Question 7

what are the causes of epididymitis ?

Answer 7

Bacterial infection – STI caused by chlamydia trachomatis and Neisseria gonorrhoeae

Non sexually transmitted uropathogens like E. Coli and Klebsiella can also cause.

Viral infection – Mumps orchiditis

Question 8

what are the S&S of epididymitis ?

Answer 8

• Gradual onset of pain (hours or days).
• Dysuria, urethral discharge, and pyrexia are common. The hemisctroum is hot and erythematous.
• Tenderness and induration are localized to the epididymis and spermatic cord in epididymitis.
• Cremasteric reflex is preserved.
• Prehn’s sign (relief of pain with scrotal elevation).

Question 9

what InV are done in epididymitis ?

Answer 9

urine dip - infection

first void urine NAAT - STI

Further STI screening

routine bloods and cultures - infection

US imaging
- rule out complications like testicular abscess and confirm diagnosis

Question 10

what are the types of testicular cancer?

Answer 10

Germ cell tumours (95%)

• seminomas
• Non seminomatous (NSGCT) -

Non-Germ cell tumours

• leydig or sertoli cell tumours
• usually benign

Question 11

what are the clinical features of testicular cancer?

Answer 11

• The usual presentation is with a painless testicular mass.
• Typical features are irregular, firm, fixed, and does not transilluminate.
• Palpate the abdomen for intra-abdominal masses (either para-aortic node masses or hepatomegaly).
• Check for supraclavicular lymphadenopathy and signs of lung or neurological disease.

Question 12

what are the InV for testicular cancer?

Answer 12

Any clinically suspicious mass requires urgent testicular ultrasound scan. Typical features are a non-homogeneous mass with increased vascularity.

• Serum tumour markers, B-HCG and AFP. Increased levels suggest metastatic disease in NSGCTs, but may be normal in localized or metastatic disease; very rarely elevated in seminoma even if metastatic.
• CT scan of abdomen and chest. To assess presence of metastases.
• CT brain, bone scan. Only if clinically indicated.

Serum LDH is raised in 50% of cases.

Question 13

what is the staging system for testicular tumours?

Answer 13

Marsden staging

• Stage 1, confined to testis.
• Stage 2, abdominal nodal spread.
• Stage 3, nodal disease outside the abdomen.
• Stage 4, extralymphatic spread.

Question 14

what are the treatments for testicular cancer?

Answer 14

• Orchidectomy is carried out at the earliest opportunity; this is performed via an inguinal approach so that the spermatic cord can be clamped prior to mobilization of testis.
• Seminoma is radiosensitive and even widespread local disease responds well to radiotherapy.
• NSGCT is chemosensitive and even widespread metastatic disease responds well.