Testicular, Scrotal, Penile

Question 1

Differential diagnoses of lump in scrotum

Answer 1

-Testicular Ca
-Epidydimal cyst
-Hydrocele
-Varicocoele
-Orchitis / epididymo-orchitis /epididymitis
-Testicular/Scrotal abscess
-Testicular Rupture
-Inguinal hernia
-Scrotal sebaceous cyst (skin)

Question 2

Differential diagnoses of pain in scrotum

Answer 2

-Testicular Torsion
-Torsion of Appendix Testis
-Orchitis / epididymo-orchitis / epididymitis

-Other causes:
=Testicular Ca
=Epididymal cyst
=Hydrocele
=Varicocoele
=Testicular/Scrotal abscess/Fournier’s
=Testicular Rupture
=Inguinal hernia

Question 3

History of testicular problems

Answer 3

-Chronicity – acute/chronic
-Progressing / Receding
-?Preceding event – trauma, epididymo-orchitis
-Systemic symptoms – infection, Malignancy
=FH – testicular Ca, cryptorchidism (UDT)

Question 4

Scrotum examination

Answer 4

-Abd, Supraclavicular: ?palpable LN
-Scrotum – Examine patient Standing:
=Rt & Lt hemi scrotal examination
=Inguinal regions–incl ext ing ring (hernia, UDT)
=Cough / Valsalva: ?enlargement (varicocoele)
=?Transillumination – brilliant, Cantonese lantern, blue dot sign
=?manipulation of retractile testis to scrotum
=Testes: position (normal vs high-riding),lie (longitudinal vs oblique/transverse)
=Examine also supine-?reducible/resolvable varicocele

Question 5

Investigation of testicular problems

Answer 5

-Bloods: FBC, U&E, LFT
-Tumour Markers: AFP, β-HCG, LDH

-Confirm the Dx: Scrotal USS +/- Doppler If cancer suspected:
=Stage the Disease (TNM): CT C/A/P

-Refer MDT
-Consider: semen cryopreservation (sperm-banking), testic Bx (via inguinal approach)

Question 6

Types of testicular cancers

Answer 6

-Definition:
=Primary testicular Tumour
=Mets

-GCT Germ Cell Tumours (90%)
=Seminoma (48%)
=NSGCT (42%): teratoma, choriocarcinoma
=Mixed (10%)

-Sex Cord Stromal (3%)
=Leydig-, Sertoli-cell

-Other (7%):
=Lymphoma, mets, Benign (epidermoid cyst; adenomatoid tumour)

Question 7

Pathology of scrotal lumps

Answer 7

-GCT Germ Cell Tumours (90%)
=Seminoma (48%)
=NS GCT (42%): teratoma, choriocarcinoma, embryonal, yolk sac
=Mixed (10%)

-Sex Cord Stromal (3%)
=Leydig-, Sertoli-cell

-Other (7%):
=Lymphoma, mets, Benign (epidermoid cyst; adenomatoid tumour)

Question 8

Epidemiology and aetiology of testicular cancers

Answer 8

-Incidence:
=6 per 100,000 men
=Commonest solid tumour in young men (20-45y)
=Accounts for 1-2% all male Ca
=Considered one of most curable Ca

-Age:
=20-45y typically
=20-35y Teratoma
=35-45y Seminoma
=>60y Lymphoma

-Sex/Gender: male Ca

-Aetiology:
=Caucasian: 3x risk cf Black
=UDT/Cryptorchidism: 10x risk, 10% cases
=HIV
=Genetic

Question 9

Risk factors for testicular cancer

Answer 9

infertility (increases risk by a factor of 3)
Undescended testes
Increased height
cryptorchidism
family history
Klinefelter’s syndrome
mumps orchitis

Question 10

Tumour markers (raised with met disease) in testicular cancers

Answer 10

-Used for Dx, Staging, Prognostication (Good/Intermed/Poor) &Monitoring Rx

=Raised AFP: NSGCT only, not with Seminoma
=Raised LDH: typically Seminoma (some limited rise with NSGCT)
=Raised β-HCG: NSGCT, Seminoma

seminomas: seminomas: hCG may be elevated in around 20%
non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
LDH is elevated in around 40% of germ cell tumours

Question 11

Presentation of testicular cancers

Answer 11

-Painless lump: non-tender, arising from testice, hard, irregular, not fluctuant, no transillumination
-Occ short Hx pain in testis (5%)
-Met Sx increased risk if tunica albuginea breached: wgt loss, LN, abd pain
-Hydrocele
-Gynaecomastia
=this occurs due to an increased oestrogen:androgen ratio
=germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone
=leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens

Question 12

Investigation of testicular cancers

Answer 12

-Bloods: FBC, U&E, LFT
-Tumour Markers: AFP, β-HCG, LDH
-Confirm the Dx: Scrotal USS +/- Doppler
-Stage the Disease (TNM): CT C/A/P
-Refer MDT
-Consider: semen cryopreservation (sperm-banking), testic Bx (via inguinal approach)

Question 13

Management and prognosis of testicular cancers

Answer 13

-Semen cryopreservation

-Surgical Rx:
=Inguinal orchidectomy (curative in 80% patients)
=Occasional: RPLND (Retroperitoneal LN Dissection)

-Oncol Rx
=Seminoma: Radio-Sensitive – EBRT
=NSGCT: Cisplatin chemo Rx

-TNM Staging
=T1-2: organ confirmed, T3 locally advanced

-Prognosis:
=Survival >90% 5ys for Stage 1
=Survival <50% 5ys for Poor Prognostic groups

Question 14

Overview of epidydimal cyst

Answer 14

-Epididymal cysts occur at the head of the epididymis (at the top of the testicle). A cyst is a fluid-filled sac. An epididymal cyst that contains sperm is called a spermatocele. Management of epididymal cysts and spermatoceles is identical.

Epididymal cysts are very common in adults, occurring in around 30% of men. Most cases are asymptomatic. Patients may present having felt a lump, or they may be found incidentally on ultrasound for another indication.

Examination findings are:
=Soft, round lump
=Typically at the top of the testicle, posterior
=Associated with the epididymis
=Separate from the testicle
=May be able to transilluminate large cysts (appearing separate from the testicle)

Usually, they are entirely harmless and are not associated with infertility or cancer. Occasionally, they may cause pain or discomfort, and removal may be considered. Exceptionally rarely, there may be torsion of the cyst, causing acute pain and swelling.

Question 15

Overview of hydrocele

Answer 15

A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes. They are usually painless and present with a soft scrotal swelling. The tunica vaginalis is a sealed pouch of membrane that surrounds the testes. Originally the tunica vaginalis is part of the peritoneal membrane. During the development of the fetus, it becomes separated from the peritoneal membrane and remains in the scrotum, partially covering each testicle.
=Communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in new-born males (clinically apparent in 5-10%) and usually resolve within the first few months of life
=Non-communicating: caused by excessive fluid production within the tunica vaginalis

Examination findings with a hydrocele are:
=The testicle is palpable within the hydrocele (swelling confined to scrotum, can get above the mass on exam)
=Soft, fluctuant and may be large, non-tender. Usually anterior to and below testicle
=Irreducible and has no bowel sounds (distinguishing it from a hernia)
=Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)
=USS required if doubt/ underlying testis cannot be palpated

Hydroceles can be idiopathic, with no apparent cause, or secondary to:
=Testicular cancer
=Testicular torsion
=Epididymo-orchitis
=Trauma

Management involves excluding serious causes (e.g., cancer). Idiopathic hydroceles may be managed conservatively. Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases. Infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years

Question 16

What is a varicocele?

Answer 16

A varicocele occurs where the veins in the pampiniform plexus become swollen. They are common, affecting around 15% of men. They can cause impaired fertility, probably due to disrupting the temperature in the affected testicle. They may result in testicular atrophy, reducing the size and function of the testicle.

The pampiniform plexus is a venous plexus, which is found in the spermatic cord and drains the testes. The pampiniform plexus drains into the testicular vein. It plays a role in regulating the temperature of blood entering the testes by absorbing heat from the nearby testicular artery. The testicles need to be at an optimum temperature for producing sperm.

Varicoceles are the result of increased resistance in the testicular vein. Incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus.

The right testicular vein drains directly into the inferior vena cava. The left testicular vein drains into the left renal vein. Most varicoceles (90%) occur on the left due to increased resistance in the left testicular vein. A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma.

Question 17

Overview of varicocele

Answer 17

-Throbbing/dull pain or discomfort, worse on standing
-A dragging sensation
-Sub-fertility or infertility

-Examination findings are:
=A scrotal mass that feels like a “bag of worms”
=More common on left side (>80%)
=More prominent on standing
=Disappears when lying down
=Asymmetry in testicular size if the varicocele has affected the growth of the testicle

Varicoceles that do not disappear when lying down raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein. These warrant an urgent referral to urology for further investigation.

-Investigations to consider are:
=Ultrasound with Doppler imaging can be used to confirm the diagnosis
=Semen analysis if there are concerns about fertility
=Hormonal tests (e.g., FSH and testosterone) if there are concerns about function

-Uncomplicated cases can be managed conservatively.
-Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.

Question 18

Overview of epididymo-orchitis

Answer 18

Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae, typically seen in sexually active younger adults) or the bladder (E. coli, typically seen in older adults with a low-risk sexual history). Mumps: parotid gland swelling

Features
=unilateral testicular pain and swelling, tenderness on palpation
=Dragging or heavy sensation
=urethral discharge may be present, but urethritis is often asymptomatic
=factors suggesting testicular torsion include patients < 20 years, severe pain and an acute onset
=Fever or sepsis

The most important differential diagnosis is testicular torsion. This needs to be excluded urgently to prevent ischaemia of the testicle.

Investigations are typically guided by the age of the patient
=in younger adults assess for sexually transmitted infections (STI): age under 35, increased number of sexual partners in last 12 months, discharge
=in older adults with a low-risk sexual history send a mid-stream urine (MSU) for microscopy and culture, NAAT, charcoal swab of discharge (gonorrhoea), saliva swap for PCR (mumps), serum antibodies doe mumps, USS

Management
=if an STI is the most likely cause advise urgent referral to a local specialist sexual health clinic CKS
==if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
=if enteric organisms are the most likely cause CKS: E.coli ofloxacin 14 days, levofloxacin 10 days, co-amoxiclav 10 days
==send an MSU as above
==treating empirically with an oral quinolone for 2 weeks (e.g. ofloxacin)
=further investigations following treatment may be recommended to exclude any underlying structural abnormalities

Question 19

Overview of inguinal hernia

Answer 19

Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia.

Features
=groin lump
=superior and medial to the pubic tubercle
disappears on pressure or when the patient lies down
=discomfort and ache: often worse with activity, severe pain is uncommon
=strangulation is rare

Whilst traditional textbooks describe the anatomical differences between indirect (hernia through the inguinal canal) and direct hernias (through the posterior wall of the inguinal canal) this is of no relevance to the clinical management.

Management
the clinical consensus is currently to treat medically fit patients even if they are asymptomatic
a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients
mesh repair is associated with the lowest recurrence rate
unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically

The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks

Complications
early: bruising, wound infection
late: chronic pain, recurrence

Question 20

Epidemiology and aetiology of penile cancer

Answer 20

-Definition:
=Predom Sq Cell Ca
=Rare: AdenoCa, Kaposi’s sarcoma, BCC, melanoma
=Usually pre-malig lesions: CIS

-Incidence:
=Rare: represent <1% of urological Ca
=~600-700 new cases/y in UK; Lifetime risk: 1:500 UK males; >60% cases preventable

-Age:
=Rare <40y
=Incidence increases with age, peaking in 70y

-Sex/Gender: male Ca

-Aetiology: Risk Factors (RFs):
=Smoking
=HPV
=Foreskin
=CIS

Question 21

Presentation of penile cancer

Answer 21

-Painless mass / lesion /ulcer on distal aspect penis / glans / foreskin +/- bleeding
-Progressive phimosis with bleeding beneath
-Rarely: inguinal mass (local nodal mets)

Question 22

Diagnosis and staging of penile cancer

Answer 22

-Diagnosis
=Penile Bx (+/- circumcision)
=MRI for local staging

-Staging:
=MRI for local staging
=CT Chest/Abd/Pelvis

Question 23

Management and prognosis of penile cancer

Answer 23

-Extent of Rx depends on stage and grade and size of Cancer:
=Local Rx for 1ry Ca: varies from Topical treatments to major surgery-
=Imiquimod, 5-FU → Circumcision → Glansectomy & resurfacing → Partial Penectomy +/- Glans reconstruction → Radical Penectomy
=Lymph Node Rx: +/- Sentinel LN Bx +/- Inguinal LND +/- PLND
=Advanced Disease: EBRT, Chemo Rx
=Total phallic reconstruction after penile amputation for carcinoma using radial artery free flap (RAFF)

-Prognosis:
=Prognosis depends on Stage & Grade of Disease
=5ys (CSS) >90% (for small foreskin Ca) → 40% for metastatic Ca
=Overall 5ys: 74%
=Overall 10ys: 68%

Question 24

Describe undescended testis/ cryptorchidism

Answer 24

-Forms of failed testicular descent
-UDT/Cryptorchidism: testis that has incompletely descended along normal path of testicular descent
-Ectopic Testis: testis that has migrated away from normal path of testicular descent

-Incidence:
=4% of full-term births
=80% will have resolved by 6 months

-Complications UDT:
=Increased risk of- Testicular Ca, Torsion, Subfertility, Ing Hernia

-Mx UDT: Orchidopexy by 1-2y

Question 25

Describe hydrocoele

Answer 25

-Collection of fluid within parietal and visceral layers of tunica vaginalis
-May be 1ry or 2ry (infection, trauma, tumour)
-Dx: Transillumination (“Brilliantly”)+ USS
-Mx: Surgery if large & symptomatic (Jaboulay eversion, Lord’s plication)

Question 26

Describe epidydimal cyst

Answer 26

-Cyst within collecting tubules of epididymis (mainly Head)
-May be clear or opaque (spermatocoele- contain sperm)
-Dx: Transillumination (Spermatocoele – “like a Cantonese lantern”) + USS
-Mx: Surgery if large & symptomatic (excision)

Question 27

Overview of varicocoele

Answer 27

-Dilatation of pampiniform plexus of veins around testis &spermatic cord (=varicose veins)
-May be 1ry or 2ry (RCC for non-reducible Lt sided varicococele)
-Rt gonadal v- drains into IVC
-Lt gonadal v- drains into Lt Renal V

-Symptoms:
=May be asymptomatic, cause general discomfort / dragging sensation
=O/E: patient standing – “Bag of worms”

-Inx: Scrotal +/- Renal USS

-Mx: If significant then consider surgery-
=Varicocoele embolisation (Radiol), Lap ligation, Ing microdissection& ligation

Question 28

Overview of testicular torsion

Answer 28

-Definition: torsion of spermatic cord resulting in strangulation of blood supply to testis (ischaemia) +epididymis > necrosis - Urological Emergency

-Age: 10-30y, peak 13-15y
-Presentation: sudden onset severe pain, may have prev intermittent Hx, Testis in High-riding position + Oblique lie, tender++, swollen. Pain may be referred to lower abdomen. Firm swollen testicle.
-RFs: Age, “Bell-Clapper Deformity” (horizontal lie with long mesorchium), UDT
-N&V, swollen, tender testis retracted upwards, skin may be reddened
=Cremasteric reflex is lost, elevation of testis does not ease pain (Prehn’s sign)
-DDx: torsion of Appx testis, epidiymo-orchitis

-Dx: on clinical assessment – no role for Doppler USS (whirlpool sign)

-Mx:
=Immediate scrotal exploration + bilateral testicular fixation +/- orchidectomy (if necrotic). NBM, analgesia
=Testicular viability is dependent on time to surgical de-torsion, viability reduced sig after 6hr
=Patient can subsequently have testicular prosthesis after the age of 18y if orchidectomy has been performed

Question 29

Overview of torsion of appendix testis

Answer 29

-Definition: torsion of Appendix testis (hydatid of Morgagni- Müllerian duct remnant) resulting in strangulation of blood supply to Appx testis > swelling + pain + necrosis

-Age: typically <10y (cf testic torsion >10y)
-Presentation: progressive onset scrotal pain, younger patient, pain generally less severe, swelling confined to upper pole testis (if seen early), with limited testicular tenderness/swelling, small hard tender nodule, ischaemic appendage, superior aspect of testicle, testicle as a whole is not tender
-“Blue Dot” sign at upper pole of testis

-DDx: torsion of testis, epidiymo-orchitis

-Dx: on clinical assessment +/- USS

-Mx:
=Analgesia
=For scrotal exploration + excision of Appx testis if pain + swelling severe

Question 30

Causes of genital ulcers

Answer 30

-Genital herpes HSV 2, primary attacks severe and associated with fever, subsequent localised and less severe, multiple painful ulcers)
-Syphilis (painless ulcer in primary stage)
-Chancroid (painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. Sharp defined, ragged, undermined border)
-Lymphogranuloma venereum (chlamydia, small painless pustule which later forms ulcer, painful inguinal lymphadenopathy, proctocolitis)
-Behcet’s disease
-Carcinoma
-Granuloma inguinale (Klebsiella)

Question 31

Overview of Behcet’s disease

Answer 31

-Behcet’s syndrome is a complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins

-P: oral ulcers, genital ulcers, anterior uveitis. Thrombophlebitis and DVT, arthritis, aseptic meningitis, abdo pain, diarrhoea, colitis, erythema nodosum. FHx, young men

-D: clinical findings, positive pathology (puncture site following needle prick becomes inflamed with small pustule forming)

Question 32

Overview of Phimosis

Answer 32

-Non-retractile foreskin and/or ballooning during micturition in a child under two, an expectant approach should be taken in case this is physiological phimosis which will resolve in time.
=Paraphimosis is a condition caused when the foreskin of the uncircumcised penis is retracted and left behind the glans penis, leading to vascular engorgement and oedema of the distal glans

-P: penile pain, band of retracted foreskin tissue, swollen glans penis, indwelling catheter, erythema, inability to urinate freely. Non-pliable glans penis, black tissue suggests necrosis

-M: Forcible retraction can result in scar formation so should be avoided.
=Manual manipulation, puncture technique, hyaluronidase, surgical reduction/ emergency surgery
-Personal hygiene is important.
-If the child is over 2 years of age and has recurrent balanoposthitis or urinary tract infection then treatment can be considered.