URO - Scrotal Lumps Flashcards
Scrotal Lumps
Definition
Clinical Features
Investigations
Differential Diagnoses
1.) Definition - abnormal mass or swelling within the scrotum
2.) Clinical Features
- diagnoses often made from examination alone
- hx: onset, associated sx, previous episodes
- site, size, shape, symmetry, scars, skin changes
- palpate testes, epididymis and vas deference
- is the swelling separate from the testicle?
- can you get above the swelling?
- does the swelling transilluminate?
3.) Investigation
- USS of the scrotum is first-line for the majority
- mass from testes requires USS to rule out cancer
4.) Differential Diagnoses
- extra-testicular: hydrocoele, varicocele, epididymal cysts, epididymitis, inguinal hernia
- testicular: cancer, torsion, orchitis, benign lesions
Hydrocoele
Pathophysiology
Clinical Features
Management
1.) Pathophysiology - an abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis
- communicating: congenital patent processus vaginalis allowing peritoneal fluid to drain into the scrotum, usually resolves in first few months of life
- non-communicating: excessive fluid production within the tunica vaginalis, can occur secondary to epididymo-orchitis, testicular torsion, testicular cancer
2.) Clinical Features
- painless, fluctuant swelling, can be unilateral or bilateral
- can ‘get above’ the testicle as it is usually below and anterior to the testicle
- may not be able to palpate the testis separately if it’s too large
- transilluminates: due to being fluid-filled
- can get bigger in young boys when they cough/cry due to the connection between the peritoneum and scrotum
3.) Management - clinical diagnosis but USS if diagnosis unclear
- urgent USS to rule out cancer in 20-40-year-olds
- congenital hydroceles are surgically removed if not resolved in 1-2 years
Varicocele
What is it?
Aetiology
Clinical Features
Management
1.) What is it? - abnormal dilation of the pampiniform venous plexus within the spermatic cord
2.) Aetiology
- obstructed drainage of the testicular vein due to defective valves or occlusion
- 90% found on left side due to ↑chance of occlusion
- insertion angle of L testicular vein into L renal vein is more perpendicular than R testicular vein into IVC
3.) Clinical Features
- painless lump, ‘bag of worms’, ‘heavy sensation’
- examine supine (should disappear) and standing up whilst performing valsava manoeuvre (engorges veins)
- examine the abdomen to exclude renal tumour (RCC)
- alarming features: acute onset, right-sided, remains when lying flat
4.) Management - diagnosed/graded with a doppler ultrasound
- grade 1 (mild): reassurance and observation
- grade 2/3 but asymptomatic and normal semen parameters: semen analysis every 1-2 years
- grade 2/3 but symptomatic OR abnormal semen parameters: surgery (IR embolisation or vein ligation if symptomatic)
Epididymitis (and Epididymo-orchitis)
Pathophysiology
Clinical Features
Mumps Orchitis
Investigations/Imaging
Management
1.) Pathophysiology
- local extension of infection from UTIs or STIs
- <35s, STI: N.gonorrhoea, C.trachomatis, E.coli (anal)
- >35s, UTI/enteric: E.coli, Klebsiella pn. P.aeruginosa
- enteric RF: catheters, bladder outlet obstruction
2.) Clinical Features
- gradual onset unilateral scrotal pain and swelling
- fevers and rigors can also be present
- associated UTI/STI sx, reactive hydrocoele
- cremasteric reflex intact, Prehn’s sign positive (pain relieved by elevation of the scrotum)
3.) Investigations/Imaging
- bloods: FBC, CRP, blood cultures
- urinalysis +/- urine culture
- STI: first void urine for NAAT testing, further STI screening may be warranted
- US Doppler to rule out complications (e.g. abscess)
4.) Management
- analgesia, antibiotics, bed rest, scrotal support
- enteric: PO Ofloxacin BD for 14 days
- STI: IM Ceftriaxone + PO Doxycycline BD for 10-14d
Other Scrotal Lumps
Orchitis
Torsion of Hydatid of Morgagni
Epididymal Cysts (Spermatoceles)
Inguinal Hernia
1.) Orchitis - inflammation of testes only (rare)
- a common complication of mumps viral infection
- uni/bilateral, fever, 4-8d after onset of mumps parotitis
- self-limiting, rest and analgesia
- abscess may require drainage or orchidectomy
- complications: infertility, testicular atrophy
2.) Torsion of Hydatid of Morgagni
- testicular appendage (remnant of the Mullerian duct)
- becomes torted, presenting very similarly to torsion
- occurs in younger age group, normal lie of the testis
- ‘blue dot’ sign: visible infarcted hydatid (upper half)
- cremasteric reflex is still present
3.) Epididymal Cysts - benign fluid-filled (transillimunates) sacs arising from the epididymis that presents as a smooth fluctuant (multi-)nodule
- can get above, separate from testis and often posterior to testicle
- often asymptomatic requiring conservative mx but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.
- most common cause of scrotal swelling seen in primary care
- associated w/ ADPKD, CF, von Hippel-Lindau syndrome
4.) Inguinal Hernia
- enter scrotum via external inguinal ring
- cannot ‘get above’ (palpate superior surface)
- cough impulse, may disappear when flat
Testicular Torsion
Pathophysiology
Clinical Features
Investigations
Management
Complications
1.) Pathophysiology
- spermatic cord twists within tunica vaginalis –> ↓blood flow –> ↓venous return –> oedema + infarction
- ‘bell-clapper deformity’ more prone due to ↑mobility due to abnormal attachment to the tunica vaginalis
- R.F: age (12-25), previous history, FH, cryptorchidism
2.) Clinical Features
- sudden onset of severe unilateral testicular pain
- can be associated w/ N+V and referred abdo pain
- testis is tender, swollen, has a higher horizontal lie
- cremasteric reflex is absent and -ve Prehn’s sign
3.) Investigations - clinical diagnosis
- Doppler US to investigate blood flow
- urinalysis to rule out differentials (epididymo-orchitis)
4.) Management
- surgical emergency, 4-6hrs until ischaemic damage
- urgent surgical exploration for evidence of torsion
- bilateral orchidopexy (untwisted, fixed to the scrotum)
- orchidectomy if the testis is non-viable
5.) Complications
- testicular atrophy, chronic pain, infertility, future torsion
Testicular Cancer
Risk Factors
Clinical Features
Investigations
Management
1.) Risk Factors
- cryptorchidism (4-10x), previous malignancy, FH
- Kleinfelter’s syndrome
- demographic: 20-40yrs, caucasaian, north european
2.) Clinical Features
- unilateral painless testicular lump/mass
- mass is irregular, firm, fixed, does not transilluminate
- evidence of mets: weight loss, back pain, SOB, palpate supraclavicular lymph nodes
3.) Investigations
- tumour markers: PLAP, ß-hCG, AFP, LDH
- scrotal USS, staging CT w/ contrast
- biopsy not performed to prevent seeding of cancer
4.) Management - depends on tumour subtype, disease stage, and risk scoring
- surgery, radiotherapy, chemotherapy
- surgery: inguinal radical orchidectomy (enter through inguinal region to remove spermatic cord, to prevent spread to other lymph [para-aortic] nodes)
- semen analysis and cryopreservation offered
