Urology mushkies Flashcards
What are the causes of a testicular mass?
THEEOVI Tumour Hydrocele Epididymal cyst Epididymitis Orchitis Varicocoele Indirect Inguinal Hernia
What is the single biggest risk factor for testicular cancer?
A Hx of undescended/maldescended testes
What lymph nodes do the testes drain to?
Para-aortic nodes
What lymph nodes do the scrotal skin drain to?
Inguinal nodes
What testicular tumour is AFP a marker for?
50-70% Teratomas
What testicular tumour is β-HCG a marker for?
40-60% Teratomas
30% Seminomas
What testicular tumour is LDH a marker for?
Seminoma (non-specific)
What is a hydrocele?
An accumulation of fluid within the tunica vaginalis, a remnant of the processus vaginalis that accompanied the testicle during its descent
What are the possible classification systems for a hydrocele?
- Anatomical
2. Aetiological
What is the anatomical classification of hydroceles?
- Vaginal = accumulation in the tunica vaginalis that doesnt extend up the cord
- Congenital = proximal part of processus has not obliterated and the sac communicates directly with the peritoneum
- Infantile = processus is obliterated at the deep ring but still extends up the cord
- Hydrocele of the cord = fluid accumulates around the ductus deferens, testicular traction will pull it inferiorly, can be hard to distinguish from an inguinal hernia
What is the aetiological classification of hydroceles?
- Primary = Caused by a patent processus vaginalis, commonest type, young men + large + tense
- Secondary = Vaginal type can be caused by a variety of pathologies e.g. testicular tumours, trauma, torsion, epididymo-orchitis
What is the management of hydroceles?
- Non-surgical = watch and wait (ensure no Ca), aspiration (symptomatic relief only as will accumulate)
- Surgical = Lord’s repair (plication of tunica vaginalis), Jaboulay’s repair (eversion of the sac)
What is an epididymal cyst?
A retention cyst of a tubule of the rete testis or the epididymis
What is a spermatocoele?
A retention cyst of a tubule of the rete testis or the epididymis distended with watery fluid that contains spermatozoa.
What is a varicocoele?
- Dilated, tortuous, superficial veins of the pampiniform plexus
- 98% left sided, 50% bilateral
How do you classify varicocoeles?
- Primary = 15% young men, often around puberty, anatomical cause (?nutcracker syndrome), disappears when pt lies supine
- Secondary = suddenly appearing in older men, can be sinister, retroperitoneal disease affecting the testicular vein (e.g. renal cell carcinoma extending into L renal vein), doesnt disappear when pt lies supine
What is nutcracker syndrome?
Compression of the Left Renal Vein between the AA and SMA
What is SMA syndrome?
Compression of the third part of the duodenum by the AA and SMA
What are the symptoms of a varicocoele?
- Dragging sensation exacerbated by exertion
2. Subfertility (commonest surgically correctable cause)
Why do 98% varicocoeles occur on the left? (x4)
- Left testicular vein is more vertical where it joins the left renal vein compared to the obliquity of the right testicular vein where it joins the IVC
- Left renal vein can be compressed by the colon
- Left testicular vein is longer than the right
- Left testicular vein often lacks a terminal valve to prevent backflow
What are the management options for a varicocoele?
- Non-surgical = scrotal support, transfemoral radiological embolisation of the testicular vein
- Surgical = Palomo operation, laparoscopic approach also possible
What is the commonest malignancy in men 15-45y/o?
Testicular tumours
What are the tumour markers for testicular tumours?
AFP, βHCG, Placental ALP
How do you classify testicular tumours?
- Germ cell tumours (95%) –> Seminomas (50%), Teratomas
- Yolk sac tumours = commonest testicular tumour in children
- Choriocarcinoma
- Leydig or Sertoli cell (may secrete oestrogens –> gynaecomastia)
- Lymphoma (NHL is commonst testicular mass >60y/o)
What kind of tumours do young troopers get?
Teratomas
What kind of tumours do old sergeants get?
Seminomas
What are the leading causes of epididymo-orchitis in <35y/o?
STIs = C. trachomatis and N. gonorrhoeae
What is the leading cause of epididymo-orchitis in >35y/o?
E.coli
What does it means if one is Prehn’s sign +ive?
There is relief of pain upon elevation of the scrotum, a sign of epididymo-orchitis
What are the 4 key questions to ask when examining a scrotal lump?
ATPP
- Can you get above it?
- Is it tender?
- Is the testis palpable separately?
- Does it transilluminate?
What is a scrotal mass you can’t get above?
An inguinoscrotal hernia
Scrotal Lump you can get above
Separately palpable?: No
Transilluminate?: No
HOT
Haematocoele
Orchitis
Tumour
Scrotal Lump you can get above
Separately palpable?: No
Transilluminate?: Yes
Hydrocoele
Scrotal Lump you can get above
Separately palpable?: Yes
Transilluminate?: No
VESS Varicocoele Epididymitis Spermatocoele Sperm granuloma
Scrotal Lump you can get above
Separately palpable?: Yes
Transilluminate?: Yes
Epididymal cyst
What is the management of a hydrocoele?
- Non-surgical = watch and wait (ensure no Ca) + aspiration (symptom relief only as will accumulate)
- Surgical = Lord’s repair (plication of the tunica vaginalis) + Jaboulay’s repair (eversion of the sac)
What is the management of a epididymal cyst?
- Non-surgical = if cyst isnt troublesome it shouldnt be removed due to the risk of operative damage and subsequent post-op fibrosis –> subfertility
- Surgical = very large of painful cysts can be removed, excision of the entire epididymis may be indicated to prevent the recurrence of painful cysts
What is the management of a varicocoele?
- Non-surgical = scrotal support or transfemoral embolisation of the testicular vein
- Surgical = often advised as the problem usually gets worse with age and can cause subfertility –> Palomo operation (laparoscopic approach also possible)
What is the management of a testicular tumour?
All testicular tumours are treated with orchidectomy (groin incision with early clamping of spermatic cord to prevent seeding)
Mx of epididymal cyst?
- Non-surgical = if not troublesome, shouldnt be removed
- Surgical = very large or painful cysts can be removed, excision of the entire epididymis may be indicated to prevent the recurrence of painful cysts
Seminoma Mx?
- Early = DXT to para-aortic nodes
2. Late = DXT + combination chemo
Teratoma Mx?
- Early = observation
2. Late = combination chemo (BEP Bleomycin, Etoposide, Cisplatin)
