Lumps and bumps

Question 1

For each of the following pts complaining of scrotal swellings, please choose the most likely diagnosis:

1. A 16 yo boy presents with sudden onset pain in his R scrotum and vomiting. O/E the R testis appears swollen and is hanging higher than the L.
2. A 49 yo man complains of gradually enlarging, painless swelling of his L scrotum. He says it has been present for abbout 2 years. O/E the testis is impalpable but it is possible to get above the swelling. The swelling transluminates bright brightly.
3. A 28 yo man complains of a ‘dragging’ sensation and slight discomfort in his scrotum. O/E the swelling is located above the testis but is limited to the scroutm. It disappears when the pt lies flat but there is no cough sensation.
4. A 35 yo man with a Hx of undescended testis presents with a hard painless testicular lump. Blood tests show an elebavated beta-human chorionic gonadotrophin.
5. A 20 yo man complains of mild pain in his L testicle after playing cricket in the park. O/E the L testicle is irregular in shape to the R. He reports having and orchidopexy when he was younger.

Options from: Epididymo-orchitis, varicocele, torsion of the hyatid of Morgagni, testicular torsion, hydrocele, Mumps orchitis, seminoma, teratoma

Answer 1

1. Testicular torsion
   
   • Sudden onset pain/swelling and young age suggests torsion. This is a surgical emergency. Incidence is higher for undescended testes. Pain may be referred to abdomen as the testis retains its embryological nerve supply from T10 sympathetic pathway. Irreversible damage occurs within 6-12 hrs. To differentiate from epididymitis: in torsion, pain NOT relieved by elevating the twisted testis (-ve Prehn’s sign), and also in torsion the affected testis usually lies higher in the scortu.
2. Hydrocele
   
   • =abnormal collection of fluid in tunica vaginalis. making the testis impalpable. Primary occur in older men, develop slowly and are painless. Secondary may be to tumours/inflammation of underlying testes and epididymis. Characteristically they transilluminate brightly.
3. Varicocele
   
   • =Collection of varicose veins in the pampiniform plexus (venous network that drains testicle). Pts present with scrotal swelling that is visible on standing and feels like a ‘bag of worms’. L>Rside. May occur secondary to obstruction of L testicular vein by a renal adenocarcinoma.
4. Seminoma
5. Teratoma
   
   • [4+5] There are 2 types of malignant testicular tumours: seminomas (60%) and teratomas (40%). Seminomas arise from seminiferous tubules and occur in 30-40 yos whereas teratomas are germ-cell tumours which occur in 20-30 yos. They are associated with undescended testes (even after orchidopexy) and may both present as hard, irregular, painless mass or as a secondary hydrocele. They may spread to lungs and liver (via bloodstream) and to the para-aortic lymph nodes (NOT inguinal). Teratomas produce both alpha-fetoprotein (a-FP) and beta-human chorionic gonadotrophin (B-hCG), whilst seminomas only produce B-hCG.