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YA - Interactive seminars/University lectures > MISC - Common Px of testicular & scrotal disease > Flashcards

MISC - Common Px of testicular & scrotal disease Flashcards

1
Q

22yo man, 1 week Hx of a painless lump in his scrotum.

DDx?

A

Testicular cancer
Epididymorchitis
Hydrocoel
Varicoceal (dilation of venous plexus)

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2
Q

Risk factors for testicular cancer

A

Cryptochordism (mal-descended testes): missed in 20-30%

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3
Q

Risk factors for epididymorchitis

A
  • STI

- UTI

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4
Q

How do you examine for varicoceal?

A
  1. Stand up to aid with gravity
  2. Cough/Valsalva manoeuver

The valves are incompetent in varicoceal.

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5
Q

What tumour markers do testes secrete?

A

alpha-fetoprotein
beta hCG
LDH

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6
Q

Ix for testes

A

US (best)

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7
Q

Describe physical exam for the scrotal/testicular disease

A

Focused scrotal exam:

  • inspection: erythema, oedema, transillumination
  • palpation: size, shape, position, consistency, tenderness

General:

  • abdo: masses, hernia, liver, spleen
  • lungs: effusion, consolidation
  • lymph nodes
  • neuro if necessary
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8
Q

Where do testicular cancers metastasise to?

A

Lymph nodes: retroperitoneal (lymphatics follow the vascular supply, for which the testicles, they come from high up where they developped)

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9
Q

Which testicular cancer does not produce tumour markers?

A

Seminomas usually do not produce tumour markers but sometimes produces a low level of beta hCG

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10
Q

How does “can get above it” differentiate your diagnosis in scrotal mass?

A

Can hold above scrotum near inguinal ligament: indicates that the mass origin is intrascrotal. e.g. hydrocoel

Cannot hold above scrotum near inguinal ligament: indicates that the mass origin is ABOVE scrotum. e.g. inguinal hernia.

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11
Q

Classify scrotal conditions:

  • (5) benign intrascrotal
  • (3) malignant intrascrotal
  • (3) extrascrotal
A

Intrascrotal - Benign:

  • hydrocoele
  • epididymal cyst
  • varicocoele
  • benign tumour
  • idiopathic scrotal oedema

Intrascrotal - malignant:

  • testicular cancer
  • lymphoma
  • other

Extrascrotal:

  • inguinal hernia
  • ascites
  • generalised oedema
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12
Q

Scrotal lump is [what] until proven otherwise

A

Testicular cancer

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13
Q

What are the investigations of choice for testicular cancer?

A

Urgent scrotal US & tumour markers (alpha-fetoprotein, LDH, beta hCG)

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14
Q

Where do testicular cancers metastasise first to?

A

Retroperitoneal lymph nodes & chest (mediastinal LN & lungs)

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15
Q

Describe the clinical syndrome of the acute scrotum. What are its possible causes?

A

New onset scrotal pain +/- swelling, tenderness, erythema

MANY causes. Sources include appendage torsion, spermatic cord torsion, epididymitis, scrotal edema/erythema, orchitis, trauma, hernia/hydrocoele, varicocele, intrascrotal mass, other.

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16
Q

Discuss acute torsion of the spermatic cord

  • (2) types
  • (2) predisposing factors
  • Px
  • Rx
A

•Types
–Intravaginal
–Extravaginal (neonates)

•Predisposing factors
–Cryptorchidism
–Bell clapper deformity

•Clinical
–Most common 12-18 yrs
–Acute onset severe pain
–+/- swelling
–+/- precipitating event
–N&V
–Early presentation

Rx: fixation +/- dartos pouch

17
Q

What are the possible findings on examination of spermatic cord torsion?

A 
–Tender firm testicle
–High-riding testicle
–Horizontal lie
–Absent cremasteric reflex
–No pain relief with elevation
–Thickened spermatic cord
–Epididymis not posterior to testis
18
Q

When should you perform an ultrasound or not in acute scrotum?

A

If probable torsion or high index of suspicion for it, EXPLORE (not US)

If confident it is not torsion & low index of suspicion for it, US to ‘rule out’ torsion & establish Dx.

19
Q

Describe torsion of testicular appendage

A
  • Appendix testis/epididymis
  • Most common cause of acute scrotum in pre-pubertal boys!!
  • Localised pain/tenderness superior pole of testis
  • Usually less severe
  • ‘Blue-dot’ sign
  • Conservative management (NSAIDs)
20
Q

Describe epididymitis/epididymo-orchitis

  • onset
  • Px
  • RFs
  • Ix
A 
•More insidious onset
•Gradually worsening pain
•?Urethritis / discharge
•?irritative LUTS
•RFs: IDC, chronic retention , structural abnormality, instrumentation
•PE
–Swelling / tenderness
–Fever
–Hydrocoele
•Ix:
–U/A and MSU
–Urine / urethral swab for PCR
–USS
21
Q

What are the causes of epididymitis/epididymo-orchitis?

A

Bacterial:

  • men less than 35yo: (STIs) Neisseria Gonorrhoae, Chlamydia trachomatis
  • men >35yo: E. coli, other GNBs

Viral: mumps, Coxsackie
Granulomatous: TB, BCG

Non-infective:

  • Autoimmune: Behcet’s
  • Drug: Amiodarone
  • Testicular tumour
22
Q

What are the treatments of epididymitis/epididymo-orchitis?

A 
•Elevation
•Analgesia
•Empiric ABs
•GNB coverage
–Trimethoprim / cephalexin /augmentin / norfloxacin x 2/52
–Amp & gent
•STI coverage
–Ceftriaxone 500 mg IM OD x 3/7 & azithromycin 1 g PO stat & doxycycline 100 mg BID x 2/52 (or second PO dose pf azithromycin at 1 week
•Resolution
–Pain in 2-3/7
–Swelling ~months
•Failure to resolve
–Resistance?
–Complication? (USS)
–Tumour??? (USS)
•Follow-up
–STI screen and contact tracing etc.
–If UTI -> urology
23
Q

Discuss blunt testicular trauma

  • Px
  • Mx
A
  • Contusion -> fracture-dislocation
  • CFs: pain, swelling, bruising, haematocoele
  • ?urethral injury
  • ?tunica albuginea intact
  • Tx: early exploration (within 72 hours!)
24
Q

Acute scrotal swelling/pain in young boys is [what] until proven otherwise.

A

Testicular torsion

25
Q

Px of testicular torsion

A
  • Pain
  • Diffuse tenderness
  • Horizontal lie of testicle
  • Absent cremaster reflex, negative Prehn’s sign
26
Q

Px of epididymitis

A
  • pain
  • epididymal tenderness
  • present cremasteric reflex
  • positive Prehn’s sign
27
Q

Px of orchitis

A
  • pain
  • diffuse tenderness
  • present cremaster reflex
  • positive Prehn’s sign
28
Q

Px of haematocele

A
  • Pain
  • diffuse tenderness
  • NO transillumination
29
Q

Px of hydrocele

A
  • NO pain
  • testis NOT separable from hydrocele
  • palpable cord
  • transillumination
  • hx of trauma

I.e. transillumination only in hydrocele + spermatocele.

30
Q

Px of spermatocele

A
  • NO pain
  • testis separable from spermatocele
  • cord palpable
  • transillumiation
31
Q

Px of varicocele

A
  • NO pain
  • ‘bag of worms’
  • NO transillumination
  • increases in size with Valsalva & decreases in size if supine
32
Q

Px of indirect inguinal hernia

A
  • NO pain (but yes if strangulated)
  • testis SEPARABLE from hernia
  • cord not palpable
  • cough impulse may transmit
  • may be reducible
  • no transillumination
33
Q

Px of tumour of testis

A
  • NO pain (but yes if haemorrhagic)

- hard lump/nodule

34
Q

Px of generaslied/dependent oedema in testis

A
  • NO pain
  • diffuse swelling
  • often post op or immobilised. check for liver dysfunction

YA - Interactive seminars/University lectures (87 decks)

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