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Genitourinary > Scrotal disease: Varicocele, Testicular torsion, Epididymal cyst + Hydrocele > Flashcards

Scrotal disease: Varicocele, Testicular torsion, Epididymal cyst + Hydrocele Flashcards

1
Q

What should you always assume about a testicular lump?

A

A testicular lump is CANCER until proven otherwise.

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2
Q

What 3 questions should you think when diagnosing scrotal masses?

A
  1. Can you get above it?
  2. Is it separate from the testis?
  3. Cystic or solid?
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3
Q

A lump that’s separate from the testicle could be:

A
  • Epidydimitis / varicocele if solid
  • Epidydimal cyst if fluid filled
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4
Q

Give 4 key causes of scrotal or testicular lumps.

A
  1. Hydrocele
  2. Varicocele
  3. Epididymal cyst
  4. Testicular cancer
  5. Epididymo-orchitis
  6. Inguinal hernia
  7. Testicular torsion
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5
Q

If a you cannot above the testicular lump, what could it be?

A

Cannot get above - Inguinoscrotal hernia or proximally extending hydrocele

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6
Q

If the testicular lump is separate & cystic, what could it be?

A

Separate & cystic - Epididymal cyst

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7
Q

If the testicular lump is separate & solid, what could it be?

A

Separate & solid - Epididymitis or Varicocele

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8
Q

If the testicular lump is testicular & cystic, what could it be?

A

Testicular & cystic - Hydrocele

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9
Q

If the testicular lump is testicular & solid, what could it be?

A

Testicular & solid - Tumour, haematocele

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10
Q

What is a varicocele?

A

Abnormal dilation/Swelling of the testicular veins in the pampiniform venomous plexus, caused by venous reflux

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11
Q

What is the pampiniform plexus?

A

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.

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12
Q

How do varicoceles form?

A

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.

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13
Q

Which side is it more common to have a varicocele and why?

A

More common on the left:

  • Right testicular vein drains directly into the inferior vena cava.
  • Left testicular vein drains into the left renal vein
  • The angle at which the left testicular vein enters the left renal vein causes increased reflux due to the renal vein being compressed.
  • Increased resistance in the left testicular vein
  • The incompetent + ineffective valves in the left testicular veins allow blood to flow back.
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14
Q

If the left scrotum is smaller, where is the varicocele?

A

Left

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15
Q

What could cause a left sided varicocele?

A

Renal cell carcinoma (RCC)

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16
Q

Describe the clinical presentation of a varicocele.

A
  • A scrotal mass that feels like a “bag of worms”
  • More prominent on standing
  • Disappears when lying down
  • Asymmetry in testicular size if the varicocele has affected the growth of the testicle (Scrotum hangs lower on the side of the varicocele)
  • Patient may complain of a dull ache or scrotal heaviness.
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17
Q

What does a varicocele classically feel like?

A

A bag of worms

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18
Q

How does a varicocele change when lying down?

A

It should disappear
If it doesn’t, there could be a retroperitoneal tumour

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19
Q

What can varicoceles cause?

A
  • Impaired fertility, probably due to disrupting the temperature in the affected testicle
  • Testicular atrophy, reducing the size and function of the testicle.
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20
Q

Diagnosis of a varicocele.

A
  • Colour doppler ultrasound (see blood flow)
  • Venography
  • Semen analysis if there are concerns about fertility
  • Hormonal tests (e.g., FSH & testosterone) for concerns about function
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21
Q

Management of varicoceles.

A
  1. No further action needed - Provide advice and reassurance.
  2. Offer semen analysis if fertility is a concern.
  3. Surgery if there is pain, infertility or testicular atrophy
22
Q

Define testicular torsion.

A

Torsion (twisting) of the spermatic cord resulting in occlusion of the testicular blood vessels - which can rapidly lead to ischaemia and infarct and thus the potential loss of the testis.

23
Q

Which cell line is most susceptible to ischaemia?

A

Germ cells

24
Q

Is testicular torsion an urological emergency or not?

A

YES!!

25
Q

Give 4 risk factors for testicular torsion.

A

Young
Trauma
Bell clapper deformity
Bicycle riding
Cryptorchidism
Large testicles

26
Q

What is a bell-clapper deformity?

A

One of the causes of testicular torsion.

Normally, the testicle is fixed posteriorly to the tunica vaginalis.

A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent.
The testicle hangs in a horizontal position (like a bell-clapper), instead of the typical more vertical position.
It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord.
As it rotates, it twists the vessels and cuts off the blood supply.

27
Q

Describe the clinical presentation of testicular torsion.

A

Presents with an acute rapid onset of unilateral testicular pain, and may be associated with abdominal pain and vomiting.
Sometimes abdominal pain is the only symptom in boys.

  • Any boy presenting with abdominal pain - the testes should be checked
  • SUDDEN onset of pain in 1 testis - makes walking uncomfortable
  • Pain often comes on during sport or physical activity
  • Pain in abdomen, nausea and vomiting are common
  • Inflammation of one testis - it is very tender, hot and swollen
  • Testis may lie high and transversely
  • With intermittent torsion, the pain may have passed on presentation - but if it was severe and the lie is horizontal, then prophylactic fixing may be wise
28
Q

Physical examination of testicular torsion.

A

Testicular torsion is often triggered by activity, such as playing sports. Ask what the patient was doing at the time when the pain started.

Examination findings are:
1. Firm swollen testicle

  1. Elevated (retracted) testicle
  2. Absent cremasteric reflex
    - The normal response is an immediate contraction of the cremaster muscle that pulls up the testis ipsilaterally (on the same side of the body).
  3. Abnormal testicular lie (often horizontal)
  4. Rotation, so that epididymis is not in normal posterior position
29
Q

What is Prehn’s sign for?
What is a positive Prehn’s sign?

A

To identify testicular torsion

Positive when lifting the testicle = relief of pain
Positive sign = epidydimitis, NOT testicular torsion

30
Q

Investigation of testicular torsion.

A
  1. Doppler ultrasound may demonstrate lack of blood flow to testis
    - Can show the whirlpool sign = a spiral appearance to the spermatic cord and blood vessels.
  2. Urinalysis to exclude infection and epididymis
  • DO NOT DELAY SURGICAL EXPLORATION
31
Q

What are the success rates of surgery depending on the time lapsed?

A

If surgery is performed in < 6hrs, the salvage rate is 90-100%.

If > 24hrs, it is 0-10%.

32
Q

Treatment of testicular torsion.

A

Surgery - a urological emergency, and there is an urgent requirement for treatment. Any delay in treatment will prolong the ischaemia and reduce the chances of saving the testicle.

  1. Orchiopexy
    - Correcting the position of the testicles and fixing them in place
    - Expose and untwist testis - 6 hour window to save testis
  2. Orchidectomy
    - Removing the testicle
    - If the surgery is delayed or there is necrosis
33
Q

Surgery for testicular torsion - preparation / management.

A

Nil by mouth, in preparation for surgery.
Analgesia as required.
Urgent senior urology assessment.
Surgical exploration of the scrotum.

34
Q

What is the main differential diagnosis for testicular torsion?

A

Epididymo-orchitis

35
Q

Give 4 conditions as differential diagnosis for testicular torsion.

A
  1. Epididymo-orchitis (MAIN ONE)
  2. Tumour, trauma and an acute hydrocele
  3. Torsion of testicular or epididymal appendage (remnant of Mullerian duct)
  4. Idiopathic scrotal oedema
36
Q

What is the difference of testicular torsion to testicular appendage torsion?

A

Torsion of testicular or epididymal appendage (remnant of Mullerian duct):
* Usually occurs in boys between 7-12yrs and causes less pain
* Small blue nodule under scrotum
* Due to the surge in gonadotrophins that signal the onset of puberty

37
Q

What is an epididymal cyst?

A

Smooth, extra-testicular, spherical cyst (fluid-filled sac) in the head of the epididymis (at the top of the testicle)

38
Q

What is an epididymal cyst filled with sperm called?

A

Spermatocele.

39
Q

Are epididymal cysts uncommon in adults?

A

No - very common in adults, occurring in around 30% of men.

40
Q

What does an epididymal cyst feel like?

A
  • Smooth
  • Feels clearly separate from testicle - well-defined
41
Q

Describe the clinical presentation of an epididymal cyst.

A

Most cases are asymptomatic.

Examination findings are:

  1. Soft, round, well-defined lump
  2. Typically at the top of the testicle
  3. Associated with the epididymis
  4. Separate from the testicle (testis is palpable quite separately from the cyst)
  5. May be able to transilluminate large cysts (appearing separate from the testicle)
42
Q

Investigations for an epidydimal cyst.

A

Scrotal Ultrasound:
- Transluminates on exam, as it is fluid filled

43
Q

Treatment of an epididymal cyst.

A
  • Usually not necessary
  • If painful and symptomatic then surgical excision
44
Q

What is a hydrocele?

A

Abnormal collection of fluid within the tunica vaginalis - between the parietal and visceral layers

45
Q

Aetiology of a hydrocele?

A

Primary hydrocele - Idiopathic - most common especially in younger men
Secondary hydrocele:
- Testis tumour
- Trauma
- Infection
- TB
- Testicular torsion
- Generalised oedema

46
Q

What are the 2 types of hydroceles?

A
  1. Simple hydrocele
  2. Communicating hydrocele
47
Q

What is a simple hydrocele caused by?

A

Overproduction of serous fluid by the mesothelium in the tunica vaginalis

48
Q

What is a communicating hydrocele caused by?

A

Processus vaginalis fails to close at birth, allowing peritoneal fluid to communicate freely with the scrotal portion

49
Q

What does a hydrocele look/feel like?

A
  • Painless soft swelling.
  • In the scrotum, above and below testicle.
  • Not reducible + no bowel sounds.
  • Transluminates by shining torch through the skin, into the fluid (the testicle floats within the fluid))
50
Q

Diagnosis of a hydrocele.

A
  1. Ultrasound
  2. Serum alpha-fetoprotein and human chorionic gonadotrophin to help
    exclude malignant teratomas or other germ cell tumours
51
Q

Treatment of unproblematic hydroceles.

A
  • Resolve spontaneously
  • Many of infancy resolve by 2 yrs
52
Q

3 management options for a large or symptomatic hydrocele?

A

Surgery
Aspiration
Sclerotherapy

Genitourinary (17 decks)

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