Scrotal lumps

Question 1

What should you ask about in the history of a scrotal lump?

Answer 1

Time of onset, associated symptoms such as pain, previous episodes

Question 2

What should inspection of the lump include?

Answer 2

The 6Ss

Site, size, shape symmetry, skin changes, scars

Question 3

When palpating the lump what should be commented on?

Answer 3

Tenderness, temperature, transillumination
CAMPFIRE
Consistency, attachments, mobility, pulsation, fluctuation, irreducibility, regional lymph nodes and edge
Also palpate the testis, epididymis and vas deferens

Question 4

What investigations would you do for someone with a scrotal lump?

Answer 4

Ultrasound scan of the scrotum

blood tests and further imaging

Question 5

Why would you not take a biopsy for testicular cancer?

Answer 5

seeding

Question 6

How is a diagnosis of testicular cancer made?

Answer 6

clinical features, ultrasound, histopathological examination of the testis after a orchidectomy

Question 7

What blood tests are done for testicular cancer?

Answer 7

testicular tumour markers- lactate dehydrogenase (LDH), alpha fetoprotein (AFP) and beta-human chorionic gonadotrophin (beta hCG)

Question 8

How would you assess for widespread pulmonary metastasis in testicular cancer?

Answer 8

Chest radiograph

Question 9

How would you assess for metastasis of the para-aortic lymph nodes and further?

Answer 9

CT Scan of the chest- abdomen- pelvis

Question 10

How can scrotal lumps be classified?

Answer 10

Testicular or extra-testicular

Question 11

What are the extra-testicular scrotal lumps?

Answer 11

Hydrocoele
Varicocoele
Epididymal cyst 
Epididymitis
Inguinal hernia

Question 12

What are the testicular scrotal lumps?

Answer 12

Testicular tumours
Orchitis
Testicular torsion

Question 13

What is a hydrocoele?

Answer 13

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

Question 14

What are the clinical features of a hydrocoele?

Answer 14

Painless
Fluctuant swelling
transilluminates
Unilateral or bilateral

Question 15

What is a congenital hydrocoele?

Answer 15

effects up to 3% of male neonates and regress spontaneously by 1 or 2 years old, in infants they are caused by patent processes vaginalis which required ligation to stop recurrence

Question 16

What transilluminates?

Answer 16

Fluid, solids will not

Question 17

What can cause hydrocoeles in older males?

Answer 17

trauma, infection, malignancy

Question 18

What is a varicocoele?

Answer 18

abnormal dilatation of the pampiniform venous plexus

Question 19

What does a varicocoele look like?

Answer 19

A bag of worms with a dragging sensation that may disappear when lying flat

Question 20

In what positions should you examine a varicocoele?

Answer 20

Standing up, lying down and valsalva manoeuvre

Question 21

Which side do varicocoeles usually present?

Answer 21

The left side as drains directly into the left renal vein rather than the inferior vena cava

Question 22

What are the complications of a varicocoele?

Answer 22

infertility, testicular atrophy due to increase in intra-scrotal temperature so should get a seman analysis

Question 23

What are the red flag signs with a varicocoele?

Answer 23

acute onset, ride sided or remain when lying flat, should examine abdomen as may be due to renal tumour

Question 24

What is the management?

Answer 24

If asymptomatic then no treatment needed, or ligation of spermatic veins and embolisation

Question 25

What is an eididymal cyst?

Answer 25

benign fluid filled sacs arising from the epididymis

Question 26

How do epididymal cysts present?

Answer 26

smooth fluctuant nodule found above and separate from the testis that will transilluminate, ca be multiple

Question 27

What is the treatment for epididymal cysts?

Answer 27

usually do not need treatment as no association with malignancy and rarely have symptoms, operating may cause infertility

Question 28

What is epididymitis?

Answer 28

Inflammation of the epididymis

Question 29

What is the presentation of epididymitis?

Answer 29

unilateral acute onset scrotal pain, associated swelling, redness, fever, tender and pain which is received by elevation of the testis (prehns sign)

Question 30

What is the treatment of Epididymitis?

Answer 30

usually bacterial in origin e.g. STI or enteric organisms so oral antibiotics and analgesia will help

Question 31

How do inguinal hernias pass into the scrotum?

Answer 31

External ring

Question 32

How can you examine an inguinal hernia?

Answer 32

you cannot get above an inguinal hernia within the scrotum (can not palpate its superior surface) , a cough may exacerbate the swelling, may disappear when lying flat

Question 33

How would testicular cancer present?

Answer 33

Painless lump arising from the testis | Firm irregular mass that does not transilluminate

Question 34

How would you diagnose testicular cancer?

Answer 34

urgent ultrasound scan and tumour markers

Question 35

How is testicular cancer treated?

Answer 35

Radical inguinal orchidectomy and chemotherapy- 90% five year survival rate

Question 36

What is orchitis?

Answer 36

inflammation of the testis

Question 37

What causes orchitis?

Answer 37

usually mumps

Question 38

what is orchitis usually paired with?

Answer 38

Epididymitis | Epididymo-orchitis

Question 39

What is a complication of orchitis?

Answer 39

Intra- testicular abscess

Question 40

What is testicular torsion?

Answer 40

Twisting of the testis on the spermatic cord causing ischaemia

Question 41

How does testicular torsion present?

Answer 41

Sudden onset very severe unilateral scrotal pain with nausea and vomiting, tender, raised and swollen testis with a loss of cremasteric reflex

Question 42

What increases incidence of testicular torsion?

Answer 42

Bell clapper deformity | high attachment of tunica vaginalis allowing rotation

Question 43

What is the treatment for testicular torsion?

Answer 43

surgical emergency so scrotal exploration and fixation must occur, salvage rates decline after 6 hours

Question 44

What are some examples of benign testicular lesions?

Answer 44

Leydig cell tumours, sertoli cell tumours and lipomas or fibromas