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Flashcards in Urology - Scrotal swelling or pain Deck (40)
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What are the most common swellings in young males?

Torsion is common in adolescence and in the early twenties, and although not a swelling should be considered in cases of testicular pain.

Tumours, trauma and acute infections are common.


What are the most common swellings in old men?

Hydrocele and hernias are most common.


What is the most likely cause of a swelling on the scrotum?

This is most likely to be a sebaceous cyst. They are normally attached to the skin, just fluctuant and do not transilluminate.

In a child this may also be infantile scrotal oedema. Acute idiopathic scrotal swelling presents with hot, tender, bright red testicles. Tenderness is less than in torsion and is commonest in young boys. The key distinguishing feature between this and torsion is that the child is normally not bothered by the swelling. It tends to resolve over 48-72 hours.


What classically causes a testicular lump that you "cannot get above" during examination?

This is most likely to be an inguinoscrotal hernia.


What are the distinguishing features of an epididymal cyst?

The key features of an epididymal cyst is that it is separate to and behind the testes (posterior, superior), it is possible to get above the swelling thus distinguishing it from an inguinoscrotal hernia, and the swelling is cystic and thus transilluminates and fluctuant.

Along with hydroceles and varicoceles they are one of the "soft" testicular conditions.


How are epididymal cysts managed?

They are usually frequent and multiple and may be bilateral. Although usually painless they are sometimes tender. They are confirmed by ultrasound and is not usually removed unless they are symptomatic.


What are spermatoceles?

Spermatoceles are a subtype of epididymal cyst that contain milky fluid rather than the usual clear fluid. But it is only possible to make this distinction following removal or aspiration of the cyst, so it is best to avoid using the term spermatocele.


What is a varicocele? When are the visible?

A varicocele is a collection of dilated and tortuous veins in the spermatic cord - it is often referred to as a "bag of worms" on examination and patients report a dragging sensation. There can occasionally be haematospermia.

Importantly, the veins should be empty when the patient lies down so a varicocele will only be palpable if the patient stands up.


Why are varicocele's most common on the left?

This is due to the anatomy of the venous drainage of the left testicle. The left pampiniform plexus drains into the renal vein, whereas the right drains directly into the IVC.


What can a sudden left sided varicocele indicate?

Patients who develop a sudden left sided varicocele should be investigated for renal masses. A tumour extending into the renal vein can obstruct venous return from the left testes and thus cause a varicocele. The most likely tumours are a clear cell carcinoma in adults and a nephroblastoma in children.


How should a scrotal lump be examined?

Remember to think SSS,CCC, TTT
- Site, size, shape
- Colour (any overlying skin changes), contour, consistency (i.e. hard or soft)
- Temperature (may indicate infection), tenderness, transillumination (only fluid filled masses - i.e. hydroceles and cysts - will transilluminate)


What are the features of a hydrocele?

Hydroceles are a collection of fluid within the tunica vaginalis. The key features on examination are that there is fluid (and hence the lump is fluctuant) surrounding the testes and thus it is not possible to palpate the testes separately. They also transilluminate and can reach considerable size.


What is the difference between primary and secondary hydroceles?

Primary hydroceles are idiopathic.
Secondary hydroceles are secondary to trauma, infection or testicular cancer. Secondary hydroceles usually present in men in their 20s to 40s as this age group is most susceptible to the mentioned pathologies.


What hard and painless lumps can occur in the testes?

Hard and painless lumps are going to be tumours, syphilis or tuberculosis, and haematomas.


What are the features of testicular tumours?

The key feature on examination is that they are painless, firm swellings. They may have a lax secondary hydrocele and are associated with abdominal lymphadenopathy. This is really important, testicular cancer will spread via the lymphatics to the para aortic lymph nodes NOT the inguinal nodes so it is important to palpate the abdomen in suspected cases.


What is a syphilitic gummata?

This is another hard and painless testicular lump. It is firm a rubbery and usually associated with other features of secondary syphilis. TB can also produces a firm non painful swelling of the testes. It is uncommon outside the developing world and is usually associated with miliary disease.


What are the features of a haematocele?

Just like a hydrocele, this is a collection of fluid (this time blood) outside the testes which are often difficult to palpate. The difference being that a haematocele will not transilluminate. There is usually a history of trauma.


What is testicular torsion?

Torsion is where there is rotation of the testes on the spermatic cord that compromises the arterial blood supply. It is usually characterised by rapid onset in young, pubertal males. Torsion is a urological emergency and the testes can usually be saved if surgery is performed within 6 hours of symptom onset - ischemia is time dependent.


What is torsion of the hydatid or Morgagni? What are the signs?

The hydatid or Morgagni is the appendix testes and is an embryological remnant of the upper pole of the testes. Early signs are a lump on the upper pole of the testes and a blue spot on transillumination. Later the whole testes becomes swollen and exploratory surgery may be required to rule out full torsion.


What is the most common cause of testicular torsion?

There are 2 types of testicular torsion - intra-vaginal and extra-vaginal. Intra-vaginal torsion affects males of any age but most commonly adolescent boys. Extra-vaginal torsion affects neonates in the perinatal period and is a rare disease.

The "bell clapper" abnormality is the most common anatomical defect associated with development of intra-vaginal torsion. This is where there is investment of the tunica vaginalis on the cord. Other aetiologies include trauma.

The exact aetiology of extra-vaginal torsion is unknown and no anatomical defect can usually be found.


When torsion is repaired why are both testes operated on even if only one is affected?

The contralateral testes is fixed to the posterior wall to prevent asynchronous bilateral testicular torsion.


What organisms most commonly cause orchitis?

Orchitis is inflammation of the testes. It can be caused by viruses or bacteria.

Viral causes - mumps, glandular fever (EBV)
Bacteria - coliforms (e.g. E.coli, Klebsiella), chlamydial

The swelling is usually confined to the testes.


What is epididymo-orchitis? What agents usually cause it?

Epididymo-orchitis is inflammation of the epididymis and testes which are painful and swollen. There is associated erythema, fever and pyuria and the pain is usually relieved by elevating the testes (Phren's test).

The causative agent is age dependent. <35 it is most likely to be an STI caused by either Neisseria or chlamydia. >35 cases are most commonly caused by non sexually transmitted infections such as E.coli and enteroccocus feacalis (coliforms).

Rare causes of epididymitis include:
- reversible sterile epididymitis with the drug amiodarone
- association with vasculitis - esp. Bechets and HSP


How is epididymo-orchitis treated?

The management approach to epididymo-orchitis is as follows:
- symptomatic relief (bed rest, scrotal elevation and anglesia)
- antibiotic therapy if infection is present (patients may have signs of a systemic infection - e.g. fever, raised WCC)
- prevention of transmission to others
- prevention of complications (e.g. testicular abscess, infertility, chronic pain etc)

Empirical antibiotic therapy differs depending on the age of the patient. Patients <35 with suspected STI related epididymitis should be treated with ceftriaxone and doxycycline (this is to cover both gonococcal and chlamydial causes).

Cases in >35s where coliforms are suspected should be treated with a quinolone (e.g. ciprofloxacin). Because of high resistance rates, quinolones are not recommended for sexually transmitted cases.


What are essential investigations for patients wth scrotal swelling?

- FBC: infection
- ultrasound: painless, and has a high sensitivity and specificity for certain pathologies such as tumours
- doppler ultrasound: may confirm presence of blood flow where torsion is thought unlikely
- CT scan: staging for testicular tumours
- Surgery


In what age groups are testicular tumours most common?

Testicular cancer is most common between the ages of 20-40. It is the commonest solid tumour in young males.


What is the aetiology of testicular tumours?

Cryptorchidism is an important risk factor. It is associated with a 50 fold increase in risk of developing testicular cancer. Significantly, risk is unaffected by orhcidoplexy.

There is also a higher incidence in white men.


What are the 3 types of testicular tumour? What markers are associated with each?

1) Germ cell tumours (90%) - these secrete AFP and B-HCG
- seminoma - secrete placental alkaline phosphate
- non-seminomatous germ cell tumours - embryonal carcinoma, teratocarcinoma, choricarcinoma (types of teratoma)

2) Stroma tumours
- Leydig cell
- Sertoli cell
- Granulosa cell

3) Metastatic tumours


What are the macroscopic and microscopic features of seminomas?

Macroscopically the tumour is well circumscribed, pale, and creamy white. Necrosis and haemorrhage are rare unless the tumour is very big. Seminomas are malignant tumours and tend to spread via lymphatics, initially to para aortic lymph nodes.

Microscopically, the tumour consists of sheets of uniform cells with clear cytoplasm and a round central nucleus. These clusters of cells are separated by fine lines of fibrous septa which are usually infiltrated by small lymphocytes.


What are the macroscopic and microscopic features of non seminomatous teratomas?

Teratomas are the second most common type of germ cell testicular tumour. Macroscopically, the testes are heterogenous, haemorrhagic and soft in contrast to seminomas.

Microscopically, most teratomas are immature consisting of fetal type tissues such as cartilage, poorly differentiated epithelial structures (such as glands) and primitive mesenchyme.

There are different grades of teratomas which are identified based on their degree of differentiation. The more undifferentiated the tumour the more likely it is to metastasise.


Do teratomas and seminomas affect the same age groups?

No. Teratomas tend to affect younger men aged between 20-30 whilst seminomas affect older men over 40.

Think of the mnemonic "troops and soldiers" to remember this.


How are testicular tumours staged?

Stage I: confined to the scrotum
Stage II: spread to retroperitoneal lymph nodes below the diaphragm
Stage III: distant metastases


How do testicular tumours spread?

Germ cell tumours (seminomas and teratomas) metastasise to para-aortic lymph nodes, lung and brain.

In contrast, stroma tumours rarely metastasise.


What are the clinical features of testicular tumours?

Most tumours regardless of the type will present as a painless, hard, swelling of the testes. They are often discovered accidentally or after trauma. Examination reveals a hard, irregular, non tender testicular mass.

Bleeding into the tumour may mimic acute torsion.


What serum markers are associated with testicular tumours?

AFP and HCG are usually normal in seminomas. They are raised in teratomas and yolk sac tumours.

Lactate dehydrogenase is raised in 10-20% of seminomas.


Investigations in testicular cancer?

- Bloods: for tumour markers
- Scrotal ultrasound: diagnosis
- Chest X ray to assess lungs and mediastinum: metastases
- CT scan of chest and abdomen: to detect lymph nodes
- Laparoscopy: to assess abdominal lymph nodes


How are testicular tumours managed?

First line treatment is radical orchidectomy (via groin incision) and histological diagnosis. Further treatment depends on staging and histology.

Stage I: radiotherapy to abdominal lymph nodes (?)
Stage II: radiotherapy to abdominal lymph nodes
Stage III: chemotherapy (bleomycin, etoposide, cisplatin)

Stage I: RPLND - retroperitoneal lymph node dissection
Stage II: chemotherapy + RPLND
Stage III: chemotherapy (+ RPLND if good response)

NB - bleomycin can lead to rare but potentially serious pulmonary toxicity


How is relapsing seminoma or teratoma treated?

Unlike other cancers, patients with relapsed testicular cancer are often cured with second line chemotherapy regimes. The VeIP regime is often used for patients with good prognostic factors, such as low tumour markers, and a complete response to first line therapy:
- vinblastine
- ifosfamide
- mesna
- cisplatin

If a patient has poor prognostic factors then a regime with etoposide and carboplatin is used.


What is the prognosis of testicular cancer?

Overall cure rates are over 90% and node negative disease has almost 100% 5 year survival. Seminomas have a slightly better prognosis than teratomas


What would (i) continually elevated tumour marker levels after orchidectomy and (ii) rising levels during the post operative follow period?

(i) Presence of a metastatic tumour
(ii) Evidence of growth of previously undetected metastases