Urology - Scrotal swelling or pain Flashcards
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.
