83. Testicular/scrotal swelling (and 74. groin swelling) Flashcards
Index conditions
a) scrotal
b) groin
a) Scrotal:
1. Inguinal hernias
2. Hydrocoele
3. Epididymo-orchitis (bacterial, viral)
4. Incompletely descended testis
5. Tesicular trauma (e.g. haematoma)
6. Varicoele
7. Epididymal cyst
8. Testicular tumours
9. Incomplete descent of testis
10. Torsion of testis
b) Groin:
1. Inguinal and femoral hernias
2. Lymphadenopathy
3. Vascular abnormalities (e.g. femoral artery aneurysm, infected injection site)
Aetiology.
a) Painful scrotal swelling
b) Painless scrotal swelling
c) Painful groin swelling
d) Painless groin swelling
a) Torsion of testis. Torsion of a testicular or epididymal appendage. Epididymo-orchitis or orchitis. Strangulated inguinal hernia. Haematocele/haematoma.
b) Inguinal hernia (may sometimes be painful). Hydrocele. Epididymal cyst. Spermatocele (feels similar to epididymal cyst but is filled with semen). Varicocele.
Testicular tumour. Skin swellings (as for groin lumps)
c) Tender lymph nodes; Strangulated femoral hernia; Psoas abscess
d) Skin swellings - e.g. epidermal (sebaceous) cyst, contact dermatitis. Non-tender nodes. Inguinal/ femoral hernia. Undescended/ectopic testis. Vascular: Femoral artery aneurysm. Saphena varix.
Associated symptoms.
a) Urethral discharge or dysuria
b) Abdominal pain, nausea and vomiting
c) Back pain, weight loss, dyspnoea
d) Parotid swelling
a) Suggests epididymo-orchitis (STI, or rarely UTI)
b) Testicular torsion.
c) Can occur with metastatic testicular cancer.
d) Mumps orchitis
Examination.
a) Tenderness
b) Consistency
c) Hernia- positive signs
d) Testicular lie
e) Cremasteric reflex
f) Left-sided ‘bag of worms’
g) Transillumination - 2 main differentials (distinguishing features?)
h) Regional areas - assess for…?
a) Torsion, epididymo-orchitis, strangulated hernia
b) Firm and solid (malignancy) vs. soft and fluctuant (cystic, hernia)
c) Reducible, cough impulse, protrudes on sit-up, cannot ‘get above’ the mass
d) Transverse/high-riding in torsion
e) Absence suggests torsion
f) Varicocele
g) Suggests cystic swelling:
- Hydrocele - surround the testis
- Epididymal cyst (spermatocele) - separate to the testis
h) Lymphadenopathy
Differential to NOT miss (1).
14 year old boy.
Sudden onset pain, referred to abdomen; may have had previous self-limiting pain episodes. Reports nausea and vomiting. Cremasteric reflex absent.
Testis elevated and lying transversely.
TORSION (time is bollock)
DDx:
- epididymo-orchitis (more likely in adults)
- torsion of testicular/epididymal appendage (blue spot)
Differential to NOT miss (2).
Man aged 30 years.
Painless and non-tender testicular swelling; descibed as a dragging sensation. On palpation, solid/firm swelling involving all or part of the testis.
a) Dx?
b) other symptoms you MUST ask about
a) Testicular cancer
b) Metastatic: back or flank pain, dyspnoea, supraclavicular lymphadenopathy, abdominal mass (enlarged para-aortic lymph nodes), weight loss.
May also have: gynaecomastia, epididymo-orchitis, or hydrocele
Differential to NOT miss (3).
45 year old with tender groin mass that disappears on lying down and is reducible, has a positive cough impulse and feels soft and fluctuant. Cannot get above the swelling. Auscultation reveals bowel sounds from the mass.
Patient has severe abdominal pain and recent constipation.
Obstructed/ strangulated hernia (more likely if femoral)
Differential to NOT miss (4).
Man aged 60 years.
Raised papule, plaque, or ulcer on the scrotal wall; purulent. Inguinal lymphadenopathy present.
Scrotal SCC - Extremely rare!
Investigations.
a) If testicular cancer clinically suspected - ?
b) If testicular cancer possible/mass unknown - ?
c) Other
d) If suspected torsion or strangulated/obstructed hernia - ?
a) 2-week wait urology; AFP and B-hCG while waiting
b) USS
c) STI screen, biopsy any persistent lymph nodes/lesions
d) Immediate surgical review
