Scrotal Masses & Inguinal Hernias, part 2

Varicocele

-Dilation of the veins above the testis -Left side prominent and found in 15% men -Most common cause of male infertility -Cause is poorly understood -Typically asymptomatic -With palpation, they are spongy (bag of worms) -Does not transluminate -Increases in size when standing/valsa maneuver -Ultrasound -Urology referral

Hydrocele Treatment

-Most resolve spontaneously over time -No treatment needed if normal testicle, patient is asymptomatic and non-communicating (in just one scrotal sac) -Ultrasound -Refer to urology if symptomatic or communicating or if unsure

Hydrocele

-Presence of fluid within the tunica vaginalis -Occurs in all age groups -Size varies but larger than most lesions -Transilluminates -Discerns solid from cystic mass -Etiology really unknown -Mostly benign, however 10% of testicular tumors concurrent with hydrocele -

Testicular CA risk factors

-Risk Factors include cryptorchidism, FH, tobacco use, the white race and infertility. -Testicular cancer caused by cryptorchidism is decreasing with earlier surgical intervention. -Having a brother with testicular cancer increases the patient's risk by 6 to 10 fold. -Smoking doubles a man's risk of testicular cancer, and this increased risk may not improve with smoking cessation. -In the US, Caucasians develop testicular cancer at a rate 4 times that of African Americans.

Inguinal Hernia

-Soft tissue protruding through the lower abdominal wall -Can be painful when coughing, heavy lifting -Can be benign or be life-threatening -Pt's may c/o "a heavy sensation in the groin" -Pain & swelling may present in the scrotum and around the testicles when the protruding intestine descends into the scrotum

Testicular CA

-Testicular Cancer is rare but it is also the most common malignancy in young men between the ages of 15-35 y/o. -Differential diagnosis between tumor, torsion, and epididymitis can be difficult.

Testicular CA dx

-The key to the diagnosis is the identification of a distinct hard nodule or nodules on the affected teste. -The typical presentation that we expect is that of a patient who presents with a discrete painless mass on the testicle. -The most common presenting feature is testicular swelling in 73% of men, with testiculr pain in 18-46% of cases. -Some patients c/o scrotal heaviness and firmness of the affected testicle. -Some men have symptoms identical to epididymitis; if your patient fails to respond to treatment of epididymitis, another diagnosis should be considered and the patient should be reassessed for testicular cancer.

Testicular Cancer Dx and screening

-To make the diagnosis, the patient needs a Scrotal Doppler Ultrasound. -If you find a mass, it is best to refer to urology. They can do the US and then they have to perform further diagnostic tests like a CT of the chest, abdomen, and pelvis to evaluate for metastasis. -Routine screening for testicular cancer in asymptomatic men has not been shown to reduce mortality. As a result, the US Preventative Services Task Force and the American Cancer Society recommend against routine screening by patients or clinicians.

Cryptorchidism

-Undescended testicle into the scrotum -Typically congenital defect -Testes should be palpated on all well-baby exams -Diagnosed on physical exam -If found, consult -Treatment is surgical -Infertility major complication -Testicular Cancer well-established complication

Hydrocele pic

-Will not know if this swelling is fluid filled or a solid mass unless you try to transilluminate it. -When you do, the light will shine straight through the mass and that will give you the diagnosis of a fluid filled cyst. - These lesions are also typically not painful.

Inguinal Hernia Causes and Types

Causes: -Increased pressure within the abdomen -A pre-existing weak spot in the abdominal wall Incarcerated Hernia -Serious complication -Intestine gets "trapped" -Can lead to a small bowel obstruction (SBO) Strangulated Hernia -Serious condition which can cause a diminish blood flow to the trapped portion of the intestine -Can lead to a bowel infarct which is life-threatening -Requires immediate referral to surgery