Scrotal Mass

Testicular swelling and pain with scrotal wall erythema and a reactive hydrocele.

Physical Exam epididymo-orchitis

Non-tender/tender swollen scrotum on 1 or both sides which feels like a water-filled balloon.

Physical Exam hydrocele

Mass palpated in inguinal canal Non-tender if not strangulated or incarcerated Enlarges with Valsava or standing

Physical exam of hernia

Color Doppler Ultrasound

Transverse power Doppler image of both testes illustrates an enlarged, avascular left testicle due to torsion.

Testicular Torsion and Epididymitis are most common in who?

While more common in neonates and postpubertal boys, Testicular Torsion and Epididymitis are the most common causes of acute scrotal pain in adults

Cremasteric Reflex

While observing the ipsilateral testis, gently stroke or pinch the skin of the upper thigh. A normal response is cremasteric contraction with elevation of the testis. The reflex is usually absent in patients with testicular torsion but present in patients with Epididymitis and other causes of scrotal pain³

Reactive hydroceles

due to inflammatory etiologies can produce an acute reactive hydrocele.

Distinction between a spermatocele and an epididymal cyst

epididymal cystic masses that are larger than 2 cm are called spermatoceles (and are usually filled with sperm)

- 9 Male : 1 Female ratio - Higher incidence 40-59 yo

Inguinal hernia

Indicates no pain relief with lifting the affected testicle, which points towards testicular torsion . In fact, raising the testicle may increase the pain associated with torsion.

Negative Prehn's sign

- Firm, non-tender mass on testis

Physical exam of malignancy

The physical lifting of the testis relieves the pain of epididymitis but not pain caused by testicular torsion

Positive Prehen's Sign

If severe testicular pain must rule out what?

Testicular Torsion

Urological Emergency

Testicular torsion

Painful non-traumatic sudden onset Scrotal mass

Testicular torsion Appendage Torsion

Painful Scrotal Mass

Testicular torsion Appendage Torsion Epididymitis Epididymoorchitis

A remnant of the Mullerian duct present on the upper pole of the testis.

appendix testis

Initial choice to diagnose testicular cancer

scrotal ultrasound

Scrotal Ultrasound

show cystic structure on head of epididymis clearly separate from testis.

Testicular Torsion History

- Acute onset of severe, unilateral scrotal pain - Associated nausea, vomiting, scrotal swelling

Physical Exam Testicular Torsion

- High riding testicle in transverse lie -Very tender to palpation -Enlargement and edema of testicle and scrotum - Absent cremasteric reflex

Treatment for scrotal ultrasound

- Orchiectomy - Chemotherapy - Radiotherapy - Fertility preservation

Tumor markers for scrotal ultrasound

- beta-HCG (beta subunit of Human Chorionic Gonadotropin - AFP (Alpha Fetoprotein) - LDH (Lactate Dehydrogenase)

Symptoms can range from no symptoms to testicular pain and swelling with urinary tract symptoms

Epididymitis --> Epididymo-orchitis

Causes Epididymitis --> Epididymo-orchitis

Causes Usually an infectious etiology -Acute bacterial epididymitis (< 6 weeks) -Chronic bacterial epididymitis ( ≥ 6 weeks) Can be noninfectious - trauma, autoimmune disease

Diagnosis of Epididymal cyst

Clinical diagnosis Scrotal Ultrasound

Diagnosis Epididymitis --> Epididymo-orchitis

Clinical diagnosis Urine studies - confirmatory -Urinalysis -Urine culture -If urethral discharge, send for culture and nucleic acid amplification testing for chlamydia and gonorrhea. Testicular ultrasound - rule out Testicular torsion.

Epididymal cyst definition

Collection of fluid anywhere in the epididymis, but usually in the head of the epididymis.

Hydrocele definition

Collection of parietal fluid between the layers of the membrane (tunica vaginalis) that surrounds the testis or along the spermatic cord (HYDROCELE of CORD).

Present with Epididymitis, but NOT with Testicular torsion.

Cremasteric reflex

Treatment of varicocele

Dependent upon maintaining fertility and relieving pain

Usually by History & Physical Ultrasound may be required if diagnosis uncertain.

Diagnosis of Inguinal Hernia

Develop medial to the inferior epigastric vessels

Direct hernia

Painless Scrotal Mass

Epididymal Cyst Spermatocele Hydrocele Varicocele Inguinal Hernia Testicular malignancy

Smooth, round, non-tender cystic mass on epididymis

Epididymal cyst

Usually asymptomatic Incidental finding by patient or doctor

Epididymal cyst

Transilluminates painless scrotal mass

Epididymal cyst spermatocele Hydrocele

Painful non-traumatic gradual onset onset Scrotal mass

Epididymitis Epididymo orchitis

Most common cause of scrotal pain in adults in outpatient setting

Epididymitis --> Epididymo-orchitis

Physical Exam: A distinctly swollen, indurated, and tender epididymis distinct from the testis.

Epididymitis --> Epididymo-orchitis

Heaviness or dull discomfort Bulge in groin or scrotum Painful if incarcerated or strangulated

History of inguinal hernia

-Usually presents as a nodule or a painless swelling or mass of one testicle.

History of testicular malignancy

Common in male infants and the newborn. Most pediatric hydroceles are congenital and resolve within the first year of life.

Hydrocele

May occur in adult men. Can be idiopathic or inflammatory due to minor trauma, scrotal surgery, infection, epididymitis, testicular torsion or testicular tumor.

Hydrocele

History of Hydrocele

Idiopathic Reactive

Testicular Torsion Treatment

Immediate surgical exploration with intraoperative detorsion and fixation of the testes. Manual detorsion is performed if surgical intervention is not immediately available. -Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting outward and laterally. -Rotation of the testicle may need to be repeated 2-3 times for complete detorsion and to provide pain relief to the patient. -Pain relief is your guide for successful detorsion.

-Most common -Develop at internal ring lateral to inferior epigastric artery

Inguinal hernia

7 attributes of symptoms

Location - where on the body?: testicle, scrotum Quality: painful, hard/solid, soft/cystic, size, enlarging Quantity: wax/wane Onset/Timing: sudden, gradual, trauma Setting: standing, laying, straining Better or worse: Valsava Associated manifestations: abdominal pain, nausea, vomiting, dysuria, fever

Testicular malignancy

Most common solid tumor in men between the ages of 18 and 40. Most palpable testicular tumors in adults are malignant. Histologic classification is complex: Germ cell tumors (>90%)

Orchitis

Mumps orchitis is the most common viral etiology, occurring 20-30% of men with mumps.

Epididymal cyst Treatment

Reassurance and rarely surgery for Spermatocele causing chronic pain.

Diagnosis of Varicocele

Scrotal Ultrasound If diagnosis uncertain, ultrasound should be performed to rule out underlying cancer

Hydrocele diagnosis

Scrotal Ultrasound If diagnosis uncertain, ultrasound should be performed to rule out underlying cancer

Swelling of the skin means what?

Sebaceous cyst R/O Squamous cell carcinoma

Treatment of hydrocele

Surgical excision of the hydrocele sac. Simple aspiration unsuccessful due to rapid reaccumulation of fluid. If asymptomatic ( no pain or pressure), can follow clinically.

Treatment of Diagnosis Epididymitis --> Epididymo-orchitis

Surgical exploration - if severe epididymitis and testicular pain. Parenteral antibiotics - acutely febrile with sepsis Outpatient oral antibiotics, ice, and scrotal elevation - less severe cases.

Treatment of Inguinal Hernia

Surgical repair -Open procedure -Laparoscopic Watchful waiting -Patient needs to be aware of the risk of incarceration and strangulation

What is contained within the scrotum

Testes Epididymis vas deferens veins (pampiniform plexus) paratesticular tissue & spaces

"blue dot" sign in the skin of the scrotum may be seen due to infarction and necrosis of the appendix testis.

Torsion of the appendix testis

The leading cause of scrotal pathology in childhood. Most cases occur between 7- 14 years of age.

Torsion of the appendix testis

pathology physiology of testicular torsion

Torsion of the testicle results from twisting of the spermatic cord, which then compromises the blood supply. The resulting ischemia can lead to changes in testicular morphology, sperm formation, and even necrosis with complete testicular loss.

Abnormal dilation of the internal spermatic veins and pampiniform plexus that drain the testis. Present in 15-20% of post-pubertal males Left-sided predominance due to anatomy Unilateral right-sided varicoceles are very rare and should raise suspicion of inferior vena caval obstruction Common cause of infertility

Varicocele

Does not Transilluminate painless scrotal mass

Varicocele Inguinal Hernia Testicular malignancy

Many are asymptomatic. May have dull aching scrotal pain more noticeable when standing and relieved by recumbency. Testicular atrophy and infertility possible.

Varicocele History

Soft, lumpy scrotal mass ("bag of worms"); more pronounced with standing or Valsava

Varicocele PE

Idiopathic hydroceles

begin as small, painless collections of fluid in the scrotal sac. Pain may develop and increase as hydrocele size increases.