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Examination of a Scrotal Lump (Inspection (Skin: scars, erythema, blue…

- - - - Yes
        
        Does it transilluminate?
        
        Yes
        
        Epididymal cyst
        
        No
        
        Varicocele
        Spermatocele
        Sperm granuloma
        Epididymitis
      - No
        
        Does it transilluminate?
        
        No
        
        Tumour
        Orchitis
        Haematocele
        
        Yes
        
        Hydrocele
- - - - Duration
      - Pain, discomfort or other symptoms
      - Previous testicular masses or infections
      - Recent trauma
      - Treatment so far
      - Co-morbidities: e.g. heart failure
  - - - Vaginal type can be caused by a variety of pathologies
        
        Testicular tumours
        
        Epididymo-orchitis
        
        Trauma
        
        Torsion
    - - Caused by a patent processus vaginalis
        Commonest type
        Young men, large, tense
  - - - Watch-and-wait (ensure no Ca)
      - Aspiration: symptom relief only as will accumulate
    - - Lord’s Repair: plication of the tunica vaginalis
      - Jaboulay’s Repair: eversion of the sac
- - - - If the cyst isn’t troublesome it shouldn’t be removed
        There is a risk of operative damage and post-op
        fibrosis → subfertility
    - - Very large or painful cysts can be removed
        Excision of the entire epididymis may be indicated to
        prevent the recurrence of painful cysts.
- - - - Unless it’s a spermatocele
- - - - Left testicular vein is more vertical where it joins the left
        renal vein, cf. to the obliquity of the right testicular V.
        where it joins the IVC.
        Left renal vein can be compressed by the colon
        Left testicular vein is longer than the right
        Left testicular vein often lacks a terminal valve to prevent
        backflow.
    - - Often around puberty
        Anatomical cause: ? nutcracker syndrome
        
        compression of the left renal vein between the aorta and the superior mesenteric artery, which results in elevated left renal vein pressure and possible collateral vein development
    - - Retroperitoneal disease affecting the testicular V.
        E.g. renal cell carcinoma extending into L renal V.
        Don’t disappear when pt. lies supine
  - - - Scrotal support
      - Transfemoral radiological embolisation of the testicular
        vein
    - - Often advised as the problem usually gets worse w/ age
        and can → subfertility
      - Palomo operation
        
        High approach w/ transverse incision slightly above
        and medial to ASIS
        Vein exposed and ligated.
        Inguinal approach: ligation of veins in the inguinal
        canal
      - Laparoscopic approach also possible
- - - - Can get above mass
      - Separate from testis
      - Feels like a bag of worms
      - Doesn’t transilluminate
      - May have palpable cough impulse
      - Often disappear on lying supine
- - - - Pure seminomatous: 50%
        
        Seminoma: 40%
        
        Present 30-40yrs
        
        Markers Usually normal
        
        Early DXT to para-aortic LNs
        ± single dose of cisplatin
        
        Late DXT + combi chemo: BEP
      - Non-seminomatous: teratoma is commonest
        
        Teratoma
        
        20-30yrs
        
        ↑AFP + ↑βhCG in 90%
        
        Early Observation or 1-2 cycles
        of chemo
        
        Late Combination chemo: BEP
    - - Yolk sac: commonest testicular tumour in children
      - Choriocarcinoma
      - Leydig or Sertoli Cell
        
        May secrete oestrogens → gynaecomastia
      - Lymphoma: NHL is commonest testicular mass >60yrs