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Toronto Notes 2019
Scrotal Masses
Urology U31
Table 23. Benign Scrotal Masses
Type
Definition
Etiology
Hx/P/E
Investigations
Treatment
Varicocele
Dilatation and tortuosity of pampiniform plexus
15% of men
Due to incompetent valves in the testicular veins
90% left sided
“Bag of worms” Often painless Pulsates with Valsalva
P/E Valsava
Conservative
Surgical ligation of testicular veins
Percutaneous vein occlusion (balloon, sclerosing agents) Repair may improve sperm count/motility 50-75%
Spermatocele
A benign, sperm filled epididymal retention cyst
Multiple theories, including:
Distal obstruction Aneurysmal dilations of the epididymis
Agglutinated germ cells
Non-tender, cystic mass Transilluminates
P/E
U/S to rule out tumour
Conservative
Avoid needle aspiration
as it can lead to infection, reaccumulation and spilling of irritating sperm within scrotum
Excise if symptomatic
Hydrocele
Collection of serous fluid that results from a defect or irritation in the tunica vaginalis
Usually idiopathic
Found in 5-10% testicular tumours Associated with trauma/infection Communicating: patent processus vaginalis, changes size during day (peds) Non-communicating: non-patent processus vaginalis (adult)
Non-tender, intrascrotal mass Cystic
Transilluminates
U/S to rule out tumour
Conservative Needle drainage Surgical
Testicular Torsion
Twisting of the testicle
causing venous occlusion and engorgement as well as arterial ischemia and infarction
Trauma
Cryptorchidism
“Bell clapper deformity” Many occur in sleep (50%) Necrosis of glands in 5-6 h
Acute onset severe scrotal pain, swelling
GI upsets cases
Retracted and transverse testicle (horizontal lie) Negative Phren’s sign Absent cremasteric reflex
U/S Doppler with probe over testicular artery
Decrease uptake on 99mTc- pertechnetate scintillation scan (doughnut sign)
Emergency surgical exploration and bilateral orchiopexy Definitive diagnosis NOT necessary to take to OR Orchiectomy if poor prognosis
Inguinal Hernia
Protrusion of abdominal contents through the inguinal canal into the scrotum
Indirect (through internal ring, often into scrotum): congenital
Direct (through external ring, rarely into scrotum): abdominal muscle weakness
A small bulge in the groin that may increase in size with Valsalva and disappear when lying down
Can present as a swollen or enlarged scrotum
Discomfort or sharp pain – especially when straining, lifting, or exercising
Hx and P/E
Invagination of the scrotum Valsalva
Surgical repair
TORSION OF TESTICULAR APPENDIX
• twistingoftesticular/epididymalvestigialappendix
Signs and Symptoms
Acute scrotal swelling/pain in young boys is torsion until proven otherwise
Transillumination refers to light being transmitted through tissue (i.e. due to excess fluid)
Differential of a Benign Scrotal Mass
HIS BITS
Hydrocele
Infection (epididymitis/orchitis) Sperm (spermatocele)
Blood (hematocele)
Intestines (hernia)
Torsion
Some veins (varicocele)
• clinicallysimilartotesticulartorsion,butverticallieandcremasterreflexpreserved • “bluedotsign”
■ blue infarcted appendage seen through scrotal skin in children (can usually be palpated as small, tender lump)
Treatment
• analgesia–mostwillsubsideover5-7d
• surgicalexplorationandexcisionifrefractorypain
HEMATOCELE
• traumawithbleedintotunicavaginalis
• U/Shelpfultoexcludefractureoftestiswhichrequiressurgicalrepair
Treatment
• icepacks,analgesics,surgicalrepair