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Workshop-Scrotal Mass-Ensuring a Correct Dx

Workshop-Scrotal Mass-Ensuring a Correct Dx

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Published by Hakimah K. Suhaimi

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Published by: Hakimah K. Suhaimi on Apr 24, 2012
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 C o p y r i g h t
 N o tf o rS a l eo rC o m m e r c i a lD i s t r i b u t i o n
 n a u to rs eu s ep r ot e.u to rs eu s e r sc a no w n o a, s pa y,v e wa np rn tas n gec o p yo rp e r s o n au s e
The Canadian Journal of CME / February 2007
he undiagnosed scrotal mass can have significantconsequences on the health of the male if notdiagnosed and treated in a timely manner. The acutescrotum in a young patient is thought of as a urologicemergency. It is imperative that the FP possess asound approach to the diagnosis and management of ascrotal mass and be able to appropriately and emer-gently refer the patient for urologic consultation whenrequired.
Asking the right questions (Table 1) can quickly lead to an elimination of most conditions on the differen-tial diagnosis (Table 2) and will help tailor and focusthe physical examination.The greatest incidence of testicular torsion occursin boys aged 13 years to 19 years. An abrupt onset(minutes) of pain is highly suggestive of torsion and signals increased diagnostic urgency.
In this situa-tion, minimizing delay of intervention is of theessence, as the likelihood of salvaging the testicle pro-gressively diminishes over time after the onset of symptoms (Table 3).Varicoceles, spermatoceles and hydroceles tend to be painless, but not always. An inguinal hernia willusually be painless unless incarcerated, while tumourswill not cause significant discomfort except if verylarge or in the setting of acute hemorrhage.A painlessscrotal swelling whose size fluctuates indicates a pos-sible hydrocele or hernia. New, severe pain radiatingto the abdomen in the setting of such a history should make one suspect a newly incarcerated hernia.Testicular lacerations or contusions will usuallyresult in a hematocele and testicular integrity willneed to be assessed. The etiology of trauma would beelicited with history taking.Concerns about a malignant testicular tumour should be raised if there is evidence of:weight loss,respiratory symptoms and abdominal fullness.One may also see manifestations related to abnor-mal secretion of tumour markers, such as humanchorionic gonadotropin leading to gynecomastia, lac-torrhea and diminished libido.
 Physical examination
Typical findings on the investigations most commonlyused to differentiate the various causes of a scrotalmass are shown in Table 4. The varicocele will usually be palpable as “a bag of worms” in the superior aspectof the scrotum. It is very important that the patient beexamined both supine and standing and that palpation
The Scrotal Mass: Ensuring a Correct D
Matei Andreoui, MD, PGY-4; and Darrel E. Drachenberg, MD, FRCSC
Meet Peter
Peter, 17, presents to his GP because of a sudden,severe pain in his right hemiscrotum. The pain startedthree hours ago and has not abated. Several priorepisodes have occured in the past, but have alwaysonly lasted a few minutes. There is some radiation ofthe pain up to the right suprapubic region and he hashad one bout of emesis. There is no history of recenttrauma, no voiding symptoms and although sexuallyactive, Peter has not had intercourse for severalmonths.On examination, the right testis appears to haveassumed a horizontal lie and is considerably higher inthe scrotum. The cremasteric reflex is absent. Boththe testis and epidydymis are exquisitely tender. Thecord can only be palpated high in the scrotum.Transillumination is inconclusive. Urinalysis reveals afew blood cells and minimal pyuria.
Go to page 58 for more on Peter.
 Practical Pointers ForYour Practice
The Canadian Journal of CME / February 2007
 be carried out during a Valsalva effort. Left-sided varic-oceles are much more common (90% of all cases);whereas a right-sided varicocele, particularly if of acuteonset, raises the specter of a neoplasm intrinsically or extrinsically impairing gonadal vessel blood flow.
Ahydrocelewillusuallycovertheanterioraspectofthetestisand may prevent adequate examination of the testicular contour. It may also extend up to and along the sper-matic cord.The examiner should nevertheless be able to palpate the cord above the swelling, in contrast to aninguinal hernia, where this will not be possible. A sper-matocele will arise from the epididymis and be found along the cord and posterior aspect of the testis.When torsion is present, the testis assumes an elevated andhorizontalratherthanverticallie.
Thepresenceofthecremasteric reflex usually indicates that no significant tor-sion is ongoing.
A reactive hydrocele may be present.Torsionofthetesticularappendagescanpresentinasimilaway to testicular torsion, with a sudden onset of pain and may be accompanied by a blue-dot sign on the scrotum, if seen early in its evolution. The pain tends to be somewhatless severe and more localized to the upper or inferior polesofthetestisandepidydymis.Testiculartumoursusuallypre-sentasfirm,painlessmassoftenbroughttolightbyarecentinfection or trauma. Rapidly growing masses may causeacute hemorrhaging and infarction sometimes seen with ayolk-sac tumour.A reactive hydrocele is present in 10% of newly diagnosed cases.
Most varicoceles do not require treatment unless they arecausing significant discomfort, or if evidence of impaired male fertility exists in the setting of inability to conceive.Treatment entails surgical ligation or testicular veinembolization.Aspiration of a hydrocele is not recommended as it maylead to bleeding or infection and usually recurs thereafter.
The usual approach is conservative management, but surgi-calremovalorligationofthetunicavaginaliscanbecarried outifthehydroceleis ofanextremesizeandis causingdis-comfort or embarrassment to the patient. A similar 
Table 2
Differential diagnosis
VaricoceleSpermatoceleHydroceleHematoceleInguinal herniaTesticular torsionTesticular appendiceal torsionTesticular tumour (benign or malignant)Henoch-Schönlein purpuraIdiopathic scrotal edema
Dr. Andreoiu
is a resident, Urology PGY-4, University ofManitoba, Winnipeg, Manitoba.
Dr. Drachenberg
is an Assistant Professor andDirector of Research, Department of Surgery,Section of Urology, University of Manitoba,Winnipeg, Manitoba.
Table 1
Key questions
Age of patient?Is pain present and what has been its duration?Timing of pain onset – gradual vs. sudden?Have there been similar episodes in the past?Is there a history of STD’s, urinary tract infections, orrecent urethral discharge?Is there a history of recent scrotal or perineal trauma?Have there been systemic symptoms such as fever,emesis, anorexia or weight loss and lymphadenopathy?Has there been fluctuation in the size of the scrotalmass/swelling?Has the patient experienced any voiding symptoms?
Table 3
Testicular salvage rates based on durationof torsion
Hours since onset of torsion Likelihood of viability< 6 > 95%6 to 12 50% to 80%12 to 24 20% to 30%> 24 < 5%

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