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1 How to treat Pull-out section Complete How to Treat quizzes online ( to earn CPD or PDP points. inside The acute scrotum Hydrocoele, varicocoele and spermatocoele Inguinal hernia Testicular tumours The authors DR JYOTSNA JAYARAJAN, urology registrar, Austin Hospital, Heidelberg, Victoria. INGUINOSCROTAL problems in men DR SHOMIK SENGUPTA, urology consultant, Austin Hospital, Heidelberg, Victoria. Background PATHOLOGY affecting the inguinal and scrotal regions presents frequently to the GP. The underlying aetiology ranges from benign conditions requiring observation or reassurance, to surgical emergencies. The main symptoms patients report are pain or swelling in the region. The acute onset of inguinoscrotal symptoms can pose a time critical diagnostic dilemma. Systematic clinical assessment will narrow the differential diagnoses, and identify the patients who require further investigations and/or surgical referral. A thorough understanding of the anatomy of the inguinoscrotal region greatly aids clinical examination and diagnosis. Inguinoscrotal masses, such as hydrocoele, varicocoele and testicular tumours, tend to present in a more subacute fashion. The promotion of testicular self-examination among all males from adolescence onwards aids in the early detection of testicular abnormalities. Abnormalities may also be detected on routine physical examination, incidentally on imaging or even first noticed by a patient s partner. Most patients presenting with inguinoscrotal symptoms will not have serious pathology. Thorough clinical assessment helps identify patients with the must not miss diagnoses particularly testicular torsion, incarcerated inguinal hernia and testicular tumour when a delayed diagnosis can have disastrous consequences. Explanation, reassurance and counselling play a key role in the management of most patients with inguinoscrotal conditions. In the younger patient, the effect of both the condition and its treatment on testicular function and future fertility is often of paramount concern. CALCIUM THIAMIN VITAMIN B 6 AND B 12 ZINC ALL 9 ESSENTIAL AMINO ACIDS SELENIUM MAGNESIUM IRON VITAMIN A AND E NIACIN LEAN CHICKEN. A FAMILY MEAL THAT S LOADED WITH NUTRITION, NOT SATURATED FAT. * * All nutritional information based upon: stir-fried lean chicken breast. Food Standards Australia New Zealand. NUTTAB 2006: Online database of the Nutritional Composition of Australian Foods. Canberra, gov.au/nuttab2006/ S&H ACMCH0012AD 2 May 2008 Australian Doctor 29

2 ABDOMINAL pathology may give rise to symptoms in the inguinoscrotal region and vice versa. Evaluation of inguinoscrotal symptoms requires careful examination of the abdomen, inguinal region, scrotal skin and scrotal contents. Urinalysis is an important adjunct to physical examination in all patients with acute scrotal pain, as pyuria or bacteriuria suggests an infectious aetiology. Further assessment with colour Doppler ultrasonography is useful for patients with equivocal clinical findings. Inguinal region Masses in the inguinal region may arise from any of the underlying structures. On examination, reducibility, a cough impulse and audible bowel sounds within an inguinal mass are High-riding left testis in a patient with testicular torsion. consistent with an inguinal hernia. An indirect inguinal hernia descending into the scrotum may be confused with a primary scrotal mass. Inability to get the examining fingers above a scrotal mass suggests descent from above. Inguinal lymphadenopathy or femoral artery aneurysm can also present as a mass in the inguinal region. The scrotum and its contents A scrotal lump may arise from scrotal skin or internal contents. Scrotal examination is facilitated by a warm environment, minimising cremasteric contraction. With the patient standing it may be easier to visualise a varicocoele, indirect inguinal hernia and asymmetry in the lie of the testes. The average adult testes measure 5 3cm and are oval, smooth and non-tender on palpation. It is common for one testis to lie slightly lower than the other within the scrotum, and there may be a small palpable size difference between each side. Testicular descent into the scrotum begins in the seventh month in utero. Cryptorchid (undescended) testes are prone to testicular cancer, torsion and impaired spermatogenesis. The appendix testis is a sessile 2-3mm remnant of the para-mesonephric duct located on the upper pole of the testis in the groove between the testis and epididymis. Despite its small size, torsion of this structure can cause severe unilateral scrotal pain and mimic testicular torsion. The epididymis is located posterolaterally to the testis, which is important to remember when trying to distinguish between swellings of these two structures. The vas deferens is palpable as a tube-like structure medial to the epididymis and directly continuous with its lower pole. The spermatic cord containing the testicular neurovascular bundle and the vas deferens is palpable above each testis, and may be thickened or tender in testicular torsion. The processus vaginalis, an elongation of the peritoneum, descends into the scrotum with the testis. It usually becomes obliterated during the first two years of life. Persistence of the processus vaginalis predisposes to congenital hydrocoele and indirect inguinal hernia in infants, while partial closure can result in hydrocoele of the spermatic cord. The anterolateral surfaces of the testis and epididymis are covered by a remnant of the processus vaginalis, the tunica vaginalis. A potential space exists between its visceral and parietal layers, and may enlarge, forming a non-communicating hydrocoele. The acute scrotum ACUTE scrotum refers to pain and swelling of the scrotum or its contents. The most common differential diagnoses for this presentation (table 1, page 32) are the four Ts: torsion, trauma, tumour and testiculitis (inflammation/infection). Torsion of the appendix testis is the predominant cause of acute scrotal pain in children, while epididymitis is most common in adults. Torsion of the testis can occur at any age and must be suspected and excluded in any patient presenting with scrotal pain. Testicular torsion Testicular torsion is the rotation of the testis on the spermatic cord, resulting in venous congestion, testicular ischaemia and, later, necrosis. It is a true surgical emergency that must be differentiated from the other causes of unilateral testicular pain. Testicular torsion can occur at any age but predominantly affects males aged 12-30, with a peak incidence at 14. There is also a smaller peak occurring during infancy (0-12 months). Testicular torsion accounts for 16-42% of all presentations of acute scrotum. The left testis is more commonly affected and 2% of cases are bilateral. The two most important factors determining testicular salvage after torsion are time to detorsion and degree of testicular rotation. When detorsion is undertaken within six hours of symptom onset, testicular viability approaches 100%, decreasing to 20% after 12 hours and virtually 0% after 24 hours. Most testicular torsion results from an anatomical anomaly found in 12% of asymptomatic men the bell-clapper deformity, when the tunica vaginalis surrounds the entire testis and epididymis, resulting in Figure 1: The role of colour Doppler ultrasonography in investigating acute scrotum. High suspicion of torsion History: short duration of symptoms : high-riding tender testis, absent cremasteric reflex Urinalysis: negative Surgical exploration Testicular torsion is a true surgical emergency that must be differentiated from the other causes of unilateral testicular pain. Acute scrotal pain Reduced or absent testicular blood flow Surgical exploration Low suspicion of torsion History: subacute presentation, infective features Urinalysis: positive Equivocal clinical features for torsion but limited scrotal examination Colour Doppler ultrasound Normal testicular blood flow Manage underlying condition; offer reassurance deficient posterior fixation of the testis. The testis is then free to rotate within the tunica vaginalis like a gong (clapper) in a bell, predisposing to intravaginal torsion. Extravaginal torsion is less common and occurs almost exclusively in neonates. The cryptorchid testis is many times more prone to torsion than a normal descended testis. Testicular torsion may be precipitated by exercise, sexual activity and trauma, but often occurs at rest. In the patient with severe testicular pain persisting for longer than one hour after trauma, testicular injury or torsion should be excluded. Clinical features The patient with testicular torsion characteristically describes a sudden onset of severe unilateral scrotal pain (see Authors case studies Testicular torsion, page 34). Associated nausea and vomiting is common, as is abdominal pain. Testicular pain radiating into the groin and lower abdomen may be mistaken for abdominal pathology unless the genitalia are carefully examined. Some patients report preceding episodes of intermittent testicular pain that spontaneously resolved, suggesting intermittent torsion and detorsion, and increasing suspicion of testicular torsion. The gradual onset of moderate testicular pain, particularly with associated dysuria, is more suggestive of epididymitis. The pain of appendiceal torsion is also usually more subacute than testicular torsion. A study reviewing 172 patients presenting with acute scrotal pain identified the three most important clinical predictors of testicular torsion as: Onset of pain less than six hours. Absence of the cremasteric reflex. Diffuse testicular tenderness. None of the patients without these features had testicular torsion, whereas 87% with all three did. 1 The overlying scrotum may be swollen and erythematous in both torsion and inflammatory conditions. The torted testis is usually swollen, globally tender to palpation and positioned higher and more horizontal than the contralateral testis, because of twisting of the spermatic cord. The last of these findings is highly suggestive of torsion. The torted spermatic cord may be palpable as a thickening above the affected testis. Normal position of the epididymis does not exclude torsion, as the testis may have rotated 360 or 720. Elevation of the scrotum may improve the pain of epididymitis (Prehn s sign) but not the pain of torsion. Normally a positive cremasteric reflex is found in most males over the age of 30 months and is defined as a minimal 0.5cm elevation of the ipsilateral scrotum on pinching or stroking of the upper medial thigh. In the patient with acute scrotal pain ipsilateral loss of the cremasteric reflex is the most sensitive physical finding for diagnosing testicular torsion. Loss of the reflex in patients with testicular torsion has a sensitivity approaching 100%, although the specificity is only 66%, as the reflex may sometimes be absent in other conditions, including epididymitis. Investigations If testicular torsion is suspected clinically, imaging should not delay prompt surgical referral for exploration. White cell count may be raised in up to 60% of cases of testicular torsion, and is unreliable for differentiating torsion from epididymitis. Urinalysis should be performed in all patients presenting with acute scrotum, and is usually normal in torsion. Because of the delay involved, imaging should only be performed in patients with equivocal clinical features and a low suspicion for torsion (figure 1). Colour Doppler ultrasonography is the imaging modality of choice, with a sensitivity of 88% and specificity of 100% for detecting testicular torsion. In addition the presence of tumour or extra-testicular pathology such as varicocoele, hydrocoele or haematoma can be visualised. Doppler ultrasound usually shows reduced or absent intratesticular blood flow of the torted testis, compared with the contralateral side, while testicular blood flow is increased in inflammatory conditions. False-negative results on Doppler ultrasonography in testicular torsion may be seen in intermittent torsion or early in the course of torsion, when only venous outflow is impaired. A nuclear medicine scan is highly sensitive for testicular torsion. However, its use is limited by poor access and delays associated with obtaining results. Management When testicular torsion is suspected, immediate surgical scrotal exploration is the management of choice. If the testis appears viable after detorsion, orchidopexy is performed. Forty per cent of men with the bell-clapper anomaly have a similar deformity on the contralateral testis, so orchidopexy is usually performed bilaterally. If operating facilities are not immediately available, manual detorsion may be attempted. Testes usually tort towards the midline, therefore the un-torting action has been likened to opening the pages of a book, with the affected testis rotated outwards. These patients still require radiological and surgical assessment to confirm detorsion, as a testis can tort up to 720, and manual detorsion may have only partially relieved the torsion. Prognosis Despite detorsion, up to 40% of patients with unilateral torsion have subsequent subfertility, likely due to disruption of the blood-testis barrier. 2 Sperm counts and degree of testicular atrophy relate to duration of torsion. A missed torsion can later present as atrophy of the affected testis. cont d page Australian Doctor 2 May

3 from page 30 Torsion of the appendix testis Torsion of the appendix testis leads to ischaemia and infarction. Resultant pain can mimic that of testicular torsion, although it tends to have a more subacute course. Not uncommonly, patients can present days after the onset of symptoms. Appendiceal torsion is the most common cause of acute scrotum in boys under 16, with the highest frequency in those aged This condition occasionally affects adult males. Enlargement of the appendix testis during puberty promotes torsion, as can trauma or a very strong cremasteric reflex. The torted appendix testis may be evident as a tender nodule at the superior pole of the testis, with a visible blue dot. The blue-dot sign is present in only one-fifth of cases but is pathognomonic for this condition. The presence of the blue dot and a normally oriented, non-tender testis clinically excludes testicular torsion. In addition the cremasteric reflex is preserved in appendiceal torsion. Later in the course of appendiceal torsion, oedema and a reactive hydrocoele may lead to more diffuse tenderness, creating diagnostic uncertainty. Urgent surgical referral is advised for patients with equivocal clinical features. Investigation and management On colour Doppler ultrasound the torted appendix testis is visible as a hypoechoic nodule. The adjacent testis has normal blood flow. Surgery may be undertaken to confirm the diagnosis and may hasten symptom relief. Surgery is not essential in confirmed cases, as no harm is caused if the gangrenous appendix testis is not removed. When conservatively treated, pain usually resolves within a week and can be managed with NSAIDs and scrotal support. Testicular trauma Most males at some stage experience minor scrotal trauma. More severe testicular injuries can be sustained during straddle injuries, impact from projectiles and blunt trauma from contact sports. Blunt trauma to the scrotum can cause considerable haematocoele without testicular rupture. The testes are covered by a strong fibrous layer, the tunica albuginea, and significant force is necessary to cause testicular rupture. Patients often experience instant scrotal pain with associated nausea and vomiting. frequently Figure 2: Ultrasound showing left epididymo-orchitis. reveals scrotal swelling, erythema and an exquisitely tender testis that may be illdefined on palpation. Patients with significant scrotal swelling, or pain lasting more than one hour, should undergo imaging with colour Doppler ultrasonography. The latter symptom is particularly important to consider, as testicular torsion can be precipitated by local trauma. The presence of testicular rupture or large haematocoele also requires prompt urological referral. Surgical intervention in these patients hastens recovery and promotes testicular preservation. Epididymitis and orchitis Epididymitis results from inflammation of the epididymis secondary to infection or chemical irritation. The condition is the most common cause of acute scrotum in young adults, often presenting to GPs and emergency physicians. Most epididymitis results from the retrograde introduction of urethral organisms via the vas, and occasionally from haematogenous spread (eg, tuberculosis). Severe acute epididymitis can involve the adjacent testis, leading to epididymoorchitis. Orchitis may also result from a viral infection (eg, mumps, rubella, coxsackie virus). The typical causative organism of infectious epididymitis is age related. In patients under 35, sexually transmitted pathogens are most common. Chlamydia trachomatis accounts for more than half of cases, with Neisseria gonorrhoeae being responsible for most of the remainder. These organisms must also be considered when treating sexually active males of any age with epididymitis. Coliform bacteria (Escherichia coli) are the Table 1: Differential diagnoses for acute scrotal pain Condition Most common age Pain history Risk factors Bloods/urinalysis Ultrasound Testicular torsion years Severe sudden-onset Bell-clapper High-riding/horizontal testis Elevated WCC (60%) Reduced or 2. Neonates testicular pain deformity Unilateral absence of Usually normal absent blood ± nausea Cryptorchidism cremasteric reflex urinalysis flow to affected Trauma Globally tender testis testis Torsion of Prepubertal Gradual onset of Prepubertal age Tender superior pole of testis Usually normal Hypoechoic appendix testis testicular pain Blue dot sign visible on urinalysis nodule affected side of scrotum Normal testicular blood flow Epididymitis/orchitis Postpubertal Gradual onset of moderate Sexually active Tender epididymis Pyuria Epididymal testicular pain ± dysuria Genitourinary Scrotal swelling and Bacteriuria and/or instrumentation erythema orange peel testicular Previous UTIs/STIs appearance swelling Chronic retention Prehn s sign elevating Increased blood the scrotum decreases pain flow to testis Abscess or reactive hydrocoele Tumour years Variable: painless, Cryptorchidism Firm testicular mass Elevated tumour Testicular mass ± dull ache or Contralateral Gynaecomastia (in markers (AFP, reactive post-traumatic pain testicular tumour 30% of patients with beta-hcg, LDH) hydrocoele First-degree Leydig cell tumours) family history Evidence of distal disease hepatomegaly, bone pain Trauma Any age but Moderate or severe High-impact sports Swollen tender scrotum Normal or Evidence of usually <35 years scrotal pain after injury Other blunt trauma Poorly defined testis haematuria haematocoele or testicular rupture WCC = white cell count, AFP = alpha fetoprotein, beta-hcg = beta human chorionic gonadotrophin, LDH = lactate dehydrogenase predominant cause of epididymitis in patients with an indwelling catheter, recent urological instrumentation or an underlying urological condition. E coli is the most common pathogen in prepubescent males with epididymitis, 50% of whom have an underlying urological anomaly, and in men over 35 who have obstructive urinary conditions. In younger males, secondary epididymitis may occur after a Mycoplasma pneumoniae, enterovirus or adenovirus infection. Non-infectious (chemical) epididymitis results from inflammation triggered by trauma or the reflux of sterile urine, and is an infrequent cause of epididymal pain. Urethro-vasal reflux may occur secondary to a urological abnormality, or in normal males who perform a Valsalva manoeuvre (eg, during weight-lifting) or strenuous exercise with a full bladder. Clinical features Patients often report a more gradual onset of scrotal pain and swelling than that of torsion. Associated irritative urinary symptoms (frequency, urgency and dysuria) are common. Only one-quarter of patients with acute infectious epididymitis report systemic symptoms at presentation. Mumps orchitis is usually preceded by parotitis, fevers and malaise. Risk factors such as urinary instrumentation and obstructive urinary symptoms should be elicited. A history of overseas travel (as a cause of TB, brucellosis, and schistosomiasis) is relevant, as is immunisation status (mumps orchitis) and risk factors for STIs. Clinically the affected epididymis is tender to palpation, with overlying scrotal erythema and induration. Scrotal examination may be impaired by a reactive hydrocoele and scrotal oedema. Global tenderness of the testicular and epididymal complex seen in epididymoorchitis may be clinically difficult to distinguish from torsion. Isolated orchitis may also resemble torsion, especially in the absence of systemic symptoms. Torsion is unlikely in the presence of a normal cremasteric reflex and the Prehn s sign: where elevation of the scrotum decreases the pain of epididymitis, while exacerbating or causing no effect on the pain of torsion. Investigations Laboratory investigations usually reveal an elevated white cell count on FBC. All patients should undergo midstream urine culture and, if relevant, urethral swabs or urinary PCR for STIs. In patients with equivocal history or examination when torsion has not been excluded, imaging should not delay surgical assessment. Diagnostic imaging can be appropriate in patients with a more subacute presentation (see figure 1, page 30). In inflammatory conditions, colour Doppler ultrasound usually reveals a hyperaemic epididymis and/or testis, compared with decreased or no blood flow in torsion (figure 2). Associated complications such as a reactive hydrocoele or abscess are readily visualised. Management Antimicrobial therapy is initially empirical, including cover for chlamydia and gonorrhoea when appropriate, and then pathogendirected after urine culture results. Patients who are systemically unwell, with secondary urinary retention or high analgesic needs, warrant inpatient hospital management. Surgical assessment is required for patients with possible torsion or those with intrascrotal abscess. All prepubescent boys should be investigated for an underlying urological abnormality. Supportive measures are an adjunct to antimicrobial therapy, or the mainstay in chemical epididymitis. Symptomatic relief can be obtained by rest, ice-packs, scrotal elevation and support, and use of NSAIDs. 32 Australian Doctor 2 May

4 Inguinoscrotal masses PATIENTS may notice inguinoscrotal swellings during routine self-examination, incidentally after trauma or with the onset of associated discomfort or pain. Key features on examination Is the lump subcutaneous? Is it possible to get above the lump? Is the lump cystic or solid? Is it transilluminable? Is the lump separate from the testis? Does the mass reduce when the patient is supine? The examiner s fingers are able to get above a primary scrotal mass, but not those descending from above, such as an indirect inguinal hernia. Scrotal lumps may be solid or cystic. The latter includes hydrocoele, spermatocoele and varicocoele. Cystic lumps are usually soft, fluctuant to palpation in two planes, and trans-illuminable. Exceptions are tense or blood-filled cysts, which may resemble a solid lump or be poorly transilluminable. Any solid scrotal mass is testicular cancer until proven otherwise. Patients with likely benign scrotal masses that do not allow thorough clinical examination should also have ultrasonography to exclude a testicular abnormality. Although most cystic scrotal masses have a benign aetiology, certain features such as an acute onset raise the suspicion of an underlying pathology. Thorough history and examination allow selection of the minority of patients requiring further investigation and referral. Cutaneous conditions of the scrotum Scrotal skin is susceptible to the same pathologies as skin elsewhere on the body. Sebaceous cysts occurring near the groin are prone to infection, and warrant excision if symptomatic, enlarging or cosmetically concerning to the patient. Scrotal skin is also liable to fungal infections (tinea cruris) and folliculitis, due to the moist environment. Figure 3: Varicocoele. Table 2: Grading system to classify varicocoele 2 Grade 1 Grade 2 Grade 3 Varicocoele only palpable during Valsalva maneouvre Varicocoele palpable without Valsalva maneouvre Varicocoele visually detectable Table 3: Varicocoele indication for urological referral Underlying pathology Infertility Symptomatic varicocoele Cosmetic concerns Adolescents with large unilateral varicocoele, testicular atrophy or size asymmetry of >2mL Any solid scrotal mass is testicular cancer until proven otherwise. Hydrocoele A hydrocoele is a collection of serous fluid within the layers of the tunica vaginalis. There is a high incidence in infants, particularly those born prematurely, and they can be associated with inguinal hernias. The persistence of the processus vaginalis in infants allows peritoneal fluid to communicate with the scrotum, resulting in a communicating (congenital) hydrocoele. Most of these resolve within the first year of life as the child matures, and the defect spontaneously closes. In adults, hydrocoele results from an imbalance between fluid production and resorption within the layers of the tunica vaginalis. Hydrocoele affects about 1% of adult men, most commonly in the year age group. Acute hydrocoele can occur secondary to torsion, infection or malignancy. Clinical features: Patients often report a scrotal swelling that can enlarge over the course of the day, associated with a dragging sensation in the scrotal region. Although often painless, a hydrocoele may cause discomfort if large, pathological or complicated by secondary haemorrhage. On examination a hydrocoele is typically smooth, cystic and trans-illuminable. The testis should be palpably separate although large hydrocoeles may impede examination. Management: Patients with suboptimal testicular examination or an acutely emerging hydrocoele warrant further investigation with ultrasonography to exclude underlying pathology. Benign hydrocoeles only require treatment if symptomatic, cosmetically concerning or suspected to be impairing fertility. Large hydrocoeles can result in testicular atrophy secondary to pressure effects. Surgery is the definitive treatment for hydrocoeles, as they tend to recur after aspiration. Various surgical techniques are described, but all aim to drain the fluid by opening the tunical space, with subsequent obliteration of the potential space by excision, eversion and/or plication of the tunica vaginalis. Varicocoele Varicocoele results from tortuosity and dilation of the veins forming the pampiniform plexus of the scrotum, usually due to incompetent or absent valves in the gonadal veins. It is a common condition affecting 15% of postpubescent males and is rarely diagnosed before puberty. Most clinically apparent varicocoeles are left sided (90-95%) (figure 3), although recent studies have challenged the traditional concept of varicocoele as a predominantly unilateral disease. Up to 80-85% of patients with a clinically apparent left-sided varicocoele in fact have a contralateral varicocoele that can often only be detected on imaging. It is uncommon to have an isolated right-sided varicocoele. Some varicocoeles result from pathological obstruction of venous drainage by retroperitoneal masses, renal malignancy involving the renal vein, or inferior vena cava obstruction from tumour or thrombus. Varicocoeles are the most common identifiable cause of male infertility, affecting 30-40% of these men. Proposed mechanisms include increased scrotal temperature and pressure impairing spermatogenesis. In adolescents, varicocoeles are also known to slow testicular growth, leading to decreased testicular volume on the affected side. Clinical features: Most patients with varicocoeles are asymptomatic. Those with symptoms may report a feeling of fullness or dragging in the scrotal region. Varicocoele is often discovered incidentally on routine physical examination or during investigation of male infertility. should be conducted with the patient standing and supine. Smaller varicocoeles may only be evident with the Valsalva maneouvre. A prominent varicocoele is characteristically described as resembling a bag of worms on palpation. Varicocoeles may be classified according to their examination characteristics (table 2). With the patient supine most varicocoeles should become less prominent. Assessment of testicular size, and thorough abdominal examination for the presence of masses, should also be conducted at this time. Management: After clinical assessment only a minority of patients with this common condition require further investigation or referral (table 3). In patients with a varicocoele that either emerges acutely, enlarges rapidly, fails to diminish on lying supine or who have an isolated right-sided varicocoele, pathological venous obstruction must be excluded by ultrasonography. As testicular atrophy is an indication for surgical referral, ultrasound is also recommended in adolescents with varicocoele to accurately assess testicular size. Treatment methods include surgical excision or radiological embolisation of the varicocoele. There is no clear consensus regarding the benefit of treating a varicocoele in a sub-fertile man with no other abnormalities, although sperm quality may improve after treatment and translate to an increased chance of conception. There are no good controlled prospective studies in adolescents to demonstrate early varicocoelectomy prevents future infertility. Spermatocoele Spermatocoele is a sperm-containing cyst arising from the head of the epididymis either idiopathically or secondary to trauma or inflammation and causing ductal obstruction. It usually presents as a painless nodule distinct from the testis. On examination a spermatocoele is evident above the testis as a cystic, trans-illuminable nodule that is mobile and non-tender. In contrast to a hydrocoele, a spermatocoele should always allow thorough-palpation of the adjacent testis. Most spermatocoeles require no treatment unless symptomatic or there are cosmetic concerns. Inguinal hernia A large indirect hernia may present as a scrotal mass with a positive cough impulse. A hernia containing bowel loops may have audible bowel sounds. In contrast to most other scrotal masses such as hydrocoele, varicocoele and testicular tumour, an inguinal hernia is reducible. The exception is a strangulated or incarcerated inguinal hernia, which can present with acute scrotal pain and may mimic testicular torsion. These patients require urgent surgical review. Testicular tumours Background The incidence of testicular cancer is second only to melanoma in men aged Its incidence has doubled over the past 30 years in most industrialised nations, but survival rates even for metastatic disease remains excellent. The mean age of presentation is 30, with Australian males having a one in 221 lifetime risk of developing testicular cancer before age 75. Risk factors for testicular tumours include cryptorchidism, family history of testicular malignancy in firstdegree relatives, tumour of the contralateral testis and Klinefelter s syndrome. A cryptorchid testis has a 3-5% chance of developing cancer, with the risk proportional to the extent of maldescent. Most testicular cancers (95%) are germ cell tumours; the remainder are either gonadal stromal tumours (5%) or metastases from another site (<1%). Testicular germ cell tumours are divided into two broad histological categories for treatment purposes: pure seminoma and non-seminomatous germ cell tumours. The latter group includes embryonal carcinoma, choriocarcinoma, yolk sac tumour, teratoma and mixed tumours. Seminomas and mixed germ cell tumours are most common in postpubertal males up to age 40; yolk sac tumours and pure teratoma predominate in infants. Testicular lymphoma and secondary tumours are most likely to affect men over 50. Clinical features Typically patients present with a unilateral painless lump detected by themselves or their partner. Some report regional pain due to haemorrhage or infarction within the tumour, torsion or incidental preceding trauma. The most common misdiagnosis at initial presentation for this group is epididymitis. In 10% initial presentation is with symptoms of systemic metastases. This includes: Neck lumps from supraclavicular nodal metastases. Cough or dyspnoea from pulmonary metastases. Abdominal symptoms or bone pain from retroperitoneal disease or bony involvement, respectively. Lower-limb oedema from iliac venous compression or thrombosis. The systemic endocrine effects of the tumour may result in gynaecomastia (5% with testicular germ cell tumours) or precocious puberty in younger patients. On examination each testis should be careful palpated, taking note of any diffuse rubbery enlargement or focal, hard irregular areas. The normal testis can be used as a reference. Each hemi-scrotum can then be examined for a reactive hydrocoele and local tumour involvement, followed by thorough systemic examination for evidence of distant metastases. Management Any patient with a palpable testicular mass is presumed to have testicular cancer until proven otherwise. Ultrasonography is the preferred investigation and can distinguish between orchitis, intratesticular tumours and extratesticular masses such as spermatocoele or hydrocoele. Most germ cell tumours are evident as welldefined heterogeneous hypoechoic intratesticular lesions. There may be focal necrosis or calcification. Males with inguinoscrotal symptoms and an unclear cont d next page 2 May 2008 Australian Doctor 33

5 from previous page diagnosis, or in whom testicular examination is limited by a large hydrocoele or varicocoele also warrant diagnostic ultrasonography. In patients with suspected testicular cancer on examination and ultrasonography, further investigations and urological referral should be expedited. Routinely indicated investigations include: LFTs. Measurement of selected serum tumour markers (alpha fetoprotein [AFP], beta-human chorionic gonadotrophin [beta-hcg], lactate dehydrogenase). Chest X-ray and CT of the abdomen and pelvis for metastatic disease. Serum beta-hcg is elevated in 40-60% of all germ cell tumours, including choriocarcinoma, yolk sac tumours and pure seminomas. Patients with pure seminomas may have completely normal tumour markers or elevated serum beta-hcg. Serum AFP is not produced by pure seminomas, so elevated levels, which are found in 50-70% of germ cell tumours, indicate the presence of non-seminomatous elements, and such tumours are treated as non-seminomatous or mixed tumours. Definitive initial treatment involves inguinal orchidectomy, which also provides histological diagnosis. Scrotal incisions are avoided because they can lead to tumour metastases to inguinal lymph nodes or local involvement of scrotal skin. Additional therapies are required for patients with more advanced disease. Subsequent treatment depends on histology and staging. For men with localised testicular tumours, the subsequent risk of metastatic recurrence is 20-50%, depending on risk factors. As such, a decision needs to be made between close surveillance or adjuvant therapy (chemotherapy for non-seminoma, radiotherapy for seminoma). Risk factors for recurrence, such as local T-stage, histological subtype and lymphovascular invasion, as well as patient-related factors such as reliability and convenience of follow-up, may impact on this decision. Surveillance is facilitated when markers are initially elevated and subsequently normalise, and requires clinical, radiographic and laboratory assessment every 1-2 months for the first two years postoperatively. Patients with obvious metastatic disease, either at the time of presentation or subsequently while on surveillance, are usually treated with chemotherapy. In this context, elevated serum markers in the absence of radiographic abnormalities are taken to signify metastatic disease. Retroperitoneal lymph node dissection is indicated for residual masses post chemotherapy, which may contain chemoresistant tumour or treatment-related necrosis or fibrosis. Occasionally this procedure is carried out primarily for staging purposes. The overall five-year survival for testicular cancer is 95%. Current chemotherapeutic regimens offer a cure for most men with metastatic testicular cancer, with lesser toxicity effects than previous regimens. As testicular cancer often affects young men, subsequent fertility is a major issue. Orchidectomy and adjuvant therapies may impact on fertility, and patients may choose to store semen before starting treatment. Conclusion The diagnosis of a testicular malignancy can be delayed by both patient and physician factors. Patients may misunderstand the significance of their symptoms or simply ignore a scrotal lump for fear of the diagnosis. Physicians too may delay diagnosis by attributing symptoms to benign conditions such as epididymitis, hydrocoele or varicocoele. A diagnosis may be missed by omitting testicular examination in patients with abdominal symptoms, or by failing to image patients with suboptimal testicular examination. Promoting regular testicular self-examination, and maintaining vigilance for testicular cancer in patients presenting with inguinoscrotal symptoms aids prompt diagnosis and management. Authors case studies Testicular torsion A 21-YEAR-old previously well young man was awoken at 2am with severe left iliac fossa pain. The patient presented to an emergency department five hours later, after developing left testicular pain. There was no history of trauma, dysuria or GI symptoms. The patient reported previous episodes of similar left testicular pain that had resolved spontaneously. The patient was afebrile. Abdominal examination was unremarkable. Scrotal examination revealed moderate global left testicular tenderness. The lie of the testis was difficult to determine because of swelling. Urinalysis was positive for blood and leucocytes but negative for nitrites. Scrotal Doppler ultrasonography revealed normal bilateral testicular blood flow. The patient was diagnosed with epididymitis and discharged with oral antibiotics. The patient re-presented to the emergency department two days later with low-grade temperature and persistent left scrotal pain. On examination, the left testis was exquisitely tender with extensive boggy swelling. The left cremasteric reflex was absent. Urinalysis from his previous presentation showed no bacterial growth. Repeat Doppler ultrasonography showed an oedematous left testis with no blood flow (figure 4). During urgent scrotal exploration left testicular torsion was confirmed. Despite detorsion the left Figure 4: Doppler ultrasound of a torted testis. Figure 5: The necrotic testis at orchidectomy. Figure 6: Doppler ultrasound of a testis tumour. Figure 7: Testis tumour specimen. testis was non-viable (figure 5). Left orchidectomy and right orchidopexy were performed. Pathology showed established necrosis of the testis, suggesting torsion had occurred some time before the patient s second presentation. The patient s low-grade temperature at his second presentation was likely due to inflammatory changes associated with testicular necrosis. Clinical points Scrotal pathology can present with abdominal or inguinal symptoms. Testicular torsion should be considered in any male reporting severe abdominal or scrotal pain waking him from sleep. Almost one-third of patients with torsion report previous episodes of testicular pain (suggesting intermittent torsion). As testicular torsion must be surgically excluded, imaging was not appropriate in this case. While Doppler ultrasonography is a valuable investigation in patients with equivocal clinical presentations, early in the course of torsion (first six hours), testicular blood flow may appear normal or even slightly increased. Testicular tumour A 30-year-old man presented to a sexual health clinic with eight days of right scrotal fullness, testicular discomfort and occasional dysuria. He recalled right testicular discomfort a month earlier after minor trauma, which had spontaneously resolved. There was no other urological history. After examination, right scrotal fullness was attributed to a hydrocoele over the testis. After providing a urine sample for microbiology, the patient was started on empirical antibiotics for epididymitis and scheduled for review in a week. At review the patient s symptoms had not improved. Urinalysis was unremarkable. Scrotal ultrasound was ordered, which showed a heterogeneous cm mass within the right testis (figure 6). A rightsided reactive hydrocoele was also noted. The patient was urgently referred for urological assessment. Scrotal examination revealed irregular fullness of the right testis beneath the hydrocoele. Tumour markers and CT of the chest, abdomen and pelvis were ordered. AFP was 102kU/L (normal range <10kU/L) and betahcg 181 IU/L (normal range < 2.7 IU/L), suggesting non-seminomatous germ cell tumour. There was no clinical or radiological evidence of metastatic disease. The patient chose to bank sperm before his right inguinal orchidectomy. Histopathology confirmed non-seminomatous germ cell tumour (figure 7), with the patient s tumour markers normalising postoperatively. He is currently in an active surveillance program involving regular imaging and measurement of tumour markers to detect any recurrence. Practice points A reactive hydrocoele may be the first sign of an underlying testicular malignancy. Ultrasonography is recommended for patients with a new hydrocoele and those with inguinoscrotal symptoms and suboptimal testicular examination. As with torsion, patients with testicular tumour may initially be misdiagnosed with epididymitis, because of similarities in presentation. GP s contribution DR ASHLEY BERRY Lugarno, NSW Case study SM is a 20-year-old who was involved in a motor bike accident in which he suffered a fractured femur. I saw him about 12 months after the accident, when he presented with a lump in the right groin. According to him, it had developed since the accident and was becoming larger and more uncomfortable. He was adamant that it was not present pre-accident. On examination, there was a definite palpable lump in the right inguinal region which increased in size with coughing. On palpation the patient described the lump as being uncomfortable. It did not extend into the scrotum and seemed to reduce in size when he was supine. I diagnosed what appeared to be a right indirect inguinal hernia and referred him to a surgeon. The specialist was unsure if this was a hernia, lymph node or cyst, and referred the patient for an ultrasound. The ultrasound showed an undescended testis in the right groin, mm, 8cm proximal to the scrotal sac. There was no lymphadenopathy or cyst. The patient was booked in for orchidopexy. Questions for the authors I have not seen a retracted testis post-trauma is this possible? Should he have surgery to the other testis to ensure it doesn t retract or tort in the future? We have not come across any reports of post-traumatic testicular retraction in adults. This patient more likely has a previously undiagnosed cryptorchid testis or an ectopic testis. In order of occurrence, a congenitally undescended testis (UDT) may be found just outside the external ring (suprascrotal), in the inguinal canal or in the abdomen. Alternatively there may be an acquired UDT about one-third of retractile testes (can be manipulated into the scrotum if the cremasteric reflex is overcome) become undescended by puberty. An ectopic testis completes its descent through the external ring but then becomes diverted to an aberrant posicont d page Australian Doctor 2 May

6 from page 34 tion (most commonly the superficial inguinal pouch). They are occasionally palpable in the scrotum during childhood if there is enough laxity in the cord, but later appear to ascend and pull out of the scrotum as the child grows. It is unclear whether this patient had a palpable right testis in the scrotum at any age. Patients with acquired UDT, or an ectopic testis that was palpable in the scrotum during childhood, tend to present much later for orchidopexy. If the patient has a left testis in the scrotum there would be no indication to perform orchidopexy on the left side. SM asked me about fertility is this likely to be affected? Germ cell density in the undescended testes decreases from the first year of life onwards. Once postpubertal an undescended testis will demonstrate limited or no spermatogenesis. Both testes may be abnormal although only one fails to descend. Despite this, paternity rates for men with unilateral cryptorchidism are still quite favourable. This patient is at increased risk of testicular cancer and warrants regular testicular self examination and review to identify pathology early. General questions for the authors I have seen a cricketer, hit in the groin by a cricket ball, develop a swollen scrotum requiring elevation and ice. How often can torsion develop after such trauma and what is the accuracy in diagnosing torsion post trauma? It is reported up to 6% of testicular torsion has a traumatic aetiology. Patients with severe post-traumatic testicular pain, particularly with a duration more than one hour or in the absence of major clinical features of scrotal trauma, should be evaluated as an acute scrotum presentation. Doppler ultrasonography is very sensitive in differentiating testicular trauma from torsion in these patients. I have only seen one infertile patient with a varicocoele, who had it removed without improvement in his sperm count. How often does removing the varicocoele improve the sperm count? Post adult varicocoelectomy studies suggest improvement in semen quality in about 65% of cases. However, the effects on fertility are more controversial. Early studies showed the pregnancy rate in treated couples was almost double that of untreated couples, but there are conflicting results in more recent well-controlled studies. Despite improved semen quality, correction of the adult varicocoele may result in fertility in less than 50% of patients. References 1. Karmazyn B, et al. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatric Radiology 2005; 35: Dubin L, Amelar RD. Varicocoele size and results of varicocoelectomy in selected subfertile men with varicocoele. Fertility & Sterility 1970; 21: Further reading Available on request from julian.mcallan@reedbusiness. com.au Online resources mayoclinic.com. Diseases and conditions: health/diseasesindex/ DiseasesIndex How to Treat Quiz Inguinoscrotal problems in men 2 May 2008 INSTRUCTIONS Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes by post or fax. The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. ONLINE ONLY for immediate feedback 1. Which TWO statements about the anatomy of the inguinoscrotal region are correct? a) The epididymis is located anteromedially to the testis b) The appendix testis is located on the upper pole of the testis in the groove between the testis and epididymis c) Testicular descent into the scrotum begins in the seventh month in utero d) The processus vaginalis usually becomes obliterated during the first two months of life 2. Which THREE statements about assessing patients with inguinoscrotal problems are correct? a) Testicular pain may radiate to the lower abdomen, so it is important to examine the genitalia in men presenting with lower abdominal pain b) A positive cremasteric reflex is defined as a minimal 1cm elevation of the ipsilateral scrotum on pinching or stroking of the upper medial thigh c) Inability to get the examining fingers above a scrotal mass suggests descent from above d) Urinalysis should be performed in all patients presenting with acute scrotum 3. Toby, 18, presents with severe left testicular pain that came on suddenly two hours ago. Which TWO statements are correct? a) Very few patients with testicular torsion report previous episodes of testicular pain b) A normal position of the epididymis excludes torsion of the testis c) In the patient with an acute scrotum, if the affected testis lies higher and more horizontal than the contralateral testis, it is highly suggestive of torsion d) In the patient with acute scrotal pain, ipsilateral loss of the cremasteric reflex is the most sensitive physical finding for diagnosing testicular torsion 4. Which TWO statements about testicular torsion are correct? a) Colour Doppler ultrasonography has 100% sensitivity in detecting testicular torsion b) All patients with suspected testicular torsion should undergo Doppler ultrasonography c) Immediate surgical scrotal exploration is the management choice for suspected testicular torsion d) When detorsion is undertaken within six hours of symptom onset testicular viability approaches 100%, but decreases to virtually 0% after 24 hours 5. Which TWO statements about torsion of the appendix testis are correct? a) Torsion of the appendix testis is the most common cause of acute scrotal pain in adults b) The pain from torsion of the appendix testis can mimic that of testicular torsion, although it tends to be more subacute c) The cremasteric reflex is absent in torsion of the appendix testis d) The blue-dot sign is pathognomonic for torsion of the appendix testis 6. Which TWO statements about hydrocoeles are correct? a) Most babies with congenital hydrocoeles require surgery in the first year of life b) Acute hydrocoeles can occur secondary to torsion, infection or malignancy c) Patients with acutely emerging hydrocoeles should have ultrasonography d) Most hydrocoeles can be definitively treated with aspiration 7. Bruce, 28, presents with pain and swelling in the right side of the scrotum, which has come on gradually over the past 24 hours. He also reports some urinary frequency and dysuria. Which TWO statements are correct? a) Elevating the scrotum may improve the pain of torsion, but not the pain of epididymitis b) An elevated white cell count on FBC in a patient with an acute scrotum rules out a diagnosis of torsion c) Patients with possible epididymitis should undergo midstream urine culture and, if relevant, urethral swabs or urinary PCR for STIs d) In inflammatory conditions colour Doppler ultrasonography usually reveals a hyperaemic epididymis and/or testis 8. Which TWO statements about epididymitis are correct? a) Chlamydia trachomatis accounts for about one-quarter of cases of infectious epididymitis in patients under 35 b) Coliform bacteria (Escherichia coli) are the predominant cause of infectious epididymitis in patients with an indwelling catheter c) Ten per cent of prepubescent males with epididymitis have an underlying urological anomaly d) Patients who are systemically unwell, with secondary urinary retention or high analgesic needs, warrant inpatient hospital management 9. Todd, 35, presents with a right-sided varicocoele. Which THREE statements about varicocoeles are correct? a) Varicocoeles are the most common identifiable cause of male infertility b) It is uncommon to have an isolated right-sided varicocoele c) A grade 1 varicocoele can be palpated without the patient performing a Valsalva manoeuvre d) A patient with an isolated right-sided varicocoele should undergo ultrasonography 10. Curtis, 29, presents with a painless rightsided scrotal mass, which he has been aware of for a month or so. reveals an enlarged right testis with a hard irregular area. Which TWO statements are correct? a) Curtis should be presumed to have testicular cancer until proven otherwise b) Testicular cancer is the fourth most common cancer in men aged c) Curtis should undergo ultrasonography d) Most testicular cancers are gonadal stromal tumours CPD QUIZ UPDATE The RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the triennium. You can complete this online along with the quiz at Because this is a requirement, we are no longer able to accept the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online. HOW TO TREAT Editor: Dr Martine Walker Co-ordinator: Julian McAllan Quiz: Dr Wendy Morgan NEXT WEEK Early, late or abnormal sequence of pubertal changes can cause significant anxiety for adolescents and parents. Assessing and managing precocious or delayed puberty is important because of the possibility of underlying or future medical disorders. The next How to Treat looks at endocrine disorders of puberty. The authors are Dr Louise S Conwell, paediatric endocrinologist, department of endocrinology and diabetes, Royal Children s Hospital, Brisbane; and Dr Sarah K McMahon, paediatric endocrinologist, department of endocrinology and diabetes, Royal Children s Hospital, Brisbane, Qld. 36 Australian Doctor 2 May

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