Conditions of the testis Testicular cancers occur most commonly in 20 – 40-year-olds. 9 Consider any hard lump or thickening in or on the surface of the testis a carcinoma until proven otherwise. A malignancy of the testis can be focal or produce a diffuse swelling, often associated with diminished testicular sensation. Sometimes there is an associated, small, secondary hydrocoele.
Classically the swelling is painless but, occasionally, haemorrhage occurs into the tumour and may mimic an acute, painful infection. Patients may sometimes give a misleading history of trauma and may also describe the testis as‘ feeling heavy’.
The risk of malignancy is increased with an undescended testis even when the testis has been placed into its correct position( see figure 14). An ultrasound is vital in confirming the diagnosis. Serum tumour markers such as alpha fetoprotein will help diagnose the type of tumour, for example, seminoma or non-seminoma. Markers are also used to assess prognosis, determine treatment success and detect recurrence.
Epididymo-orchitis Patients with this condition present with mild to moderate pain compared with the severe pain of torsion of the testis. There is often a history of urethral irritative symptoms or discharge with orchitis.
The most common type begins as an epididymitis and spreads to the testis to become an epididymoorchitis.
In the early stages, the epididymis may be palpable, tender and diffusely enlarged.
As the infection spreads to the testis, the tissue plane between the testis and the epididymis is obliterated and the swelling increases in size.
The cord is often thickened and tender and the skin may appear inflamed and almost adherent to the testis. The cause is commonly an STI in younger patients, while Escherichea coli is the common cause in older patients, often from a urinary source. 10 However, an organism cannot often be identified.
In contrast, mumps orchitis only affects the testis and there are other features of mumps.
Epididymo-orchitis must should not be confused with a torsion of the testis.
With torsion the pain is more acute and severe. An ultrasound is able to confirm blood flow with orchitis, to differentiate this from torsion, where blood flow to the testis is absent. 11 Surgery must not be delayed for an ultrasound.
In a patient under 35, even in the presence of the irritative symptoms, one cannot assume the patient has orchitis.
If there is any doubt, refer the patient urgently to an ED or urologist. Consider an exploration of the scrotum to absolutely exclude torsion.
Torsion of the testis This condition is common in prepubertal boys but may occur up to the age of 25. 11 A typical history includes an acute onset of pain.
Figure 9. Lymph node aspirate to be smeared and sent for cytology.
Figure 10. Varicocele.
Figure 11. Compressing the varicocele.
Figure 12. Ultrasound of a hydrocele of the scrotum.
Young men with this history and tender, scrotal swelling should undergo urgent surgical exploration to either confirm or exclude torsion of the testis. An ultrasound, if immediately available, can confirm your diagnosis by showing an absence of blood flow, but do not delay any surgical exploration while waiting for an ultrasound or
Figure 13. Epididymal cyst.
Figure 14. Carcinoma of the testis in a previously undescended testis – note the scar.
Box 4. Summary of examination Inspect all sites With the patient standing
• observe scars
• patient coughs Palpate both sides with the patient standing Palpate both sides with the patient coughing Assess the swelling: reducible or irreducible while
• watching and
• asking about pain If hernia present and readily reducible, assess if indirect or direct Assess scrotum, cord, testis and epididymis Palpate other hernia sites, e. g. femoral and umbilicus THEN Examine the patient recumbent with same routine Examine abdomen and assess for divarication of rectus abdominis THEN
If hernia is present, with the hernia reduced and a hand over deep ring, get the patient to stand and assess descent to see if it is indirect or direct
tests.
If torsion is present, explore the opposite scrotum and correct the congenital abnormality predisposing to the torsion by fixing the testis to the bottom of the scrotum.
Groin pain Groin pain is a common acute or chronic problem in sportspeople but may be caused by overuse, work or exercise. These patients are often referred to a surgeon because of a suspected hernia.
Consider the many other causes of groin pain at all ages and in both sexes especially if no hernia is present on examination. 1, 2
Walking, standing or straining usually aggravates pain from a hernia. Its radiation is limited. If the pain is worse when lying down at night, this tends to suggest that it is not due to a hernia. Use screening questions to assess whether the pain originates in the hip, such as the timing of the pain( worse at night), when lying down or when getting out of the car, because these actions externally rotate the leg. 12 Hip examination is vital.
An ultrasound is usually carried out in the absence of a clinical diagnosis of hernia or when considering other musculoskeletal problems. This examination often reveals a hernia when none has been demonstrated clinically; a condition known as the occult hernia. 4 A reasonable approach might be ongoing observation but many patients are not prepared to wait.
The dual risks of not finding a hernia and the patient experiencing post-hernia chronic pain syndrome deters many surgeons from operating on the occult hernia.
13, 14
In the author’ s opinion, many occult hernias are actually small lipomas of the cord. In a random survey, we found that up to 10 % of the clinically detectable hernias seen in our practice and referred for surgery were actually lipomas. The ultrasounds had, like the surgeon, diagnosed hernias. We also noted the inaccuracy in distinguishcont’ d next page
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