Scrotal Swelling Station

Presenting Complaint - Scrotal Swelling

SOCRATES:

• Site – left testicle
• Onset – gradual onset
• Character – throbbing pain
• Radiates – the swelling is confined to the left testicle
• Associated symptoms – dysuria, testicular pain, and feeling feverish
• Time/duration – the duration is 2 weeks
• Exacerbating/relieving factors – he has taken simple analgesia for the pain, which has helped slightly.
• Severity – 7/10

Sexual History

• James split up with his girlfriend of 5 years eight months ago
• He has had 6 casual sexual relationship since.
• He uses condoms "most of the time"
• He is unaware of any of his sexual partners’ PMH
• His last STD test was at university 5 years ago

Urology Systems Review

• He denies having any urethral discharge
• No haematuria
• No LUTS (e.g. increased urinary frequency, difficulty in passing urine such as hesitancy at the start of the stream and weak flow, nocturia, or feeling of incomplete emptying)
• No urinary incontinence
• No sexual dysfunction
• No testicular trauma

Systemic Symptoms

• No nausea and vomiting
• No unintentional weight loss
• No night sweats
• No changes to appetite

Previous Medical History

• Eczema
• No previous surgeries

Drug History

• Nil regular

Allergies

• Penicillin - rash

Family History

• His father had a myocardial infarction 5 years ago. 

Social History

• Occupation – Works as a labourer.

• Smoking – Vapes only. He has never smoked.

• Alcohol – He drinks a couple of pints every Friday and Saturday (5 units per week).

ICE

• Ideas: “Do I have some kind of infection?”

  Concerns: “I’m worried I can’t afford time off work, but I don’t feel well enough to currently attend”

  Expectations: “I’d like some antibiotics”

1. Abdominal Examination

• No abdominal tenderness or masses

2. Testicular Examination

• Remember to have a chaperone present during any intimate examination!
• Inspect the patient’s penis for skin changes, the abdomen and inguinal regions for masses, the scrotum by lifting the penis, and the perineum by lifting the scrotum
  • Left testicle appears enlarged and there is some erythema present.
  • No rash to penis, groin or thighs.
  • No inguinal mass or lymphadenopathy
• Ask patient to retract their foreskin to inspect the glans and prepuce – there is no rash; however, there is a small amount of white discharge.
• Palpate:
  • Palpate each testicle in turn with the ‘normal’ one first, palpating between thumb and index finger. Assess for any scrotal masses
  • Palpate the spermatic cord
  • Perform the Prehn’s test (lift the affected testicle and if that improves the pain, that is known as a positive Prehn’s sign)
  • Assess the cremasteric reflex (stroke the inner middle of the thigh. If the testicle moves up and retracts into the scrotum, that is known as a positive Cremasteric reflex)
  • Findings: There is left testicle tenderness, global swelling but no irregularity. Spermatic cord can be identified. Swelling is separate to the testicle and firm. Prehn’s test and cremasteric reflex are positive.

3. Special Tests

• Auscultate over the testicular mass, which is negative for bowel sounds. This makes the possibility of inguinoscrotal hernia unlikely.
• Cough Impulse – ask patient to stand and then cough. An impulse was not felt under the fingers, making the possibility of inguinoscrotal hernia or varicocele unlikely.
• Transillumination was negative, suggesting a solid mass (e.g. versus fluid-filled mass (e.g. hydrocele)

4. Rectal Examination

• Prostate is rubbery and firm with a smooth surface.
• No tenderness

Differentials for a painful swollen testicle include:

• Epididymo-orchitis (due to young male patient with history of unprotected sexual intercourse presenting with painful swollen testicle, urethral discharge, dysuria, and fever)
• Testicular torsion (another important differential for painful swollen testicle, but tends to present with acute, sudden-onset, sharp pain)
• Indirect inguinal hernia (can cause a painful enlarged scrotum as an indirect inguinal hernia may extend into the scrotum)

Management

• Analgesia
• Bedside:
  • Urinalysis and urine culture
  • 1^st catch urine sample for nucleic acid amplification tests (NAATs). NB – urethral swab is an alternative to test for Chlamydia and/or Gonorrhoea. Alternatively, in women, a vulvovaginal swab can be taken)
• Lab:
  • FBC, U&Es, LFTs and CRP (to check for leucocytosis and raised CRP, which would suggest an infective aetiology)
  • Blood sample (to test for HIV and syphilis)
• Imaging:
  • Testicular ultrasound

1. What are the causes of testicular swelling?

There are many causes of testicular swelling. They include:

• Epididymal cyst (aka spermatocele)
  • Fluid-filled cyst that occurs at the head of the epididymis (above and behind the testis)
  • They are very common and occur in around 30% of men
  • Most cases are harmless, asymptomatic, and are not associated with infertility or cancer. These cases do not require treatment. Occasionally, they may cause pain or discomfort, in which case removal may be considered
• Hydrocele
  • Fluid accumulation within the tunica vaginalis (sac that surrounds the testes)
  • Typically presents as a painless, fluctuant scrotal mass that improves when lying down. The testicle is palpable within the hydrocele
  • Causes:
    • Primary/Idiopathic: Common in male newborns and is associated with a patent processus vaginalis. It typically resolves within the first year of life and requires no intervention.
    • Secondary: Due to testicular tumour, testicular torsion, epididymo-orchitis, or testicular trauma
  • An ultrasound scan should be performed to confirm diagnosis and exclude serious causes
• Epididymo-orchitis
  • Inflammation of the epididymis and testicle
  • Usually presents with a painful swollen testicle, fever, and urinary symptoms (e.g. dysuria, increased urinary frequency)
  • Causes:
    • E. Coli (most common)
    • Mumps (associated with parotid gland swelling)
    • Young male (<35 years old) who is sexually active:
      • Chlamydia: Symptoms usually occur within 1-3 weeks after exposure and is associated with a watery white discharge and dysuria.
      • Gonorrhoea: Symptoms usually occur within 1-14 days after exposure and is associated with a yellow/green discharge and dysuria
• Testicular Torsion
  • Twisting of the spermatic cord, cutting off blood supply to the testicle
  • Patients are often young, but testicular torsion can present at any age
  • It is typically characterised by rapid onset unilateral testicular pain and/or abdominal pain, nausea and vomiting and an elevated testicle that is positioned abnormally e.g. horizontally
  • NB - Testicular torsion may present as a painless scrotal mass in neonates
  • It is a urological emergency
• Varicocele
  • Dilated veins in the pampiniform plexus, which drains into the testicular vein
  • It is caused by increased resistance in the testicular vein, which results in increased backflow of pressure in the pampiniform plexus
  • Common symptoms include dull/throbbing pain in the testicle that is worse on standing and disappears when lying down, and dragging sensation in the scrotum
  • Important positive signs on examination include a “bag of worms” appearance and positive cough impulse
  • Most varicoceles are left-sided (90%)
  • Management depends on whether patient is symptomatic and whether they have problems with fertility:
    • If asymptomatic and no problems with fertility, no treatment is required
    • If there is pain or infertility, surgery or endovascular embolisation may be performed
• Testicular Cancer
  • • Testicular cancer is the commonest malignancy in males aged 15-44
    • Classification:
      • Germ Cell Tumours (95%)
        • Seminoma (55%)
        • Non-Seminomas e.g. embryonal carcinoma, teratoma, choriocarcinoma yolk sac tumour, mixed germ cell tumour
      • Non-Germ Cell Tumours e.g. Sertoli cell tumour, Leydig cell tumour
      • Secondary tumours e.g. lymphoma
• Inguinal Hernia:
  • Indirect inguinal hernia is more common than direct inguinal hernia
  • Cannot palpate ‘above’ the swelling, differentiating it from a true scrotal pathology
  • Non transilluminable

2. Why are left-sided varicoceles much more common than right-sided varicoceles?

Left-sided varicoceles are more common due to anatomical differences in how the veins from the testes drain into the body’s main veins.

• Anatomy: The left testicular vein drains into the left renal vein, which drains into the inferior vena cava (IVC). In contrast, the right testicular vein drains directly into the IVC
• There is increased pressure in the left renal vein compared to the IVC due to:
  • Vein length: The left testicular vein is longer than the right testicular vein, making it more difficult to drain.
  • Angle of entry: The left testicular vein drains into the left renal vein at 90°

3. The 1^st catch urine sample was able to diagnose Chlamydia. Given a diagnosis of epididymo-orchitis caused by Chlamydia, how would you manage this patient?

• 100mg doxycycline orally twice daily for 10-14 days
• • If doxycycline is contraindicated, you can give azithromycin 1g orally as a single dose, followed by 500mg once daily for 7 days
  • If there is a high likelihood of concomitant gonococcal infection, you should also add ceftriaxone 500mg IM as a single dose
• Contact tracing history to ensure sexual partners from the past 60 days are tested and treated accordingly.