SCROTAL SWELLINGSCase No:5

PROBLEM ORIENTED CASE BASED LEARNING

Dr.B.Selvaraj MS;Mch;FICSProfessor of Surgery

Melaka Manipal Medical collegeMelaka Malaysia 75150

OVERVIEW

• Various causes(Differential diagnosis) of scrotal swellings• Classical clinical vignette with probable diagnosis• The diagnosis in detail- only one pathology in each

episode• Mind map of the diagnosis• Tabular column of differential diagnosis depicting their

characteristic features to differentiate them from your diagnosis• References and feedback

Causes of Scrotal Swellings ACUTE PAINFUL

• Torsion testis• Acute epididymo-orchitis• Torsion of testicular

appendages

CHRONIC PAINLESS

• Hydrocele• Epididymal cyst• Spermatocele• Chronic epididymo-

orchitis• Testicular tumor• Varicocele

Classical Clinical Vignette

• A 22-year-old male presents with a left scrotal mass. He notes that he was playing soccer about 5 weeks ago and sustained mild trauma to the left hemi scrotum at that time. The trauma prompted him to palpate his testicle, at which time he noted the mass. The patient states that he had mild pain initially that resolved on its own and denies any hematoma.• He denies any pain at this time. He states that the mass does not

seem to be increasing in size and that it is approximately the size of a large almond. The mass, he notes, seems to be “in the middle” of his left testis.

Classical Clinical Vignette Testicular Carcinoma

• On review of symptoms he denies subjective fevers, chills, dysuria, gross hematuria, or urethral discharge• O/E:Physical examination reveals a firm 2 cm mass within the

left testis. There is no pain to palpation. There are no epididymal masses bilaterally, and the right testis is normal to examination. Abdominal exam reveals no masses and no hepatomegaly.• There are no supraclavicular nodes and no gynecomastia• Laboratory analysis reveals a normal urinalysis and complete

blood count.

Testicular Carcinoma-Epidemiology

• The most common malignancy to affect young men.• There is a peak frequency in early childhood, and a larger peak

incidence between 20 and 35 years of age. Uncommon after age 40.• Occurs in whites more than African-Americans.• It is a curable cancer

Testicular Carcinoma-Risk Factors

• Men with cryptorchid (undescended) testes (intra-abdominal testes with the highest risk). It is important to note that both testicles are at risk.• Surgical placement of the testis into the scrotum does not

decrease malignant risk, but facilitates surveillance.• Testicular cancer in the contralateral testis• Family H/O Testicular Cancer• Klinefelter’s syndrome

Testicular Carcinoma Clinical features

• Painless enlargement of the testicle• Firmness of the testicle; Lax Secondary hydrocele• Back or abdominal pain secondary to retroperitoneal (inter-

aortocaval) lymphadenopathy.• Weight loss. Lt supraclavicular LN +• Enlarged retro peritoneal LN; Hepatomegaly; • Dyspnea secondary to pulmonary metastasis.• Gynecomastia secondary to hormonal secretions

Testicular Carcinoma Clinical features

Testicular Carcinoma- Classification

Testicular Carcinoma- Classification

Testicular Carcinoma- Histology

Testicular Carcinoma Seminoma vs Nonseminoma

Testicular Carcinoma- Workup

• Testicular self-examination(TSE) or by a clinician• USG of Scrotum• CT scan/magnetic resonance imaging (MRI) of abdomen and pelvis

toassess for metastasis and lymphadenopathy

• Tumor markers—α-fetoprotein (AFP), human chorionic gonadotropin(HCG), and lactic dehydrogenase (LDH).

• Tissue diagnosis- high inguinal orchidectomy (diagnostic & therapeutic) – Chevassu maneuver• Trans-scrotal biopsy – contraindicated

Testicular Carcinoma- USG Scrotum

Testicular Carcinoma-Tumor Markers

• AFP : Normal value < 16 ngm/ml; Half life 5 to 7 days; Raised in Pure embryonal Ca Terato Ca Yolk sac tumor Mixed tumor

REMEMBER: AFP Not raised is Pure Choriocarcinoma or Pure Seminoma

Testicular Carcinoma-Tumor Markers

• HCG: Normal value < 5 IU/ml; Half life 24 to 36 hrs; Raised in Chorio carcinoma 100% Embryonal carcinoma 60% Terato carcinoma 55% Yolk sac tumor 25% Seminomas 7%• LDH: Normal value 105 to 333 IU/ L; Half life 1 day -Not diagnostic -prognostic marker - correlates tumor burden

Testicular Carcinoma- Staging

Testicular Carcinoma- Treatment Goals

• Treatment should be aimed at one level higher then the clinical stage• Seminomas- radiosensitive• Non seminomas- radio-resisitant hence best treated with surgery• Advanced disease or mets- chemotherapy• Radical inguinal orchidectomy is the standard first line therapy• Lymphatic spread first to the RETRO-PERITONEAL NODES• Early hematogenous spread rare• Bulky tumors or metastatic tumors initially down staged with

Neoadjuvant chemotherapy

Testicular Carcinoma- Treatment

• Surgical approach: High radical inguinal orchiectomy• Trans-scrotal biopsy of the testis or a trans-scrotal orchiectomy

should not be performed• Early seminoma: Orchiectomy + retroperitoneal x-ray therapy

(XRT).• Advanced seminoma: Orchiectomy, and combination

chemotherapy followed by restaging• Stage I nonseminoma: Orchiectomy + retroperitoneal lymph

node dissection (RPLND) or surveillance

Testicular Carcinoma- Treatment

• Stage II Nonseminoma: The optimal management of this group of patients is controversial. RPLND can be curative but have a high relapse rate. If relapse occurs, chemotherapy can be given as adjunctive therapy. Alternatively, chemotherapy can be given prior to RPLND

• Advanced stage Nonseminoma: Orchiectomy + chemotherapy ± tumor

reductive surgery.• The most commonly used chemotherapeutic regimen: EBP

(etoposide, bleomycin, cisplatin).The prognosis of seminomas is excellent due to its exquisite sensitivity to radiation!

Testicular Carcinoma- Treatment

Testicular Carcinoma - Mindmap

Scrotal Swellings- Diagnostic Algorithm

Testicular Carcinoma- Treatment Algorithm

Scrotal Swellings Ex & Px

Hx Sx Dx Tx

1. Hydrocele Primary-IdiopathicSecondary- under lying pathology

Painless big swelling; not reducible

No cough impulseGet above swelling+Transilluminant+

ClinicalIn doubt- USG of scrotum

Lord’s operationJaboulay’s operation

2. Epididymal cyst & Spermatocele

Degenaration of epididymis, occlusion of pathway

Swelling in scrotum resembles 3rd testis

Testis palpable separately; Chinese lantern appearance

ClinicalUSG of scrotum

ConservativeExcision

3. Varicocele IdiopathicAbsence of valves in testicular vein

Worm like in upper scrotum; infertility

Disappears on lying down; Bag of worms appearance

ClinicalUSG color doppler

VaricocelectomyInguinal or Retroperitoneal

4. Testicular torsion & Epididymo- orchitis

Abnormal fixation and lie of testisUTI & trauma

Severe pain& swelling scrotumNausea & vomiting

Tender hemi scrotum; cremasteric reflex absent

ClinicalUSG color doppler

Explore,detorse, orchiopexy or orchidectomyConservative

5. Testicular carcinoma

UDT, Kieinfelter’s Germ cell- Seminoma & Non seminomaNon germ cell tumor

Painless heavy swelling

Not reducibleHard in consistencyTestis felt separately

Clinical; No FNACUSG OF scrotum

High orcidectomy with or without RPLND+ RT+CT

D/D for Scrotal Swellings (Compare & Contrast) (Vertical Reading)

References

• Hunt & Marshall’s clinical problems in surgery 2nd edition• Clinical surgery made easy- a

companion to PBL by Mohan De silva 1st edition• 100 cases in surgery 2nd edition• Case files surgery 4th edition• Clinical scenarios in surgery-

decision making 1st edition• Surgery- a case based clinical

review 1st edition

• Surgery Review by Carlos Pestana• Clinical surgery pearls by

Dr Dayananda Babu 2nd edition• NMS casebook surgery 2nd edition• General Surgery- Correlations &

clinical scenarios 1st edition• Surgery review by Makary 3rd edition• Surgery- Clinical cases uncovered by

Harold Ellis 1st edition• Shelf life surgery 1st edition

Feedback & Suggestions

Thank Youhttps://www.youtube.com/watch?v=xz0ZbzgR0RM