Testicular mass approach Answers of the case pt with testicular mass The likely diagnosis is a testicular tumour. Ninety per cent of testicular tumours are germ cell tumours and are subdivided into seminomas and non-seminomatous germ cell tumours (NSGCT). ! Risk factors • Age: common between 20 and 40 years • Cryptorchidism • Race: more common in Caucasians • Previous testicular tumour • Family history • Klinefelter’s syndrome The patient’s complaint of a cough should be taken seriously, as metastases to the lungs are possible with testicular tumours. A complete physical examination of the patient should be performed as there is potential for secondary deposits in the chest and brain. Lymphatic spread is to para-aortic lymph nodes in the abdomen rather than inguinal nodes in the groin, which only occur if the tumour erodes and involves the scrotal skin. The diagnosis is confirmed with a scrotal ultrasound and serum tumour markers. Alpha- fetoprotein is elevated in NSGCT. The beta subunit of chorionic gonadotrophin (β-HCG) is elevated in NSGCT and in approximately 20 per cent of seminomas. Lactate dehydrogenase can be elevated in metastatic or bulky disease. All these markers are useful in monitoring disease progression and recurrence following various treatments. A computerized tomography scan of the chest and abdomen is required for staging purposes. When examining a lump in the scrotum it is important to determine whether you can get above the swelling. If you cannot get above the swelling then it may be a hernia. You should then ask yourself the following questions: • can the testis and epididymis be felt? • does the swelling transilluminate? • is the swelling tender? • Lump not confined to the scrotum (cannot get above the lump): • inguino-scrotal hernia: unable to get above swelling, cough impulse, does not tran- silluminate, can feel testis separately • infantile communicating hydrocoele: unable to get above swelling, no cough impulse, transilluminates, cannot feel testis separately • Lump confined to the scrotum (can get above the lump): • vaginal hydrocoele: testis and epididymis not felt easily, swelling transilluminates • haematocoele, syphilitic gumma, tumour: testis not readily identifiable, lump does not transilluminate • epididymal cyst: lump arising from epididymis which is felt and easily definable, swelling transilluminates • infection, e.g. epididymo-orchitis, TB or tumour: testis identifiable does not transilluminate Acute inflammatory conditions such as epididymo-orchitis and acute haematocoele are associated with severe tenderness and erythema of the overlying skin. KEY POINT • Systematic examination is crucial in differentiating the causes of a scrotal swelling.
Posted on: Tue, 29 Oct 2013 14:56:09 +0000
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