Scrotal Masses – A Discuss with Dr Shay – Aids West

Article courtesy of Aid West

In a break From my usual discussion on aspects of hIv, I decided to discuss what should be an integral part of all male sexually transmitted Infection (stI) screening, the testicular check. a routine stI examination in men should include a scrotal and testicular examination and as a physician, I believe it is an ideal time to instruct men on how to examine their testicles. once every one to two months should suffice. this examination, like a breast examination in women, is aimed at picking up pathology as soon as possible, thereby limiting morbidity and mortality. testicles should be checked for masses (lumps), volume (size), tenderness and cryptorchidism (hidden or obscure testes). a testicle less than 3.5cm is considered small and therefore not within the normal range. the medical term for a shrinking testicle is atrophy and may signal chronic disease and subsequent testosterone loss and infertility. and now the science bit! the testicles are in the scrotum attached to a tube called the spermatic cord. this cord contains the essential blood supply to the testicle, the testicular artery and the veins which bring the blood back to the heart, the venous return. In addition, the cord contains the vas deferens, which brings part of the semen content, in the healthy testicle, containing sperm from the testicle where it is made. Furthermore, the testicle is surrounded by two layers of tissue termed the tunica. the testicle

And now the science bit! the testicles are in the scrotum attached to a tube called the spermatic cord. this cord contains the essential blood supply to the testicle, the testicular artery and the veins which bring the blood back to the heart, the venous return. In addition, the cord contains the vas deferens, which brings part of the semen content, in the healthy testicle, containing sperm from the testicle where it is made. Furthermore, the testicle is surrounded by two layers of tissue termed the tunica. the testicle

Testicles should be checked for masses (lumps), volume (size), tenderness and cryptorchidism (hidden or obscure testes). a testicle less than 3.5cm is considered small and therefore not within the normal range. the medical term for a shrinking testicle is atrophy and may signal chronic disease and subsequent testosterone loss and infertility. and now the science bit! the testicles are in the scrotum attached to a tube called the spermatic cord. this cord contains the essential blood supply to the testicle, the testicular artery and the veins which bring the blood back to the heart, the venous return. In addition, the cord contains the vas deferens, which brings part of the semen content, in the healthy testicle, containing sperm from the testicle where it is made. Furthermore, the testicle is surrounded by two layers of tissue termed the tunica. the testicle are for most men fixed at the back to the scrotum so do not swing on the spermatic cord in the scrotum. When we discuss potential pathologies of the testicle, a basic knowledge of the anatomy of the testicle is desired. there are five ‘must not miss’ pathologies which give rise to a scrotal mass. these are testicular torsion, epididymitis, orchitis, inguinal hernia and testicular cancer. less serious abnormalities in the scrotum include hydrocoele,

There are five ‘must not miss’ pathologies which give rise to a scrotal mass. these are testicular torsion, epididymitis, orchitis, inguinal hernia and testicular cancer. less serious abnormalities in the scrotum include hydrocoele, varicocoele and spermatocoele. a testicular torsion occurs due to an anatomical deformity which allows the testicle to twist around the spermatic cord. this happens when the spermatic cord is not fixed in place at the back of the scrotum. the blood supply can then be cut off to the testicle and gangrene can set in. men with torsion usually feel a severe one-sided scrotal pain. When the urine is checked for infection, it is sterile. this is a surgical emergency and prompt intervention is essential. epididymitis, inflammation of the part of the vas deferens which is attached to the testicle, is the commonest cause of swollen testes in post-pubertal males. scrotal pain with fever and or urethral discharge is gradual. the epidiymis is enlarged and the scrotum may be red. In the under thirty fives, the commonest causes of epidiymitis are Chlamydia and Gonorrhoea. In over

A testicular torsion occurs due to an anatomical deformity which allows the testicle to twist around the spermatic cord. this happens when the spermatic cord is not fixed in place at the back of the scrotum. the blood supply can then be cut off to the testicle and gangrene can set in. men with torsion usually feel a severe one-sided scrotal pain. When the urine is checked for infection, it is sterile. this is a surgical emergency and prompt intervention is essential. epididymitis, inflammation of the part of the vas deferens which is attached to the testicle, is the commonest cause of swollen testes in post-pubertal males. scrotal pain with fever and or urethral discharge is gradual. the epidiymis is enlarged and the scrotum may be red. In the under thirty fives, the commonest causes of epidiymitis are Chlamydia and Gonorrhoea. In over thirty five, organisms which cause urinary tract infections are implicated such as e. coli. a surgical review is not warranted in uncomplicated cases. treatment is with bed rest, appropriate antibiotics and scrotal support. similarly, orchitis, inflammation of the testicle itself manifests with a sudden onset testicular pain and or temperature. the testicle is enlarged and commonly the organisms responsible are as for epidiymitis, Chlamydia and Gonorrhoea in the under thirty five, and e. coli in the over thirty fives. orchitis can occur in 20-30% of cases of mumps and is a real risk of infertility in men. tuberculosis and syphilis are rarer causes of orchitis. once again, bed rest, scrotal support and antimicrobials are advised. an inguinal hernia occurs when part of the bowel pushes through a weak part of the muscle in the groin above the scrotum, right or left. this can be either direct or indirect. With a direct inguinal hernia, the bowel pushes through the muscle forming a lump which is worse when standing or coughing. In early

An inguinal hernia occurs when part of the bowel pushes through a weak part of the muscle in the groin above the scrotum, right or left. this can be either direct or indirect. With a direct inguinal hernia, the bowel pushes through the muscle forming a lump which is worse when standing or coughing. In early cases it can be pushed in temporarily but surgical closure of the breached muscle layer is usually warranted. an indirect inguinal hernia occurs when the bowel pushes through a channel (the inguinal canal) from the lower abdomen into the scrotum. the worry here is that the blood supply to the bowel might be compromised and gangrene of the bowel may follow. as with testicular torsion, urgent surgical evaluation is essential. testicular cancer is usually identified by a physician or patient on finding a painless mass in the body of the testicle. the patient might describe a dull ache or heaviness in the scrotum on the side of the tumour. the average age is 32 years but from late teens to early-forties, as mentioned earlier, regular checking of the scrotum and testicles is strongly advised. there are different types of testicular cancer and therapeutic options, removal, chemotherapy or radiotherapy in advanced cases are indicated. a cryptorchidism (hidden or absent testicle) may herald the onset of cancer in an undescended testicle. less serious scrotal masses include hydrocoele,

Less serious scrotal masses include hydrocoele, varicocele and spermatocoele. a hydrocoele occurs when fluid builds up between the two layers of ‘tunica’ surrounding the testicle. this is usually an anatomical defect but is quite common in clinical practice. It may be uncomfortable and grow big. In this case, surgery to stick the two layers of the tunica together may be indicated. a varicocoele occurs when the plexus or network of veins bring blood from the testicle to the heart, the venous return becomes engorged. anatomically this usually occurs on the left side. It may be uncomfortable but for many is not problematic and may feel like a ‘bag of worms’ when felt in the scrotum. It is however implicated in infertility for some men due to the increased temperature of the testicles. a sudden presentation of a varicocoele in an older man should prompt investigation to rule out any blockage of the venous return by tumours in the bowel or around the kidney. Finally a spermatocoele painless cyst separate from the testicle on the top or bottom of the testicle. It is a small blocked tube from the testicle to the epidiymis and is benign and may contain a few sperm. It may need reduction but for most, no intervention is required. so to

So to summarise, physicians and patients need to be vigilant to pick up the ‘must not miss’ scrotal masses. early pick up improves outcome so regular checking is essential in the young man.

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