Case 1 – I may have noticed a lump in my scrotum

‘I have noticed a lump in my scrotum. Have I got cancer?’ Tom is a 28-year old male who presents with a swelling in the right testicle. He first became aware of the lesion a couple of weeks ago when he was playing with his 18-month old daughter who accidentally head-butted him. He has not felt any pain in the testicle. However, on closer questioning he says that he has noticed a dragging/ heavy sensation in the scrotum off and on over the last few months. He had attributed this symptom to the fact that he has recently taken to jogging to work. On examination he is found to have a non-tender, 2-cm rubbery mass at the apex of the right testicle. The lesion is ovoid. The left testicle is of normal size and consistency.

V I N D C A T E O Testicular Lump Ddx Vascular Inflammation Neoplasm Congenital Allergic Autoimmune Trauma Obstruction Skin Carbuncle Carcinoma Urticaria Contusion Sebaceous cyst Subcutaneous Tissue Cellulitis Direct inguinal hernia Tunica Vaginalis Indirect inguinal hernia Haematocele, haematoma, hydrocoele Hydrocele Venous Plexus Phlebitis Obstruction from renal carcinoma Varicocele Testis Orchitis Seminoma Teratoma Syphilis Non seminoma: Embryonal carcinoma, Chorioepithelioma, Yolk sac, teratoma Mixed germ cell Non germ cell: sex cord tumours Hydatid cyst of Morgagni Epididymis Bacterial epididymitis Cyst Spermatocele Tuberculosis Artery Torsion Vas Deferens Secondary to obstruction by carcinoma of prostate Prostate disease Lymphatics Filariasis

Probability Dx Signs & Symptoms: Rubbery consistency, painless lump, dragging sensation for 2 months makes neoplasm or cyst (epididymal cyst, Hydatid cyst of Morgagni) likely. Age 27 excludes lymphoma, more likely to be seminoma but other types (non-seminoma, mixed germ cell, sex cord tumours and non-germ cell tumours) must be ruled out by biopsy. Trauma: head butt by daughter raises possibility of trauma causing haematoma, haematocele, hydrocele. Presence of fever, pain, malaise, nausea with a Hx of unsafe sexual practices, multiple partners, etc. would make bacterial infection more likely. Mumps is most common cause of orchitis – but still need more history.

Other Hx Confirm that the daughter did actually head butt him in the goolies. Did the lump appear soon after? The lump itself: has it since changed size, consistency Associated symptoms of malignancy: weight loss, night sweats, metastases: lung (cough, haemoptysis), back pain, enlarged cervical or inguinal nodes Any symptoms associated with infection: fever, malaise, nausea, penile discharge (puss, blood), dysuria, skin changes, arthropathies PMH: cryptorchidism, UTI’s, STI’s, mumps, parotid swelling Social Hx (O/S travel, sexual Hx) Family Hx: varicose veins (varicocele), cancers

Further clinical examination? Transillumination Abdominal exam Lymph nodes Neuro Ankle edema Gynecomastia Thyroid

Investigations? Ultrasound MRI α fetoprotein β hCG LDH Sperm count AJCC/UICC TNM staging

Treatment options? Sperm cryopreservation Radical inguinal orchiectomy Testicle sparing surgery Retroperitoneal lymph node dissection Chemotherapy Active surveillance Radiation therapy

Sources Up to date: http://www.uptodate.com/contents/evaluation-of-nonacute-scrotal-pathology-in-adult-men