Testicles are normally examined if there is:
  • Pain
  • Swelling
  • Abdominal pain (torsion of testes)

Examination
  1. Usual stuff – wash hands, check right patient, introduce yourself, explain, get a chpaerone
  2. Normally, would do full abdominal exam, and check the hernia orifices (check for lumps and bumps in the groin).
  3. Get the patient to lie flat, ask for any pain
  4. Check the distribution of pubic hair (any gynaecomastia? Liver failure?), skin (scars, swelling, discolouration)
  5. Testicles should generally be at the same height, and be the same size, often the left is slightly lower than the right.
  6. Check the penis – is it twisted, lumpy, has warts (STI?), smegma – smelly white lumpy stuff under the foreskin – may indicate poor hygiene.  Look for phimosis and paraphimosis, ulcers and skanka. Make sure you look behind the foreskin!
  7. Palpation

Are both testes present?! Feel for roughly same size and shape. If they are not both present – it could be due to surgical removal, failure to descend, or retraction.
Are there any lumps? Gently roll the testicles between your fingers. Lumps:

  • Can’t get above it – probably an indirect inguinal hernia. Explain a bit about direct and indirect hernias. How do you differentiate 1) indirect and direct inguinal hernias. 2) femoral and inguinal hernias.
  • Varicocele – basically big squidgy veins at the back of the testicle – bag of worms
  • Testicular cancer – a hard lump on the testes.
  • Orchitis – caused by infection – big swollen testes.
  • Epididymitis – swollen epididymis – infection – this can lead on to cause orchitis.
  • Hydrocele – this will make the testes very large! – it is a collection of fluid around the testicle in the tunica vaginalis– it will make the testicle very difficult to feel.  – this will transluminate to a red colour!

Check the lymph nodes – the ones to check are inguinal for scrotal pathology, and para-aortic for testicular pathology.

If Masses felt need to describe them!

  • Site
  • Size
  • Shape
  • Skin colour changes
  • Transilluminate
  • (hydrocele –red light)
  • Tethering
  • Temperature
  • Tender
  • Thrill
  • Colour
  • Consistency
  • Contours
  • Cough Impulse- (positive if hernia or varicocele)
If you have found a mass need to ask yourself 3 questions;
  1. Can you get above it?
No – inguinal scrotal hernia
Yes – ask the next 2 questions
  1. Is it separate or part of the testes?
  1. Is it cystic or solid?
    • Testicular and Solid – tumour, orchitis, granuloma, gumma (characteristic tissue nodule found in the tertiary stage of syphilis).
    • Testicular and cystic – hydrocele
    • Separate and solid – epididymitis or orchitis
Look for Prehn’s Sign = lifting up testicle relieves pain
Most often caused by STI- Chlamydia and gonorrhea or E.coli
  • Separate and cystic – epidymal cyst
     (if cyst with sperm in = spermatocele)
What else you would do
  • Palpate lymph nodes
  • Do a full abdominal examination, checking hernial orifices
  • Get patient to stand up (varicoceles collapse on lying flat)
  • Summarize what you have found and other investigations you would like to do if suspected tumour…blood tests, USS, CXR (can get lung mets), CT staging (Royal Marsden’s systems – 4 stages)
Testicular Tumours
  • Age 20-30 more likely to be a teratoma
  • Age 30-40 more likely to be a seminoma
  • Tumour markers for testicular cancer are alpha feto protein( AFP), HCG and LDH.
  • Risk factors; undescended testicles
  • Treatment is surgery and radiotherapy (Seminoma is especially radio sensitive)
Differentials of lumps in groin
  • Aneurysm of femoral artery
  • Vein
  • Cysts
  • Lymphadenopathy
  • Undescended testicle
  • Hernia
Torsion of the testes
  • Common is under 20
  • Severe, sudden pain, testicular or abdominal
  • Sometimes vomiting
  • Testes may contract, lie high up and transverse
  • Needs urgent surgical exploration – orchidectomy (removal of testes) or bilateral orchidopexy (stitch testes to tunica vaginalis)

At end always inform patient that the examination is over with and THANK THEM!

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