Testicles are normally examined if there is:
- Pain
- Swelling
- Abdominal pain (torsion of testes)
Examination
- Usual stuff – wash hands, check right patient, introduce yourself, explain, get a chpaerone
- Normally, would do full abdominal exam, and check the hernia orifices (check for lumps and bumps in the groin).
- Get the patient to lie flat, ask for any pain
- Check the distribution of pubic hair (any gynaecomastia? Liver failure?), skin (scars, swelling, discolouration)
- Testicles should generally be at the same height, and be the same size, often the left is slightly lower than the right.
- 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!
- 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;
- Can you get above it?
No – inguinal scrotal hernia
Yes – ask the next 2 questions
- Is it separate or part of the testes?
- 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!