Problem 8 A scrotal swelling in a 27-year-old man
Q.1
What is the most important diagnosis to exclude and what other information should be sought from his history?
The patient is mildly autistic, unemployed, and is looked after by his older brother. He has hypothyroidism and attention deficit hyperactivity disorder. There is no history of any previous testicular or scrotal problems such as maldescent or trauma. There is no apparent history of any infections.
On examination of the scrotum and contents there is a 10 cm irregular firm mass replacing the left testis. This is not tender and not tethered to the scrotal skin. The right testis is normal to palpation. On abdominal examination there is an ill-defined fullness palpable just above the umbilicus to the left of the midline. There was no obvious gynaecomastia or supraclavicular lymph node enlargement.
You arrange an urgent ultrasound of the abdomen and testis as well as baseline bloods investigations and testicular tumour markers. In addition, and because of the abdominal findings, you arrange a CT of the chest and abdomen (Figures 8.1, 8.2). The haematological and biochemical values are within normal limits. The tumour marker and imaging studies are shown.
Investigation 8.1 Summary results
| LDH | 922 IU/L | (50–280) |
| AFP | 3 µg/L | (<11) |
| HCG | 7 IU/L | (<5) |
You appreciate that the patient almost certainly has metastatic testicular cancer and this is most likely to be a seminoma. There is no role for a trans-scrotal needle biopsy of the testicular mass and this can potentially result in tumour seeding and scrotal violation as the testis and scrotum lymphatics drain to different sites.
The patient subsequently undergoes a left radical inguinal orchidectomy and the diagnosis of seminoma confirmed.
Answers
A.1 The patient may well have a hydrocele with an underlying testicular malignancy. About 10% of patients with a testicular tumour have a previous history of cryptorchidism. Other conditions to consider include various inflammatory processes producing an epididymitis and/or an orchitis. Any history of pain, acute swelling, urethral discharge or infection might suggest exposure to a sexually transmitted disease or urinary tract infection.
A.2 In any man presenting with a scrotal swelling, it is important to elicit the anatomical characteristics of the swelling in order to define the structures from which the swelling has arisen. Conditions within the scrotum to consider include:
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