You are a junior doctor working in urology. A 27-year-old man has been referred to your clinic with concerns regarding a scrotal lump. Work through the clinical case scenario, considering what would be most appropriate at each stage.
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The patient is worried because he noticed a swelling in the left side of his scrotum.
“Doc, I’ve felt this lump…”
History of Presenting Complaint
Onset: When did he first notice the swelling?
Size: Has the swelling grown?
Pain: Is it painful or painless? It may be useful to use the SOCRATES framework for inquiring about pain.
Onset of pain (e.g. sudden, gradual)
Character (e.g. sharp, dull)
Associated symptoms with pain (e.g. nausea, vomiting)
Timing (e.g. is the pain related to anything?)
Exacerbating & relieving factors (i.e. things that make the pain worse/better)
Severity (e.g. scale of 1-10)
Was there any preceding trauma?
Associated symptoms: Infective symptoms such as fever or dysuria, systemic symptoms such as weight loss or night sweats.
Patient response: “I noticed it in the shower a few weeks ago – I didn’t think much at first because it doesn’t hurt, but now I think it’s getting bigger. I feel fine though.”
Other Components of History
See the Geeky Medics guide to taking a sexual history here.
Past medical history
Other medical diagnoses (e.g. patients with Klinefelter’s and Kallman’s syndrome have a greater risk of testicular cancer)
Previous abdominal, pelvic or perineal surgeries
Specifically, ask about a history of childhood cryptorchidism (higher risk of testicular cancer)
Specifically, ask about a family history of testicular cancer.
Illicit drug use
Patient response: “I’ve never had to come to the hospital before. I’m really worried because my Dad had one of his testicles removed, he had cancer when he was about my age. My wife and I want a baby- I don’t want to lose mine.”
General examination of the patient: Do they look well? Have they got signs of infection? Do they look cachexic? Are they in pain?
Examination of scrotum
Site of swelling
Size of swelling
Shape of swelling
Colour: Are there overlying skin changes?
Consistency: Is the lump firm or fluctuant?
Tenderness: Is it painful to examine?
Temperature: Is it hot to touch? (may indicate infection)
Scars: signs of previous surgery.
Cremasteric reflex/ Prehn’s sign
*See the Geeky Medics guide to comprehensive testicular examination, here
Chest and Abdominal Examination: Specifically examine for palpable lymph nodes or signs of lung metastasis (both signs of testicular cancer).
Testicular examination reveals a painless, firm, irregular, intratesticular swelling on the left hemiscrotum
There are no overlying skin changes
Transillumination is negative
Abdominal and respiratory examination are unremarkable
Urinalysis (may show infection/blood which may point to diagnosis)