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SU30.1-6 | Penis, Testis and Scrotum — Graded Quiz
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A 15-year-old boy presents with 5 hours of sudden severe left scrotal pain and vomiting. He is in distress; the testis is swollen, exquisitely tender and lies high in the scrotum. The on-call team proposes urgent Doppler ultrasound to confirm the diagnosis before deciding on surgery. What is the best management decision?
Correct. When the clinical picture is torsion within the salvage window (ideally <6 hours), the patient goes straight to scrotal exploration — imaging must not delay surgery, because a negative or equivocal scan can cost the testis. A clinically clear torsion is a clinical diagnosis.
Clinically clear torsion → straight to theatre. Imaging must not delay exploration; the salvage window is short (~6 h).
Clinical torsion within the salvage window is taken straight to exploration — do not delay for Doppler, as testis viability falls rapidly with time. Imaging is for equivocal cases only and must never hold up surgery in a clear-cut presentation.
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A 31-year-old man has a radical inguinal orchidectomy for a testicular germ-cell tumour. Histology shows pure seminoma. Which serum tumour marker pattern is most consistent with this diagnosis?
Correct. Pure seminoma does NOT raise AFP. Beta-hCG may be modestly elevated and LDH (a marker of tumour bulk) can be raised. A raised AFP indicates a non-seminomatous (yolk-sac) component, reclassifying management.
Pure seminoma: AFP normal; beta-hCG/LDH may rise. Raised AFP ⇒ non-seminomatous element.
AFP is NOT raised in pure seminoma — a raised AFP signals a non-seminomatous component. In seminoma, beta-hCG may be mildly elevated and LDH may rise with bulk. PSA/CEA are not testicular tumour markers.
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A 3-year-old boy is brought with recurrent balanitis and a non-retractile foreskin that is ballooning on micturition; the meatus is normally placed on the glans. Which statement best guides management of his phimosis?
Correct. This is phimosis (non-retractile foreskin). Symptomatic/pathological phimosis (recurrent balanitis, ballooning, scarring) is an indication for circumcision or a steroid trial. Forcible retraction is harmful, and penile carcinoma is a disease of older men.
Phimosis = non-retractile foreskin; symptomatic disease → circumcision/steroid. Paraphimosis = trapped retracted foreskin (emergency). Don't confuse them.
This is phimosis — symptomatic disease (recurrent balanitis/ballooning) warrants circumcision or a topical steroid trial. Paraphimosis is the emergency of a TRAPPED retracted foreskin, a different entity. Never forcibly retract.
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A 19-year-old man presents with a testicular tumour. On taking the history, he reports that this testis had been undescended and was only brought down by orchidopexy at age 9. What is the key lesson this case illustrates about undescended testis?
Correct. The malignancy risk of an undescended testis persists despite orchidopexy, and late orchidopexy is less protective — reinforcing early surgery (6–18 months) and continued self-examination. There is also a modestly increased risk in the contralateral testis.
Undescended testis: cancer risk persists post-orchidopexy (worse if late). Operate early; counsel lifelong self-examination.
The cancer risk of an undescended testis persists after orchidopexy, and late surgery is less protective. The lessons are early orchidopexy and lifelong self-examination — surgery does not abolish the risk.
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A 35-year-old man presents with a new RIGHT-sided varicocele that does NOT decompress when he lies down. Why does this presentation warrant further investigation beyond simple varicocele management?
Correct. Varicoceles are usually left-sided and decompress on lying flat. A new, isolated right-sided varicocele or one that fails to decompress raises concern for a retroperitoneal/renal mass obstructing venous return and should prompt abdominal imaging.
Right-sided/non-decompressing varicocele = red flag → image abdomen for retroperitoneal/renal mass.
Most varicoceles are left-sided and decompress when supine. A right-sided or non-decompressing varicocele is a red flag for a retroperitoneal/renal mass and merits abdominal imaging — it is not a torsion or hydrocele.
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A 28-year-old man has a scrotal swelling that surrounds and obscures the testis and transilluminates. Ultrasound is requested. What is the single most important reason to image and assess the testis itself in any hydrocele in this age group?
Correct. A hydrocele can obscure the testis, and a secondary hydrocele may form around a testicular tumour — particularly important in a young man. Ultrasound assesses the underlying testis to exclude a malignancy hidden by the fluid.
Always assess the testis in a hydrocele — fluid can hide an underlying tumour (secondary hydrocele), especially in young men.
The key reason to image a hydrocele (especially in a young man) is to exclude an underlying testicular tumour, since the fluid can conceal a malignant testis. The hydrocele itself is benign, but it must not hide a cancer.
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Why is a trans-scrotal approach (biopsy or trans-scrotal orchidectomy) strictly avoided when a testicular germ-cell tumour is suspected?
Correct. A trans-scrotal approach breaches the scrotal compartment and its lymphatic drainage, risking tumour seeding and aberrant spread to inguinal nodes. The correct procedure is radical INGUINAL orchidectomy with high cord ligation.
Never approach a testicular tumour trans-scrotally — it alters lymphatic drainage and risks seeding. Use radical INGUINAL orchidectomy.
A trans-scrotal approach disturbs scrotal lymphatic drainage and risks seeding/altered nodal spread (to inguinal nodes). The standard is radical INGUINAL orchidectomy with high ligation of the cord.
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