Scrotal Swellings
Div. of Urology, Dept.of Surgery
Medical Faculty,
University of Sumatera Utara
Common Causes of Scrotal Swellings
Hydrocele
Epididymal Cyst
Varicocele
Epididymo-orchitis
Testicular Tumour
Hydrocele
Fluid collections within the tunica vaginalis
of the scrotum or along spermaticcord.
Persistent developmental connections along
the spermatic cord or Imbalance of fluid
product versus absorption.
Little risk of clinical consequence.
Pathogenesis
The fluid collects because of an imbalance
between production and absorption.
The tunica vaginalis normally produces around
0.5ml of fluid a day.
Pathophysiology
Proc. Vaginalis is a diverticulum of the
peritoneal cavity.
It descends with the testis into the scrotum
(28th gestational week).
Common Causes
Congenital
(PPV)
Patent processus vaginalis
Acquired
Idiopathic
Tumour
Trauma
Infection
History & Examination
History:
A painless swelling in the scrotum.
Onset may be gradual or sudden.
Examination:
A scrotal swelling which you can
get above
The testis cannot be palpated separate to the
swelling
The lump transilluminates
Investigation
Because one of the causes of a hydrocele
is testicular tumour, it is important to
arrange a scrotal ultrasound to rule out
this as an underlying pathology
Treatments
Conservative management if the hydrocele is
small and causing little in the way of symptoms
Aspiration +/- injection of a sclerosing agent
Surgery:
Ligation of PPV in children
Jaboulay
Lords
Both the Jaboulay and the Lords procedure
involve incising the tunica vaginalis to allow the
hydrocele fluid to be absorbed by the scrotal
lymphatics.
Differentials
Orchitis
Testicular torsion
Indirect inguinal hernia
Traumatic injury to the testical
Epididymal Cyst
Definition
A cystic swelling arising from the
epididymis
History & Examination
History:
Painless scrotal swelling
Onset usually gradual
Examination: Scrotal swelling which you
can get
above
Testis palpable separate from the lesion
The cyst transilluminates
Management
Simple surgical excision of the cyst
Aspirating will not work because the cyst is
multiloculated
As for hydroceles, conservative management is
perfectly reasonable if the patient is
asymptomatic
Varicocoele
Definition
A varicocoele is a dilatation of the veins
of the
pampiniform plexus
Symptoms & Signs
Symptoms: Scrotal swelling
Far more common on left than on right
Dragging / aching sensation in the groin /
scrotum
Signs:
Scrotal swelling which you can get
above
Swelling feels like a Bag of worms
Significance of Varicocoele
A left sided-varicocoele may arise as a result of
obstruction to venous drainage caused by a
renal tumour
Therefore all patients with a varicocoele
should
undergo imaging (usually ultrasound) of their
kidneys
Methods of Treatment
The two main methods are:
1
2
Surgical ligation
Embolisation under X-Ray control
Epididymo-Orchitis
Definition
An inflammation of the tissues of
the epididymis and testis
Symptoms & Signs
Symptoms:
Painful scrotal swelling
Signs: A scrotal swelling which you can get
above and which is
- hot
- tender
- erythematous
Treatment
An appropriate broad-spectrum
antibiotic is used, such as
ciprofloxacin.
Ciprofloxacin
This is a fluoroquinolone antibiotic
It acts by inhibiting an enzyme called DNA
gyrase in
reproducing bacteria. This is one of the enzymes
responsible for unwinding DNA during replication
Testicular Tumours
Classification
You might sensibly start classifying testicular tumours into
benign and malignant. In fact benign solid tumours of
the testis are extremely rare.
The classification of malignant tumours is complicated by
the fact that there are different classification systems
used in the UK and USA and consequently its easy to get
confused if you read textbooks from the different
countries.
divided into:
1 Germ Cell Tumours
2 Other tumours, the commonest of which
is lymphoma, which is the commonest
testicular malignancy in the
older patient.
Germ cell tumours can be divided into
1
2
Seminomas
Non-seminomatous germ cell
tumours
But Remember
40% of testicular tumours are mixed,
i.e. they have both seminomatous
and non
seminomatous elements
Peak Age Incidence
Seminomas 40 years
NSGCTs
30 years
Symptoms & Signs
Symptoms: Painless scrotal swelling
Chance discovery
Testis feels heavier
Signs: Scrotal swelling which you can get above
The lump is craggy & does not
transilluminate
May be associated with hydrocele
May have palpable liver due to
metastases
Investigations
Radiology:
Blood Tests:
Ultrasound of testis
CT of abdomen to assess spread
Chest X Ray for metastases
AFP (alpha feto-protein)
b-hCG (human chorionic
gonadotrophin)
LDH (lactate dehydrogenase)
The blood tests are known as tumour markers.
Surgery
An inguinal orchidectomy is performed
i.e. the testis is taken out through an incision in
the groin
This is because the lymphatic drainage of the
testis is to the para-aortic nodes. An incision
in the scrotum risks spreading the tumour to
the superficial inguinal lymph nodes which
drain the scrotal skin
Other Treatments
If the tumour has metastasised, other
options for treatment include:
Radiotherapy for seminoma
Chemotherapy for NSGCTs
Sometimes a combination of the two is
required
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