CONTENTS

• ANATOMY
• CAUSES
• TORSION OF TESTIS
• EPIDIDYMO-ORCHITIS
• HYDROCELE
• EPIDIDYMAL CYST
• VARICOCELE
ANATOMY
OF SCROTUM AND TESTIS
ANATOMICAL POSITION:
STRUCTURE
OF THE
SCROTUM:
LAYERS OF THE SCROTUM:
“Some Dangerous Englishmen Called It The Testis”

S - Skin
D - Dartos M.and fascia
E - External Spermatic fascia
C - Cremasteric fascia
I - Internal Spermatic fascia
T - Tunica vaginalis
T - Tunica albuginea
Blood supply
of scrotum:
Innervation:
 Lymphatic drainage of the scrotum:

Lymph from the

skin, fasciae
and tunica
vaginalis of
scrotum drains
into the
Superficial
inguinal
lymph nodes.
Coverings
of the
Testis:
Structure of
the Testis:
The
Epididymis:
Vascular Supply:

Arterial supply
Venous drainage
Innervation:
The testicular
plexus:
a network of
nerves
derived from the
renal and aortic
plexi.
Lymphatics:

The lymphatics ascend

along the testicular
vessels and drain into
the preaortic and para
aortic groups of lymph
nodes.
MICROANATOMY
Spermatic
cord
contents:
 Causes of Scrotal Swellings

Acute Painful Chronic Painless

• Torsion testis •Hydrocele
• Torsion of testicular •Epididymal cyst
appendages •Spermatocele
• Acute epididymo-orchitis •Varicocele
•Chronic epididymo-orchitis
•Testicular tumor
TORSION OF TESTIS
 Case study - Torsion Testis
• A 14-year-old boy presents with acute onset of right scrotal
and RLQ pain for the past 4 hours. He additionally reports
nausea and one episode of vomiting. He denies any similar
past pain and reports no history of trauma.
• O/E: the skin overlying the right side of the scrotum appears
to be slightly erythematous and edematous. The right
testicle appears to be lying significantly higher in the
scrotum as compared to the left testicle.
• The entire right testicle is exquisitely tender to palpation,
whereas the left one is nontender
• He has an absent cremasteric reflex on the right.
 Torsion Testis - Etiopathogenesis
• Testicle twist in a way that its blood supply becomes
compromised
• Twisting of testis along with spermatic
cordStrangulationNecrosis
• Uncommon (normal testis is anchored and cannot rotate)
• For torsion to occur, one of several abnormalities must be
present:
• Inversion of testis
• High insertion of tunica vaginalis- hang like a bell clapper
• Separation of epididymis from the body of the testis
Clapper = Testis
 Torsion Testis - Types

In Neonates In Adolescents
 Torsion Testis – Clinical features

• Most common between 10-25 years of age

• Sudden severe pain in hemiscrotum or both sides
• Nausea & vomiting
• Scrotal skin edematous and erythematous
• Testis exquisitively tender
• Cremastric reflex absent in affected side
Torsion Testis – Clinical features
Torsion Testis – Clinical features
Torsion Testis – Clinical features
Torsion Testis – Differential diagnosis
Torsion Testis- Doppler USG

Central testicular blood flow Normal Testis

No central testicular blood flow but

excessive peripheral blood flow
 Torsion Testis – Treatment

• Ipsilateral side through a scrotal incision, Exploration,

detorsion and fixation orchiopexy
• Contralateral side Exploration and fixation orchiopexy
(anatomical predisposition is likely to be B/L)
• An infarcted testis should be removed
• In doubtful cases and nonavailability of Doppler USG Better to
explore rather than unduly delay the treatment
• Testicular salvage rate is 100% if surgery is done within 6 hrs and it
is 20% if surgery is delayed > 24 hrs
 Torsion of Testicular Appendages

• Hydatid of testis & epididymis Remnant of obliterated

Mullerian ducts
• Sudden Swelling and redness of hemiscrotum
• Tender Testis
• ‘Bluedot sign’ +ve
• Cremastric reflex intact
Torsion of Testicular appendages
“Blue dot sign”
 Torsion of Testicular Appendages -
Treatment

• Explore & Excise torsed appendages in early cases

• In delayed cases >48 hrs, conservative treatment
with antibiotics & anti inflammatory drugs
Testicular Torsion- Mindmap
EPIDIDYMO-ORCHITIS
A 24-year-old male presents to the emergency with
a painful, swollen right scrotum. The pain began 2
days ago and has become progressively worse. He is
sexually active with three partners and occasionally
uses condoms. His right scrotum is erythematous
and tender to palpation. On examination, there is a
positive Prehn’s sign. From the list below, what is the
most likely causative organism?
A. Neisseria gonorrhea
B. Escherichia coli
C. Pseudomonas aeruginosa
D. Chlamydia trachomatis
E. A paramyxovirus
 Acute epididymo-orchitis

• Inflammation of epididymis & testis due to infection or trauma

• Commonly associated with UTI or trauma
• Young  arises secondary to a sexually transmitted genital
infection (Chlamydia trachomatis, Neisseria gonorrhea)
• Older  secondary to urinary infection
• May be complication of catheterisation or instrumentation of
the urinary tract
• That’s why a dose of antibiotic is given after placing and after removal of
urinary catheter.
• Scrotal pain, swelling, and erythema
• Fever
• Thickened & tender epididymis
• Can be treated conservatively with antibiotics
(Doxycycline/quinolones) and antiinflammatory
drugs
Acute Epididymo-orchitis
Doppler USG
USG Scrotum
• Thickened Epididymis
• Reactive Hydrocele
• Thick scrotal wall

Doppler USG
• Excessive blood flow to Epididymis
• Normal testicular parenchymal
blood flow
HYDROCELE
 Case study – Vaginal Hydrocele
• A 35-year-old male patient presents with right sided scrotal
swelling of two years duration. It is a progressively
increasing painless swelling.
• O/E: the right side of the scrotum shows a swelling of 15 ×
10 cm size which is confined to the scrotum (can get above
the swelling). The surface of the swelling is smooth and
borders are well-defined. There is no local rise of
temperature. The swelling is fluctuant and transilluminant.
It is not reducible.There is no cough impulse. The right
testis is not felt separately. On percussion it is dull.
• The spermatic cord is felt above the swelling and is tender.
• The contralateral testis and genitalia are normal. There is no
evidence of any mass or lymph nodes in the abdomen
Hydrocele is an abnormal collection of serous fluid in
a part of the processus vaginalis, usually the tunica
vaginalis.
Aetiology
A hydrocele can produced in 4 different ways:

1. Defective absorption  primary

2. Excessive production  secondary
3. Lymphatic obstruction  filarial
4. Connection with patent processus vaginalis 
congenital
 Composition of Hydrocele Fluid

• Color—Straw or amber colored.

• Composition—Water, fibrinogen, inorganic salts,
albumin and cholesterol crystals
• Hydrocele fluid normally won’t clot if it is drained
into a container but will clot immediately even if it
comes into contact with a drop of blood
 Primary Vs Secondary Hydrocele
Primary Hydrocele Secondary Hydrocele

• Defective absorption of • Excessive production of fluid

fluid
• Ex: Vaginal & infantile • Ex: Filariasis, tumor, trauma
hydroceles & epididymo-orchitis
• Attain moderate to big size • Attain small size
• Difficult to palpate testis • Testis easily palpable
• Transillumination positive • Transillumination negative
• Consistency tensely
cystic • Consistency Lax cystic
• Tx: Jaboulay’s & Lord’s • Tx: Treat underlying causes
operations
 Primary Hydrocele - Types
1. Congenital hydrocele
2. Funicular hydrocele
3. Infantile hydrocele
4. Encysted hydrocele of the cord
5. Vaginal hydrocele- commonest type
6. Bilocular hydrocele/-en-bisac
7. Hydrocele of the hernial sac
 Primary Hydrocele - Clinical features

• Moderate to big size swelling

• Cough impulse negative
• Get above the swelling positive
• Not reducible
• Consistency tensely cystic
• Transillumination positive
• Testis not felt separately
• Transillumination negative in Hematocele, Pyocele,
Chylocele and thick sac
Primary Hydrocele - Clinical Pictures
 Primary Hydrocele- Complications
• Infection
• Pyocele
• Hematocele
• Atrophy of testis
• Infertility
• Hernia of hydrocele sac (rare)
• Rupture & calcifications
 Primary Hydrocele- Treatment
• Congenital hydrocele- Inguinal herniotomy

• Adult vaginal hydrocele

Small sizeLord’s plication / Jaboulay’s operation
Large sizeIncision and eversion of sac
 Complications of surgery

• Reactionary haemorrhage Hematocele

• Infection
• Pyocele
• Sinus formation
• Recurrent hydrocele
Hydrocele - Mindmap
EPIDIDYMAL CYST
Case study – Epididymal Cyst
• A 45 years old male patient presented with a
swelling in right side of the scrotum for last 3 years
which is increasing very slowly in size. There is no
pain over the swelling.
• O/E: There is a soft cystic swelling in relation to the
head of the right epididymis. The swelling has a
lobulated surface and feels like a bunch of grapes.
• Testis can be felt separately from the swelling
• The swelling is brilliantly transilluminant and has
Chinese lantern pattern appearance
 Epididymal Cyst - Etiopathogenesis

These are cysts in connection with the epididymis

divided into the following types:
1. Degeneration cysts occur due to cystic degeneration
of the epididymis Epididymal cyst
2. Retention cysts due to obstruction of the sperm
conducting mechanism Spermatocele (Ex: after
vasectomy)
 Epididymal Cyst- Clinical Features

• Most epididymal cysts occur in males over the age of 40

years
• An epididymal cyst usually contains clear fluid
• They are often multiple or multilocular and are frequently
bilateral and feels like bunch of grapes
• Brilliantly transilluminant “Chinese lantern pattern”
• Testis palpable separately
Epididymal Cyst- Clinical Features
Spermatocele
• Unilocular retention cyst
• The fluid contains spermatozoa , and resembles
barleywater appearance
• Typically lies in the epididymal head above and
behind the upper pole of the testis
 Epididymal Cyst - Treatment

• Single large cyst  Excision of cyst

• Recurrent or multilocular cyst Excision + partial
or total epididymectomy
• No role for aspiration because cysts are
multilocular
• Spermatocele if big aspiration or excision; If small
no intervention
Epididymal Cyst - Mindmap
VARICOCELE
 Case study - Varicocele
• 30 years male patient presented with a swelling in the
left side of the scrotum for last 4years. The swelling
started in the lower part of the scrotum and
subsequently the swelling is slowly increasing in size
and grown up to the root of the scrotum. The swelling
disappears on lying down position and reappears on
standing and walking
• Patient complains of dull aching pain in the left side of
the scrotum for last 6 months, the pain is more towards
the evening when the swelling enlarges in size
• There is no pain abdomen, no urinary complaints
 Case study - Varicocele
• O/E: A mass of dilated vein feeling like a bag of worms is
palpable on the left side of the scrotum along the left
spermatic cord extending from the upper pole of the
testis up to the superficial inguinal ring
• No expansile impulse on cough is palpable, instead a
thrill is palpable. On lying down and on elevation of the
scrotum the swelling disappears
• On asking the patient to stand up the dilated veins
reappeared. The left testicular volume is smaller than
the right one. Abdominal examination is normal
 Varicocele-Anatomy
• Surgical Anatomy: Pampiniform plexus of veins (15 – 20) draining the testis
and epididymis makes the major bulk of the spermatic cord. As they ascend,
the number is reduced to 12 and on reaching the superficial inguinal ring
they unite to form 4 veins. At the level of deep ring they are 2 in number and
in retroperitoneum, it forms single testicular vein.
• Left testicular vein drains into left renal vein and right testicular vein into
inferior vena cava

• It is common on the left side5 reasons.

Left testicular vein is longer than right testicular vein
Left testicular vein enters at right angle to the left renal vein
Left testicular artery is arching over left testicular vein
A loaded sigmoid colon compressing left testicular vein
Left renal vein is compressed b/w the Aorta and SMA
 Varicocele
• Varicose dilatation of • Primary or secondary
vein draining testis • May lead to infertility
• 20% , left sided
• Cause:
• Idiopathic
• Absent /incompetent
valve in proximal
testicular vein
• Obstruction
 Varicocele- Etiology

1.Idiopathic/Primary – due to incompetency of valves. 98% occur on

the left side

2.Secondary – due to obstruction of flow

 Pelvic or abdominal mass.
 Lt renal cell carcinoma with tumor thrombus in left renal vein.
 Nutcracker syndrome- SMA compressing left renal vein. Other
conditions- Retroperitoneal fibrosis or adhesions
 Varicocele
(Bag of Worms Appearance)
Clinical features Investigations
• Asymptomatic
• Symptomatic • Venous doppler of
- Dragging scrotum and groin
discomfort worse • Ultrasound abdomen
on standing at end • Semen analysis
of day
- Scrotum hangs
lower than normal
- Bag of worms
 Varicocele- Treatment
• Asymptomatic varicocele—No treatment is
required, only scrotal support and reassurance

• Symptomatic varicocele—Excision of the

pampiniform plexus in the inguinal canal after
ligating them. (Testis still has venous drainage via the
cremasteric veins)
Varicocele- Treatment
• Ligation of testicular vein
• Suprainguinal (Palomo’s)
• Inguinal (Ivanissevich)
• Subinguinal (Marc- Goldstein)*
• Scrotal
 Varicocele - Coil Embolization

• Non-surgical procedure.
• Steel coil or silicone balloon catheter is introduced into a vein
below the groin through a nick in the skin.
• Passed under X-ray guidance.
• Tiny metal coils or other embolizing agents introduced through
the catheter.
• No stitches needed.
• Patient can go back in 24hrs.
• Lower rates of complications. Less effective, higher
recurrence(5-11%), danger that the coil could migrate to the
heart and cause death
Varicocele - Coil Embolization
 Surgery- Complication

• Haemorrhage and scrotal haematoma

• Infection Pyocele
• Injury to testicular artery
• Injury to ilioinguinal nerve and pain
• Recurrence—5-10%
Varicocele - Mindmap
 D/D for Scrotal Swellings
(Compare & Contrast) (Vertical Reading)
Scrotal Swellings Ex & Px Hx Sx Dx Tx

1. Hydrocele Primary-Idiopathic Painless big No cough impulse Clinical Lord’s operation

Secondary- under swelling; not Get above swelling+ In doubt- USG of Jaboulay’s
lying pathology reducible Transilluminant+ scrotum operation
2. Epididymal Degeneration of Swelling in Testis palpable Clinical Conservative
cyst & epididymis, occlusion scrotum separately; Chinese USG of scrotum Excision
Spermatocele of pathway resembles 3rd lantern appearance
testis
3. Varicocele Idiopathic Worm like in Disappears on lying Clinical Varicocelectomy
Absence of valves in upper scrotum; down; Bag of worms USG color doppler Inguinal or
testicular vein infertility appearance Retroperitoneal
4. Testicular Abnormal fixation Severe pain& Tender hemi Clinical Explore,detorse,
torsion & and lie of testis swelling scrotum scrotum; cremasteric USG color doppler orchiopexy or
Epididymo- UTI & trauma Nausea & reflex absent orchidectomy
orchitis vomiting Conservative
5. Testicular UDT, Kieinfelter’s Painless heavy Not reducible Clinical; No FNAC High orcidectomy
carcinoma Germ cell- Seminoma swelling Hard in consistency USG OF scrotum with or without
& Non seminoma Testis felt separately RPLND+ RT+CT
Non germ cell tumor
References
• Williams, Bulstrode, O’connell, Bailey and Love’s
Short Practice of Surgery, 26th edition, 2013
• Sriram Bhat M , SRB’s Manual of Surgery, 5th
edition, 2016
• https://www.slideshare.net/babysurgeon/scrotal-
swellings-1 (Dr Selvaraj Balasubramani)
•Thank you