Swelling in Inguinosacrotal
History taking:
⮚ Biodata:
✔ Name
✔ Age:
● Funiculitis is a disease of young age.
● Others like Lymph Varix, Varicocele & Encysted hydrocele present at any age
✔ Occupation: prolonged standing could be the cause of Varicocele
✔ Married? have children? sterility in case of bilateral undescended testes
⮚ History of presenting illness:
✔ Pain?
● Funiculitis is always associated with pain.
● Tuberculous thickening of the cord, as an extension upwards from the epididymis, is
associated with pain.
● Malignant extension upward from the testis could also be associated with pain.
● Vague dragging pain is experienced on prolonged standing in case of a varicocele
● Sudden agonizing pain over inguinoscrotal region and in the lower abdomen is
complained of in torsion of the testis. On right side this condition often mimics
appendicitis. So always examine the scrotum in case of sudden lower abdominal pain
✔ Swelling (main presenting feature in encysted hydrocele of the cord, diffuse lipoma of the
cord, lymph varix etc.)
● How did it appear?
● A varicocele appears spontaneously whereas a funiculitis starts with fever, chill and
rigor.
● Where did it appear first?
● An inguinal hernia appears from above whereas an infantile hydrocele, testicular
growth and varicocele appear from below.
● An encysted hydrocele and diffuse lipoma of the cord appear first in the cord and
then gradually enlarge
● Ectopic testes commonest place: superficial inguinal pouch
● Does it disappear automatically on lying down?
● Like varicocele and lymph varix
✔ Other symptoms:
● evening raise of Temp, excessive cough, hemoptysis = tuberculous thickening of the cord
● hematuria = carcinoma of kidney in same side of varicocele
⮚ past history
✔ Previous periodic attacks of fever accompanied by pain and swelling of the SC is highly
suggestive of filarial infection.
⮚ PERSONAL HISTORY: History of exposure may be obtained in gonococcal funiculitis.
GPE:
✔ Pallor + LN (testes and epididymis drain in pre and para aortic LN whereas skin of the scrotum in
the inguinal LN)
✔ Examine chest for tuberculous epididymitis
✔ Examine abdomen for possible malignant infiltration from SC
✔ Examine the kidney bcz may be the source of malignancy
● Local examination:
⮚ Exposure: umbilicus to mid-thigh
⮚ Position: standing first the recumbent
⮚ Inspection for the swelling:
✔ Number
✔ Site:
● localized swelling in SC= hydrocele
● diffuse swelling in SC= lipoma (if not inflammatory)/funiculitis (if inflame)
● above and lateral to SIR + absent testis in the scrotum= ectopic testis
✔ Extent: cystic swelling in the mid of SC w/o any upward extension= hydrocele of the cord
✔ Size
✔ Shape
✔ Edge
✔ Surface: red+ edematous = funiculitis/ late testicular torsion (>6hrs
✔ Impulse on cough: to differentiate hernia from other conditions
✔ check if scrotum is developed bcz may be undescended testes go into torsion
✔ compare with the other side
⮚ Palpation:
✔ Temperature
✔ Tenderness
✔ Confirm the inspection finding of the swelling
✔ Constancy:
● hydrocele= cystic, fluctuant and translucent
● varicose= bag of worms
✔ Impulse of cough: positive for hernia, varicocele and sometime undescended testis
✔ Reducibility:
● positive in hernia (abruptly when laying down), varicocele (gradually when laying
down
● press by finger on EIR and ask pt to stand, varicocele will fill gradually from below
while hernia is prevented from coming
⮚ Percussion and auscultation are not important
Male external genital (scrotum)
History taking:
⮚ Biodata:
✔ Name
✔ Age: 15 years’ old
● Carcinoma of the skin of scrotum>50 years
● Malignancy of the testes is common in young pts (teratoma 20-30, seminoma 30-40)
● Torsion of the testes in teenagers
● Primary hydrocele >40 years, but can happen even in infant
● Secondary hydrocele is common in 20- 40 years
● xTuberculous orchitis in young
● Epididymal cysts and spermatoceles > 40
✔ Occupation:
● prolonged standing could be the cause of Varicocele
● carcinoma of the skin of scrotum, when skin is exposed for irritant for years
✔ Married? have children? sterility in case of bilateral undescended testes
⮚ History of presenting illness:
✔ Chief complain: Pain in R scrotum
✔ When started? Early morning
✔ Onset? Sudden (malignancy of testes is gradual and silent)
✔ Continuous/ {intermittent? How frequent, for how long?} continuous
✔ How does it start? Started when left some wt (in torsion of testes the cause can be straining at
stool, lifting heavy wt or coitus)
✔ Trauma? No (if trauma and followed immediately by a swelling = haematocele which maintain
size for long time
✔ Position? in R scrotum
✔ character? Sever, Squeezing in nature
✔ aggravating factors? Increase by movement
✔ relieving factors? nothing
✔ Radiation? to R L abdomen
✔ Severity? 9/10
✔ Specific timing? No
✔ Associated symptoms:
✔ Fever? No (fever is seen in epididymoorchitis)
✔ Vomiting? yes 2 times, food content, no blood,
✔ Dysuria? no
✔ urethral discharge? No
⮚ Past History:
✔ Previous episode? Yes, but less sever, settled by medication
✔ No chronic disease
✔ No previous surgery
Provisional diagnosis:
✔ torsions of testis (age <25, sudden sever squeezing pain, radiate to lower abdomen, no dysuria,
no urethral discharge)
D/D:
✔ Acute epididymoorchitis (pain but should be gradual, fever, less sever, no urinary symptoms
and no urethral discharge, no radiation as torsion, age >25 )
✔ Torsion of appendix
✔ Strangulated hernia
● GPE:
✔ Pallor + LN (testes and epididymis drain in pre and para aortic LN whereas skin of the scrotum in
the inguinal LN)
✔ Dehydration bcz the pt is vomiting
✔ Examine chest for tuberculus epidimitis
✔ Examine abdomine for possible malignant infiltration from SC
✔ Examine the kidney bcz adenocarcinoma of kidney may result in varicocele formation
✔ Rectal examination bcz acute prostatitis often proceeds epididymoorchitis
● Local examination:
⮚ Exposure: umbilicus to mid-thigh
⮚ Position: standing
⮚ Inspection:
✔ check if scrotum is developed bcz may be undescended testes go into torsion
✔ skin of testis:
● if red edematous= acute epididymoorchitis
● if tense + loss of normal rugosity +prominent subcutaneous veins = hydrocele
✔ Number
✔ Site:
● localized swelling in SC= hydrocele
● diffuse swelling in SC= lipoma (if not inflammatory)/funiculitis (if inflame)
● above and lateral to SIR + absent testis in the scrotum= ectopic testis
✔ Extent: up along spermatic cord?? Or groin?
✔ Size
✔ Shape
✔ Edge
✔ Surface: red+ edematous = funiculitis/ late testicular torsion (>6hrs)
✔ Impulse on cough: to differentiate hernia from other conditions
⮚ Palpation:
✔ Temperature
✔ Tenderness
✔ Confirm the inspection finding of the swelling
✔ Constancy:
● hydrocele= cystic, fluctuant and translucent
● varicose= bag of worms
✔ fluctuation:
● hold the upper pole of the scrotal swelling between the thumb and the fingers of
one hand to make the swelling tense and steady and with the thumb and the
fingers of the other hand apply intermittent pressure at the lower pole to push the
fluid up and if the fingers holding the upper pole are pushed apart = positive, like
in hydrocele
✔ translucency:
● best performed in darkness, place the torch laterally over the swallow scrotum
and a paper placed on the other side of the scrotum
● red glow= clear fluid inside the scrotum
✔ Impulse of cough:
● hold the root of the scrotum and ask the pt to cough
● expansile impulse = hernia/ hydrocele
● thrill like= varicocele or lymph varix
✔ Reducibility:
● Raise the scrotum and compress the swelling gently
● Congenital hydrocele and varicocele are reducible
✔ prehans sign: lift the testes, if pain decreases= epididymoorchitis, if increase = testicular
torsion
✔ Angells sign: testes lies horizontally in the scrotum when the patient is standing
✔ deming’s sign:affected testes is positioned up bcz of the twisting
✔ cremestric reflex: elicited by stroking or pinching the medial thigh, causing contraction of
the cremaster muscle, which elevates the testis. Will be absent in testicular torsion
✔ palpate testes
● position:
● Normal = anteverted= epididymis lies anteriorly and the body posteriorly
● Completely inverted= upside down= Globus major lies inferiorly =
predispose for testicular torsion
● Incompletely inverted= testes lie horizontally= predispose for testicular
torsion
● Size = wt (balance by the palm of the hand)
● Small = undeveloped testes
● Large/heavy= tumor / old hematocele
● Shape
● Surface: smooth / nodular
● Consistency: regular / heterogeneous
✔ Palpate epididymis for site, position size, shape, surface, consistency (normally it is firm
nodular , attached to the post of the testes)
✔ Palpate SC for site, position size, shape, surface, consistency
✔ Thick and tender = epididymitis
✔ hard and nodular= extension of malignancy of the testes
⮚ Percussion and auscultation are not important
Investigation:
● CBC/ sickling >> bcz surgery and GA need to be done
● leuckocytosis ( suggest the epidymorchitis but not rule out the torsion )
● laboratory studies ( not routinely done )
● urinalyasis ( to rule out the epidydmorchitis )
● X ray to exclude pulm TB and secondary deposite in lung from testicular tumores
● US even if U R sure about the diagnosis
● Features of torsion in US:
● 1-reduced /no blood flow to testes, whereas in epididymoorchitis = increased
● 2-heterogenous appearance of testicular paranchyma
● 3- twisting of spermatic cord
● Do sicking and CBC prior surgery
Management:
o Start IV fluid
o If patient is seen in the first 5-6 hrs., manual de-torsion is attempted🡪 Anterior pole of the
affected testis is pulled outward, away from midline towards the ipsilateral thigh.
o If manual de-torsion fails, surgical exploration is performed, and if the testis is found to be
viable it is sutured to the parietal tunica to prevent recurrence.
o There is no medical Tt, do operation
o Max time to do surgery 6-12 hrs , after that pt will loss the testes and bcm sterile
1- Derotate testes
2- Check the viability of testes
3- If viable >> it is sutured to the parietal tunica, if one is dead > remove it, if 2 don’t remove bcz of
the need for testesterone
4- Prophylactic fixation of the other testes
