Scrotal Swellings

N Vasdev
Consultant Urological and Robotic Surgeon
Lister Hospital

Associate Lecturer in Urology

University of Cambridge

Senior Clinical Tutor

Royal College of Surgeons of Edinburgh

www.nvasdevurology.com
 Introduction
This tutorial has been designed to take you through some of the
commoner conditions which can cause a swelling in the scrotum

The most important thing to remember about a swelling arising from

either the scrotum or its contents is that:

On examination it is possible to get above the swelling

If you can’t get above the swelling then that suggests that the pathology
has originated from the groin. So before we get started write down as
many causes as you can think of for a swelling in the groin or scrotum
which you cannot get above.

The answers are on the next slide.

Common Causes of a Lump in the Groin /
Scrotum Which You Cannot Get Above
 Common Causes of a Lump in the Groin /
Scrotum Which You Cannot Get Above

Inguinal Hernia
Femoral Hernia
Enlarged Inguinal Lymph Nodes
Saphena Varix
Femoral Artery Aneurysm
Lipoma
Now let’s move on to scrotal swellings. Again, write
down as many causes of a scrotal swelling which
you can get above and then review the list on the
next slide.
 Common Causes of Scrotal Swellings
Which You Can Get Above
Hydrocele
Epididymal Cyst
Varicocoele
Epididymo-orchitis
Testicular Tumour
We are now going to go through each of the
conditions on the list.

The tutorial will ask you a series of questions in each

case and you can then review the answers on the
slides which follow.
 Hydrocele
1 Define a hydrocele
2 What is the underlying pathology?
3 How might you classify the causes?
4 What might a patient with a hydrocele complain of?
5 What are the important findings to elicit on
examination?
6 Name 3 methods of treatment
 Hydrocele 2
Definition:

“A hydrocele is a collection of fluid within the tunica

vaginalis”

You should read up on the embryology of testicular

descent to appreciate how the tunica vaginalis is
formed
Hydrocele 2
 Pathogenesis of Hydrocele
The fluid collects because of an imbalance between
production and absorption.

The tunica vaginalis normally produces around

0.5ml of fluid a day.
 Common Causes of
Hydrocele
Congenital Patent processus vaginalis (PPV)

Acquired Idiopathic
Tumour
Trauma
Infection

5 marks
 Hydrocele 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
 Hydrocele 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
 Hydrocele Treatments
Include:
• 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. Read up the procedures in
a surgical textbook to understand the techniques.
 Epididymal Cyst
1 What is an epididymal cyst?
2 What might the patient complain of?
3 List three important findings on examination.
4 How are epididymal cysts treated?
 Epididymal Cyst Definition
“ A cystic swelling arising from the epididymis”
 Epididymal Cyst 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

The transilluminated appearance of the cyst is classically

described as a “Chinese Lantern”
 Epididymal Cyst 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
1 Define a varicocoele
2 What local symptoms might a patient complain of?
3 Describe the common signs on physical examination
4 Why is it important to image the kidneys?
5 Describe the two main methods of non-conservative
management?
 Varicocoele Definition
“A varicocoele is a dilatation of the veins of the
pampiniform plexus”
 Varicocoele 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
 Varicocoele: Methods of Treatment
The two main methods are:

1 Surgical ligation
2 Embolisation under X-Ray control
 Epididymo-Orchitis
1 What is epididymo-orchitis?
2 List the symptoms and signs
3 How is the condition treated?
 Definition of Epididymo-
Orchitis
“An inflammation of the tissues of the epididymis
and testis”

The commonest cause of this is infection. You need

to know some of the commoner causative organisms.

Read up on these.
 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.

Bonus Questions:
1 What class of antibiotic does ciprofloxacin
belong to?
2 What is the mode of action of 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

Urology Scrotal Swelling Tutorial Part 2

 Classification of Testicular Tumours
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 it’s easy to get confused if you read textbooks from the
different countries.

So don’t read anything now. Go to the next few slides to see how these
tumours are classified and how the systems work in the two countries
 It Starts Off Quite Easily
You can divide them into:

1 Germ Cell Tumours

2 Other tumours, the commonest of which is
lymphoma, which is the commonest
testicular malignancy in the older patient. We
won’t be saying any more about these
 Still Quite Easy
Germ cell tumours can be divided into

1 Seminomas (we’ll talk about these in a bit)

2 Non-seminomatous germ cell tumours

The classification of these is where
confusion sometimes arises. A summary
is on the next slide
 But Remember
40% of testicular tumours are mixed, i.e. they
have both seminomatous and non
seminomatous elements
 Questions
1 What is the peak age incidence of seminomas?
2 What is the peak age incidence of non-seminomatous
germ cell tumours (NSGCTs)?
3 What are the symptoms & signs of a testicular
tumour?
4 What investigations are required?
5 What surgery is usually necessary?
6 What other therapeutic options exist for seminomas &
NSGCTs?
 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: Ultrasound of testis
CT of abdomen to assess spread
Chest X Ray for metastases
Blood Tests: AFP (alpha foeto-protein)
β-hCG (human chorionic
gonadotrophin)
LDH (lactate dehydrogenase)
 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