Scrotal Swellings

Dr John Nash GPwSI Urology

Mode of Presentation

● Acute Pain

● Elective Non-acute Pain

Acute Painful Presentation

● Testicular Torsion

● Torsion of Testicular Appendage ( Hydatid of Morgagni)

● Epididymo-Orchitis

● Acute Trauma

● Acute Idiopathic Scrotal Oedema

● Henoch-Schonlein Purpura
Non-Acute Pain
● Hydrocele

● Inguinal Hernia

● Epididymal cyst

● Varicocele

● Scrotal skin lesions

Epididymo-Orchitis Testicular Torsion
Acute Idiopathic Scrotal Oedema Henoch-Schonlein Purpura
Torsion of Hydatid of Morgagni Fournier’s Gangrene
Testicular Torsion
Torsion
Testicular Torsion

● Peak incidence 12-14 yrs

● 1 per 25,000 males under age 25 yrs

● Rare after aged 30 yrs

● History of previous minor episodes important

Predisposing Factor- Bell-clapper Testis
Testes have same embryological
derivation as kidneys- common
level of innervation
T10-L1

Pain
● Rapid onset

● Scrotal

● Severe

● +/- nausea, vomiting

● +/- umbilical - see dermatomes

Scrotal Pain is Testicular
Torsion until proved
otherwise

Surgical Emergency - NCEPOD Category 1

- Surgery within 1 hour of provisional diagnosis of

Testicular Torsion

- Fast-track emergency protocols

Early Surgery
Late Surgery
Signs
● obvious discomfort
● +/- unusual gait, +/- reluctant to move.
● Scrotal region is usually very tender and may be red and swollen.

May see:
● High riding testicle
● Absence of cremasteric reflex
● Focal blue-dot at the upper pole of the testis
● Diffuse blue discoloration of the hemiscrotum or a reactive
hydrocele. A high temperature may also be observed
Investigations
● A urine sample if possible and a dipstix test performed. The urine sample may be sent for
microbiological tests at the discretion of the reviewing surgeon.

● At surgery, a microbiology swab may be taken if infection thought to be present.

Radioisotope scans and Doppler ultrasonography are not part of the initial management of acute scrotal
pain

● may contribute to delay in treatment with unacceptable consequences.

● In obese boys and when the testicular volume is about 2 ml (majority of boys under the age of 12 yrs)
the diagnostic accuracy of these tests is low resulting in limited clinical benefit.

● Likely that some units do Doppler ultrasound if no delay involved in getting to theatre
Other Acute Painful Scrotum

● Torsion of Testicular Appendage ( Hydatid of Morgagni)

● Epididymo-Orchitis

● Acute Trauma

● Acute Idiopathic Scrotal Oedema

● Henoch-Schonlein Purpura

● Fournier’s Gangrene
Torsion of Testicular Appendage ( Hydatid of
Morgagni)
Classical Blue Dot Sign
Epididymo-orchitis

● Pain, swelling and increased temperature of the Epididymis

● May involve the Testis and Scrotal skin. ( hence-”orchitis”)
● Generally caused by migration of pathogens from the urethra or
bladder. Torsion of the spermatic cord (testicular torsion) is the
most important differential diagnosis in boys and young men.
● Predominant pathogens-Chlamydia trachomatis, Gut bacteria (usually
E.coli) and N.gonorrhoeae
● Men who have anal intercourse
● Abnormalities of the urinary tract resulting in bacteriuria are at higher
risk of epididymitis caused by Enterobacteria.
● Mumps orchitis- consider if parotitis and absent MMR
Epididymo-orchitis

Investigation- Treatment-
Urinalysis and MSU Young sexually-active men- (10-14 days Rx)
Fluoroquinolone to cover Enterobacteria and
STD screen for Chlamydia and Gonorrhoea- first Chlamydia; if urethral discharge additional
void urine and discharge swab antibiotic to cover Gonococcus

Older Men- assume Enterobacteria-

Fluoroquinolone alone for 10-14 days
Acute Idiopathic Scrotal Oedema- AISO
Southampton General Hospital Catchment area= 1.9 million people - 5 year Period

● Twenty-four children with a total of 31 episodes of AISO

● AISO accounted for 30 per cent of all admissions with acute scrotal pathology in this period

● Final diagnosis in 69 per cent of cases under the age of 10 years.

● Unilateral in 48%, Bilateral in 52%

● 21% had recurrent attacks.

AISO- Prompt Ultrasound Without Delay
Henoch-Schonlein Purpura
Fournier’s Gangrene
Acute necrotic infection -”necrotising
fasciitis”

Predisposing factors

● Diabetes

● Alcoholic liver disease

● HIV

● Obesity
Incidence

Rare- max 3.2 per 100,000 Males

Can occur at any age

Predominantly >50 yrs

 Portal of Entry of Infection

Urogenital (45%) Anorectal (33%) Cutaneous (21%)

● urethral strictures ● Ischiorectal, perianal and intersphincteric ● may be occult
● indwelling catheters abscesses, esp.inadequately treated. ● pressure sore
● traumatic catheterization ● Rarely after routine anorectal procedures- ● Vulval or Bartholin’s abscess
● urethral calculi rectal mucosal biopsy, anal dilatation and ● Episiotomy
● prostate biopsy. banding of haemorrhoids. ● hysterectomy
● Carcinoma of the sigmoid colon and rectum, ● Vasectomy
appendicitis, diverticulitis and rectal ● Diathermy for genital warts;
perforation by a foreign body are also
recognized causes.
Surgical Emergency

Urgent debridement of all

infected tissue
Non-Acute Pain
 Hydrocele

Infantile Adult-type
Infantile- due to Patent Processus Vaginalis

110 Infantile Hydroceles:

● 63% complete resolution by 12 months

● 37%surgery by 14 months (persistent

size/hernia palpable)

Refer at 1yr - Tunica spontaneously closes by

1yr

Refer if hernia associated ( urgently)

J Pediatr Surg. 2010 Mar;45(3):590-3.

Adult-type
Hydrocele
Primary

● Defective reabsorption of fluid by Tunica vaginalis

Secondary

● Trauma including Post-surgery for varicocele

● Infection - epididymo-orchitis

● Testicular tumour
Clinical Features

● Can get above the swelling

● No cough impulse

● Transilluminates
 Adult-type Hydrocele- Treatment
Many men just want Reassurance- Clinical exam +/- ultrasound

Aspiration (+/- sclerotherapy to prevent recurrence Open surgery.

Cochrane review 2014. Four small studies were identified after an extensive literature search.
Limited information re study design; small number of patients enrolled: Results should be
interpreted with caution.

Surgery

● Meta-analysis showed lower rates of recurrence

● Postoperative complications-infection, fever, cost and time to work resumption higher.

● Cure at short-term follow-up was similar, however there is significant uncertainty in this
result which may be as a result of the age of one of the studies and the different agent
used compared to the other studies.
Epididymal Cyst

Very Common

20-40 % of asymptomatic males on Ultrasound

Attached to but clinically separate from Testis

Epididymis 18 feet long

Cystic degeneration / obstruction

Epididymal Cyst

Examination

● Can get above it

● No cough impulse

● Can be defined on palpation separate from

testis

● transilluminates
 Epididymal Cyst

Treatment
● Reassurance

● Avoid surgery if family not completed as risk of damage to sperm transport

mechanism

● High rate of recurrence

● Small risk of persistent pain

● Aspiration - always recur. Sclerosants - risk of persistent pain

 Varicocele
Dilatation of veins of pampiniform plexus

● 12% of Adult Men

● 25% of Men with abnormal

semenalysis

Problems

● Discomfort

● Risk of impaired testicular

development

● Risk of abnormal sperm production

Classification
Subclinical Varicocele not detected on physical exam; found by RADIOLOGICAL study.

Grade I PALPABLE DURING/AFTER VALSALVA

Grade II PALPABLE WITHOUT VALSALVA

Grade III VISIBLE

 Varicocele Anatomy
● 90+ % left-sided

Due to anatomy - left testicular vein

1. Is 8-10 cms longer than right

2. Is vertically orientated

3. Drains perpendicularly into Left

renal vein

All leads to greater hydrostatic

pressure and reflux
ATROPHY

In Adolescence-

● disparity in growth of >/= 1cm

indicates need for surgery

● Majority demonstrate catch-up

growth
 Varicoceles and Sub-Fertility
Incidence in normal: subfertile men = 12%:25% i.e. 1:2

Most men with clinical varicoceles conceive normally

Semen count, motility and morphology improve with surgery but……

Increase in pregnancy rates, over observation alone, did not reach statistical
significance

May be a role in assisted conception.

In Practice, if Fertility Clinic advised surgery…. We complied

 Treatment
Methods -depends on local experience

1. Radiologist- sclerotherapy/embolisation

2. Surgery-

Indications- Scrotal Inguinal High tie

● Significant discomfort Micro-dissection Inguinal (MDI)

● Adolescent growth disparity >/= 1cm Laparoscopic (L)

● At request of Fertility Clinic Lowest recurrence rate- MDI or L ~ 4% ; radiology 10%

Varying risks of - hydrocele, testicular atrophy etc

Varicocele……..Beware??
Traditionally Ultrasound to exclude Renal/
Clin Radiol. 2006
retroperitoneal tumour. Conclusion from available
evidence : Jul;61(7):593-9.

● Retroperitoneal tumour will manifest in other ways "Scrotal varicocele,

before the development of a varicocele exclude a renal
tumour". Is this
● Young patient with a varicocele will almost never
evidence based?
have a retroperitoneal tumour

● Extended US relevant only when varicocele

develops in patient 40 yrs. Even then- a rare
finding and there will be other clinical
manifestations of the primary tumour.
Varicocele……..Beware??

Right sided varicocele …….suggests IVC

compression

Sudden onset new varicocele…..> 40 yrs

Non-draining varicocele…….suggests IVC or Renal

Vein compression
Testicular Tumours
Testicular Cancer

● highest incidence 30-34yr olds

● 2418 cases diagnosed in 2014

● 1 diagnosed every 14 yrs per GP in UK ( wte)

● Rare < 15 yrs and >60 yrs

Less Likely Presentations

● Testicular pain - presentation in 20%

● Back and loin pain -from LN mets in 11%

● Gynaecomastia -from bHCG in 7%

● Hydrocele alone - occasional

 Testicular
Microcalcification
Definition - 5 or more echogenic foci per high-
powered view, in either or both testes.

Prevalence
● Male population =5%- cancer incidence= 1%
● sub-fertile men =2.4% ~ ~ = 4%
When is Microcalcification(MC)a Risk Factor for Testicular Cancer?

● Small testis (<12mls)

● Undescended testis including PMH of orchidopexy
● Subfertility
● Contralateral testicular cancer

These are features of TDS = Testicular Dysgenesis Syndrome

MC and Testicular Dysgenesis- EAU Guideline

Microcalcification plus ONE or more features of Testicular Dysgenesis

● Advise testicular biopsy- if negative, then annual Ultrasound until aged

55 yrs

Microcalcification and NO features of Testicular Dysgenesis

● No biopsy and No Ultrasound surveillance

Epidemiology
● Whites : Blacks 3:1

● 10% occurs in undescended testis (x3-14 relative

risk cf normally descended)

● Family History - Father x5 incidence ; Brother x8

incidence

● Bilateral in 1-2% of cases

Investigations
Ultrasound- urgent

Tumour Markers - nb - only positive in 51% of cases

● AFP

● BetaHCG

● LDH
Thankyou