Scrotal swelling

Mogesie Tsegaw

Supervised by:
Dr. Gedion (Assistant professor of general surgery)
Dr. Kejela (General surgery resident)
 Outline

 Anatomy of the scrotum and testis

 Differential diagnosis

 Approach to a patient with scrotal swelling

 Painful scrotal swelling

 Painless scrotal swelling

 The wall of scrotum has the following layers

1-skin
2-superficial fascia
3-external spermatic fascia derived from the external oblique
4-cremasteric muscle derived from the internal oblique
5- internal spermatic fascia derived from the fascia transversalis
6-tunica vaginalis (remnant of
Peritoneum )
 Con’t…

 Coverings of the spermatic cord:

• Tunica vaginalis - covers the anterior surface of the spermatic
cord just above the testis
• Internal spermatic fascia (transversalis/endoabdominal fascia)
• Cremasteric fascia (fascia of internal oblique muscle)
• External spermatic fascia (aponeurosis of the external oblique
muscle)
The cremasteric fascia contains loops of cremasteric muscle,
which draws the testis superiorly in the scrotum when it is cold.
 Contents of spermatic cord

 Ductus deferens (conveys sperm from the epididymis to the ejaculatory duct)

 Arteries

• Testicular artery (arises from the abdominal aorta at L2)

• Artery of the ductus deferens (arises from inferior vesical artery
• Cremasteric artery (arises from the inferior epigastric artery)
 Veins
• Pampiniform plexus (formed by up to 12 veins, drain into right and left
testicular veins)
 Con’t…

 Nerves
• Sympathetic nerve fibers on arteries
• Sympathetic and parasympathetic nerve fibers on the ductus
deferens
• Genital branch of the genitofemoral nerve supplying the
cremaster muscle
 Lymphatics
• Testis- to para-aortic LNs
• Scrotum- to superficial inguinal LNs
 Differential diagnosis of scrotal swelling

 ACUTE  CHRONIC
• Hydrocele
• Testicular torsion
• Varicocele
• Testicular appendage torsion • Inguinal hernia
• Testicular trauma • Epididymal cysts
• Spermatocele
• Infection/inflammation • Testicular tumers
-epididymi-orchitis
 Con’t…

Painful Painless

• Torsion of testis or • Intra-scrotal tumors

appendages • Idiopathic scrotal edema

• Trauma • hydrocele

• Infection/inflammation • Varicocele

• Hernia (strangulation) • Indirect inguinal hernia

 Approach to a patient with scrotal swelling

 History

• timing of onset: acute or insidious onset

• associated symptoms or prior episodes
• age at presentation
 Con’t...

Preparation
• expose from the waist down and the scrotum examined with the
patient first standing, then supine
• pediatric patients may be best in their carer’s lap.
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Physical examination

Inspection

• General inspection- noting whether the patient is unwell or in pain.

Next, assess the inguinoscrotal region for colour, testicular lie, size,

shape, symmetry, presence of lesions/lumps/oedema/ scars, ‘blue

dot sign (may become visible only when the skin is stretched)
 Con’t...

palpation
• Ask the patient about pain before palpating and begin with the
normal side to allow comparison when examining the abnormal
side.
• Palpation is easiest in the supine position,
• varicocele/hernia are best appreciated with the patient standing
• Due to testicular mobility, it is recommended to ‘fix’ each testicle
between both thumbs and index/ middle fingers.
 Con’t…

• palpate the epididymis (head body and tail).

• Palpate the spermatic cord at the scrotal neck by rolling it
between thumb and index finger; the vas deferens is appreciated
as a rubbery, cord-like structure slipping between the fingers.
• Finally, palpate the groin lymph nodes particularly if
infection/neoplasm are suspected.
 Con’t…

What to assess on Palpation ?

A) Palpation of the Swelling and appreciate :
• Location, size, shape, surface, warmness, tenderness,
consistency, Characterise any lumps and determine if they are
separate from the testis .
• Varicocele is soft, with typical feel of ‘bag of worms’’.
• Hydrocele is smooth and soft
• Testis not felt separately in case of hydrocele
 Con’t…

B) Get above the swelling:

• In standing position cord is palpated for structures by placing
thumb in front and fingers behind the root of the scrotum.

• In hydrocele one can get above the swelling – means only cord
structures are felt and nothing else.
 Con’t…

• In inguinoscrotal hernia, one can not get above the swelling.

• Cord with additional structures are also felt.

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C) Check Reducibility
• Inguinal and inguinoscrotal hernia is reducible.
• Hydrocele is not reducible.Exception is congenital hydrocele
which communicates with abdominal cavity.
• Varicocele gets reduced while lying down but slowly and
gradually.
 Con’t…

D) Fluctuation:
• Upper part of the scrotum is held between thumb and fingers of one
hand to steady the swelling; thumb and fingers of other hand are held
at lower pole.

• Intermittent pressure from lower fingers will push apart the fingers over
upper part and vice versa.
• Test is repeated in opposite direction.
• Hydrocele, encysted hydrocele, epididymal cyst, spermatocele, are
fluctuant swellings in the scrotum.
 Con’t…

Special tests
 Impulse on coughing

• Hernia shows expansile impulse on coughing.

• Varicocele shows impulse on coughing
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 Transillumination
• It is done in a dark room using a pen torch.
• Pen torch is placed laterally in the
anterior part of the scrotum.
• Never place it posteriorly as testis
will interfere with proper illumination.
• Hydrocele and epididymal cyst are
• transilluminant
 Con’t…

 Cremasteric reflex-  is a superficial reflex observed in human

males.
• elicited by lightly stroking or poking the superior and medial
(inner) part of the thigh . The normal response is an immediate
contraction of the cremaster muscle that pulls up
the testis ipsilaterally.
• may be absent with testicular torsion
 Investigation

• CBC
• Urinalysis: bacteria, WBC’s, crystals
commonly in epididymitis
• Radiographic studies
Ultrasonography(to see haematocele, pyocele, secondary
hydrocele, varicocele, testicular tumour.
Doppler US.
tumor markers: α-fetoprotein, β-human chorionic gonadotropin, and
lactate dehydrogenase
• urine culture
PAINLESS SCROTAL SWELLING
 Hydrocele

• an abnormal collection of serous fluid in a part of the processus vaginalis,

usually the tunica

Etiopathogenesis- 4 d/t ways

1) Excess fluid production with in the sac

2) Defective fluid absorption
3) Interference with lymphatic drainage
4) Communication with peritoneal cavity
 Con’t…

Types
1. Congenital- processus vaginalis remains patent or closes defectively

 Defective fluid absorption/Communication with peritoneal cavity.

Includes:
A) Congenital (communicating) or true hydrocele- processus vaginalis
is patent & communicates with peritoneal cavity.
 Seen in infants
B) Infantile hydrocoele -The sac from the scrotum is patent up to the
deep inguinal ring.
 Con’t…

C )Encysted hydrocele - aloculated fluid collection along the

spermatic cord as a result of aberrant closure of the processus
vaginalis.
D) Vaginal hydrocoele -Occurs when hydrocoele sac is patent only
in the scrotum.
E) Funicular hydrocele-has got two communicating sacs, one
above and one below the neck of scrotum. Upper one lies in the
inguinal canal.
Con’t…
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2. Acquired hydrocoele- either idiopathic (primary) or due to secondary

causes.
Idiopathic hydrocele- is the most common type of hydrocoele which is
seen in young adults, middle age and beyond.
It is due to following causes:
a. Defective absorption of fluid
b. Defective lymphatic drainage
 Con’t…

Secondary hydrocoele- due to underlying conditions such as:

• Infection such as ( filariasis, TB, epididymitis, syphilis)
• Trauma
• Malignancy
• Post-herniorrhapy
Con’t…
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• inspection-Asymmetrical swelling
• Palpation findings- Fluctuant swelling, not reducible.
 Depending on type of hydrocoele: may or may not be able to get
above mass. Testis and epididymis may not be definable,
generally non-tender.
• special tests -Translucent, no cough impulse.
 Inguinal hernia

• most common ( young , Rt. Side )

• 10% bilateral .
• Hernia in babies are a result of persistent processus vaginalis.
• If strangulated >> painful and may cause testicular atrophy
• Surgery is usually recommended .
 Con’t…

• Inspection-Unilateral swelling, abdomen may be distended.

• Palpation -May be soft and reducible, or firm and irreducible.
 Unable to get above mass, testis and epididymis definable,
may be tender (if irreducible/ strangulated, or non-tender).
• special tests -Presence of bowel sounds on auscultation; cough
impulse may be present.
 Varicocele

• an abnormal dilatation and enlargement of the scrotal venous

plexus (pampiniform) draining the testis
• Afecting 10–20% of adult males.
• Mostly idiopathic
• About 90% are left sided, b/c :
 LTV is longer than RTV
 RTV enters right angle to renal vein
 LTA arching over LTV
 Loaded sigmoid colon compressing the LTV
 nutcracker’ effect
 Con’t…

Note- absence or failure of the antirefux valve an the junction of

TVs and RVs/IVC could be possible etiology.

• If a left varicocele is identifed, there is a 30–40% probability that it

is a bilateral condition.
• Typically develop during late childhood and adolescence.
• Varicoceles occur in around 15–20% of all males but are found in
about 40% of infertile males.
 Con’t…

Clinical features
• most are asymptomatic,
• dragging discomfort that is worse on standing at the end of the
day.
• in the erect position, the scrotum on the affected side often hangs
lower than normal
• Inspection-‘Bag of worms’ may be seen.
• Palpation- Asymmetrical soft swelling, not reducible, bag of
worms”, testicular atrophy in long standing cases
 Con’t…

 Able to get above mass, testis and epididymis definable, generally

non-tender
 lying down the veins empties the veins by gravity and provides an
opportunity to ensure that the underlying testis is normal to palpation.
• special tests - No transillumination, “, cough impulse may be
present.
 Con’t…

• Obstruction of the testicular vein by a renal tumour or nephrectomy

is a cause of varicocele in later life.
• In such cases the varicocele does not decompress in the supine
position.
• Isolated right-sided varicocele is extremely rare. But, If patient
presents, exclude a retroperitoneal mass and deep vein thrombosis
 Epididymal cysts

• are clear fluid filled cystic degeneration and epididymis

• They are very common, usually multiple and vary in size at
presentation.
• usually found in middle age and are often bilateral.
• The clusters of tense cysts feel like tiny bunches of grapes that
lie posterior to, and quite separate from, the testis.
• They should transilluminate. The diagnosis can by confrmed by
ultrasound
• Testis can be felt separately
 Con’t…

HX
• Painless scrotal swelling
• Gradual onset
P/E
• get above +ve
• Testis palpable separate from
the lesion
• Transilluminates
 Spermatocele

• Unilocular retention cyst derived from a portion of the sperm-

conducting mechanism of the epididymis.
• It is usually softer and laxer than other cystic lesions in the
scrotum but, like them, it transilluminates.
• The fluid contains spermatozoa and resembles “barley water in
appearance”.
• Spermatoceles are usually small. Small spermatoceles can be
Con’t…
 Testicular cancers

• Most cases of primary testicular cancer are germ cell origin (95%);
the remainder are stromal (Leydig cell) or sex cord (Sertoli cell)
tumors.
• Risk factors for testicular tumors include cryptorchidism, family
history of testicular cancer.
• Testicular malignant neoplasms are the most common tumors in men
between the ages of 20 and 40 years.
 Con’t…

• Germ cell–derived tumors- divided into pure seminoma and

mixed nonseminoma germ cell tumors (NSGCTs) 50% each
• Seminomas – classic seminoma (85%) and spermatocytic
seminoma.
• NSGCTs can be divided into numerous histologic types:
 embryonal carcinoma,
 yolk sac or endodermal sinus tumors,
 choriocarcinoma,
 teratoma,
 mixed germ cell tumors.
 Features

• Painless solid swelling of the testis(mostly).

• Heaviness in the scrotum.
• may simulate epididymo-orchitis and, rarely, acute painful
enlargement of the testis occurs because of hemorrhage into the
tumour, which can mimic testicular torsion.
• Palpable abdominal mass due to metastasis.
• Chest symptoms due to metastases (shortness of breath, or
hemoptysis)
PAINFUL SCROTAL SWELLING
 Testicular torsion

• Is surgical emergency the twisting of the spermatic cord and its

contents such that the testicular blood supply becomes
compromised.
• accounts for 10–15% of acute scrotal disease in children.
• Torsion of the testis is uncommon because the normal testis is
anchored and cannot rotate.
• Testicular torsion is most common between 10 and 25 years of age
 Con’t…

Types of torsion
• Extravaginal torsion- outside tunica vaginalis
 seen almost exclusively in neonates due to increased mobility of the
testicle before the descent into the scrotum ( the lower pole of the
testis is not yet fixed on the scrotum).
• Intavaginal torsion- inside tunica vaginalis as a result of
high investment of the tunica vaginalis, causing the testis to hang within
the tunica like a clapper in a bell .
 This is the most common cause in adolescents and is typically a
bilateral abnormality.
Con’t…
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Treatment:
Definitive treatment- surgical detorsion
Manual detorsion- medial to lateral, “Opening a book” may
need to rotate 2-3 times for complete detorsion.
 Con’t…

precipitating/predisposing factors for torsion

 Cryptorchid testis
 Trauma
 Bell clapper abnormality
 straining at stool,
 lifting of a heavy weight,
 sexual activity and sport
 The two main factors determining damage to the testis ?
the extent of the twist and the duration of the episode.
 Con’t…

• Twists of 720° cause more rapid ischaemia than twists of 360° or

less, and if the testis can be untwisted within 6 hours of the
torsion taking place there is nearly a 100% chance of testicular
salvage compared with a 20% salvage rate if the surgery is
delayed for 24 hours.
 Con’t…

Hx Palpation
sudden severe pain in the groin • Abnormal lie (horizontal, high),
and the lower abdomen, firm and tender testicle
nausea, vomiting  able to get above swelling,
P/E testis and epididymis may or
inspection may not be definable
Swelling, erythematous or dark special tests -Absent
hemiscrotum. cremasteric reflex, no
transillumination
 Torsion of a testicular appendage

• cannot always be distinguished with certainty from testicular

torsion.
• The most common structure to twist is the appendix of the testis
(the hydatid of Morgagni)
 Con’t…

Hx
Usually a more gradual onset, pain moderately severe
P/E
• Inspection- ‘’Blue dot sign’’ (due to blood loss to the piece of
tissue)
• Palpation - Normal lie, soft testicle with pinpoint tenderness.
• special tests - Cremasteric reflex present, no
transillumination.
 Testicular trauma

• Usually in sports injuries or violance.

• may result in bleeding into the
layers of tunica vaginalis resulting
in haematocele.
Clinical features
 severe pain, scrotal
 swelling, bruising, tender,
 enlarged testis.
 Infections of the testis and epididymis

Epididymo-orchitis
• Acute epididymitis most commonly occurs in men aged 20–59
years (43%) and in men aged 20–39 years and 29% in men aged
40–59 years).
• Childhood (prepubertal) epididymitis is rare.
• 47% of prepubertal boys with epididymitis have associated
urogenital abnormalities, including ectopic vas deferens or
ureters, and urethral abnormalities.
 Con’t…

• A general rule- epididymitis arises in sexually active young men

from a sexually transmitted genital infection, while in older men it
more usually arises from a urinary infection or may be secondary
to an indwelling urethral catheter.
• In young sexually active men, the most common cause of
epididymitis is now Chlamydia trachomatis.
• In older men with bladder outflow obstruction, epididymitis may
result from a urinary infection – it is proposed that a high pressure
in the prostatic urethra might cause reflux of infected urine up the
vasa.
 Con’t…

Clinical features
 ache in the groin

 fever
 epididymis and testis swell and become painful.

 red, oedematous and shiny scrotum, may become adherent to the

epididymis.
 Con’t…

Tuberculous epididymo-orchitis
• usually begins insidiously.
• The frequency with which the lower pole of the epididymis is
involved first indicates that the infection is usually retrograde from
a tuberculous focus in the seminal vesicles.
 Con’t…

Clinical features
• firm, discrete swelling of the lower pole of the epididymis.
• epididymis becomes firm and craggy as the disease progress.
• There is a secondary hydrocele in 30% of cases. The seminal
vesicles feel indurated and swollen. In neglected cases, a
tuberculous ‘cold’ abscess forms, which may discharge.
• In two-thirds of cases there is evidence of renal tuberculosis or
previous disease.
Reference
• Bailey & Love's Short Practice of Surgery, 28th Edition
• Schwartz's Principles of Surgery, 11th edition
• Manipal Manual of Surgery 5th Edition
THANK YOU !