Scrotal Swelling
Scrotal Swelling
Rawan Alshabeeb
Afnan Almarshadi
Supervised by:
Dr. Hamdan Al- Hazmi
Outline
Anatomy of the scrotum
Differential diagnosis
Approach to a patient with scrotal
swelling
Painfull scrotal swelling
Painless scrotal swelling
The wall of scrotum has the following
layers(imp for mcq)
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 )
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)
* 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
* Lymphatic vessels draining the testis and closely associated structures
* lumbar lymph nodes
Differential diagnosis of scrotal
swelling
Acute Chronic
Torsion of testis or appendages Intra-scrotal tumors
Trauma Systemic diseases:
Infection/inflammation: Idiopathic lymphedema
epididymo-orchitis Henoch-Schonlein purpura
Hernia
Idiopathic scrotal edema
hydrocele
varicocele
Painful
Torsion of testis or appendages
Trauma
Infection/inflammation
Hernia (strangulation)
Painless
Intra-scrotal tumors
Idiopathic scrotal edema
hydrocele
varicocele
- We have We have 3 ways of DDX must say
them all in exam ;
1- acute vs chronic
2- painful vs painless
3- get above it vs cant
Approach to a patient with scrotal
swelling
History
timing of onset: acute or insidious onset
associated symptoms or prior episodes
age at presentation
Physical examination
general appearance
lie of testes(to diffrentiate between torsion and epidiymo
orchitis), scrotal skin, fluid collection,
testes or epididymis tenderness
Get above the swelling ?
Investigation:
Noninvasive assessment of
anatomy and determining
the presence or absence of
blood flow.
sensitivity: 88.9%
specificity of 98.8%
operator dependent.
. FIGURE 1. Color Doppler
ultrasonogram showing acute
torsion affecting the left testis
in a 14-year-old boy who had
acute pain for four hours. Note
decreased blood flow in the left
testis compared with the right
testis
Color Doppler ultrasound
Testicular pain
&swelling( Sudden)
radiating to the lower
abdomen
Usually in sports
injuries or violance.
may result in bleeding
into the layers of tunica
vaginalis resulting in
haematocele.
S&S: severe pain,
scrotal swelling,
bruising, tender,
enlarged testis.
Management
Investigation:
scrotal ultrasound (beware of an underlying malignancy).
Treatment: CONSERVATIVE
Bed rest
Scrotal elevation
Surgical exploration may needed if:
1- expanding scrotal hematoma
2- To evcuate the haematocele and to repair the split in tunica
albugenea.
3- very sever pain
4- Infections of testis & epididymis
May be acute or chronic.
Acute or chronic orchitis may be due to mumps.
Acute epididymo-orchitis may be due to coliform
organisms or gonorrhoea.
Also can follow instrumentation or operations on
prostate.
Chronic epididymo-orchitis :common cause of is a
partially treated acute one & TB or brucellosis .
clinical features :
pain, edematous, swelling redness of the scrotum,
often associated with pyrexia.
+/- symptoms of UTI
In children differentiation from torsion is often
impossible and scrotum should be explored.
Enlarged tender testis and epididymis.
Prehn sign is +ve
Bilatral swelling and pain could be caused by
lymphoma
-ve Prehn's sign indicates no pain relief with
lifting the affected testicle, which points
towards testicular torsion which is a surgical
emergency and must be relieved within 6
hours.
Positive Prehn's sign indicates there is pain
relief with lifting the affected testicle, which
points towards epididymitis.
Management
Investigation:
FBC, MSU, Early morning urine specimens for TB culture.
Treatment:
Acute: Bed rest, Analgesia,
ABx: I.V ciprofluxacin until culture and sensitivity.
Examine the pt in 3 days, if better continue antibiotics, , if pain
worsens, consider chronic causes
Chronic: TB-antituberculous drugs.
Orchidectomy if fails.
Long ABx treatment for non tuberculous epididymo-orchitis.
PAINLESS
SCROTAL
SWELLING
1- Hydrocele;
Is collection of abnormal
quantity of serous fluid in
the tunica vaginalis.If it
contains pus or blood it is
called pyocele or
haematocele
respectively.Hydrocele is
more common than the
two other varieties.
etiology
1-primary;(newborns)
The cause is unknown
Associated with patency
of proccessus vaginalis.
It classified as follows;
1-communicating;
it connect with the
peritoneal cavity.
2-
noncommunicating;
it dose not connect
with peritoneal
cavity.
2- secondary; where the fluid
accumulate secondary to pathology
inside the testis like epididymo-
orchitis,testicular tumor and trauma.
infection --- increase production
+decrease excretion
Clinical presentation;
Age;
primary hyrocele are most common newborns
Secondary are more common between 20 to 40 years.
Symptoms;
1-painless swelling
2-frequent and painful micturation may occur if hydrocele is
secondary to epididymo-orchitis
Hydrocele not affect fertility
Clinical picture
Examination;
Position; the swelling usually unilateral but can be bilateral
.if communicating can not feel the cord above the lump.
Colour and temperature; normal
Tenderness; primary are not tender but secondary may be
tender
Composition; fluctuant and have fluid thrill if large enough
Reducibility; can not reduced
Testis impalpable(In communicating type) and
transillumenate
transillumenatE
Mangement;
Primary; in children
Communicating;
most neonatal hydrocele resolve in first 2 year of
life if persists repair as herniotomy(inguinal
incision ).
NEVER do surgery before 2 years of age.(EXCEPT in
1- very large amount -2- if cant differentiate between it and hernia
3- increase intrabdominal pressure)
NEVER do needle aspiration EVEN in the non- communicating
type(cuz it will reaccumulate)
Noncommunicating;
usually resolves spontaneously
In adult; surgical excision; opening the tunica
vaginalis longitudinally (scrotal incision ), emptying
the hydrocele, everting the sac after excising the
redundant sac and suturing the sac behind the cord
thus obliterating the potential space
Secondary treatment of the underlying condition
Case ;
40 y old man came with painless , transeluminate hydrocele .
What's ur next step ?
A; do an US for scrotom to R/O testicular tumor
2- Indirect 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 .
3-Varicocele
Definition
Is dilatation and tortuosity of the pampiniform plexus, which is
the network of veins that drain the testicle.
Due to defective valve or compression of the vein by a nearby
structure, can cause dilatation of the veins
If metastasized :
1. If seminoma: Radiotherapy plus chemotherapy.
2. If teratoma: combination chemotherpay 3
drugs(etoposide, vinblastine, methotrexate,
bleomycin, cisplastin)( not imp )