Scrotal Swelling Fadhly

Scrotal Swellings
Fadhly Shariman
Anatomy;
Scrotum can be considered as an

outpouching of the lower part of the
anterior abdominal wall.it contains the
Testis,Epididymides,lower end of
spermatic cord
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
Spermatic cord
Structure of spermatic cord ;
1-vas deferens
2-testicular artery
3- testicular veins (pampiniform plexus)
4-testicular lymph vessels
5-autonomic nerves
6-processus vaginalis
7-cremasteric artery
8-artery of the vas deferens 9-genital branch of the
genitofemoral nerve
Testis
The testis is a firm mobile organ lying within the
scrotum.Each testis is surrounded by atough fibrous
capsule the tunica albuginea
Extending from the inner surface of the capsule is a

series of fibrous septa that divide the interior of the
organ into lobules.lying within each lobule are one to
three coiled tubules open into a network of channels
called the rete testis.the efferent ductules connect the
rete to upper end of epididymis
 Blood supply; testicular artery is a branch of
the abdominal aorta.
 The testicular veins emerge from the testis
as network the pampiniform plexus this
becomes reduced to a single vein ascend
through the inguinal canal
 The right testicular vein drain into IVC an
 The left join the left renal vein
Epididymis
The epididymis is a firm structure
lying posterior to the testis with the vas
deferens lying on its medial side.it has
the head,body and tail. The tube
emerges from the tail as the vas
deferens which enter the spermatic
cord.
Common Causes of Scrotal Swellings
1. Hydrocele
2. Epididymal Cyst
3. Varicocoele
4. Epididymo-orchitis
5. Testicular Tumour
1. Hydrocele
• Fluid collections within the tunica
vaginalis of the scrotum or a long
spermatic cord.
• Persistent developmental connections a
long the spermatic cord or Imbalance of
fluid produc versus absorption.
• Little risk of clinical consequence.
• Classified as : - communicating
- non communicating
• Almost congenital hydrocele communicate with

the abdominal cavity
• Adult hydrocele
because of local injury, infections, radiotherapy
Pathogenesis
• The fluid collects because of an imbalance

between production and absorption.
• The tunica vaginalis normally produces
around 0.5ml of fluid a day.
• Pathophysiology
- Proc. Vaginalis is a diverticulum of the
peritoneal cavity.
- It descends with the testis into the
scrotum (28th gestational week).
Failure of obliteration of the processus vaginalis leads to a spectrum anomalies
Common Causes
Congenital Patent processus vaginalis (PPV)
Acquired Idiopathic
Tumour
Trauma
Infection
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
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
• Simple hydrocele do not require radiographic
studies
• Ultrasound : to identify abnormalities in the
testis
• Doppler ultrasound flow study
• Abdominal X-ray (an acute hydrocele or
incarcerated hernia)
Differentials
– Orchitis
– Testicular torsion
– Indirect inguinal hernia
– Traumatic injury to the testical
Treatments
• Conservative management if the hydrocele is
small and causing little in the way of symptoms
• Surgical treatment :
- High ligation paten processus vaginalis
- excision of the sac
• Hydrocele aspiration
- not recommended
- high rate of recurrence
- a risk of infection
Treatments
Can be divided into 2 approaches
I. an inguinal approach with ligation of the
proc. vaginalis
The procedur of choice for pediatric hydrocele
II. Scrotal approach with excision or eversion
and suturing of the tunica vaginalis
For chronic non communicating hydrocele
Jaboulay / Lords procedure.
2. Epididymal Cyst
Definition
“ A cystic swelling arising from the epididymis”
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
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
3. Varicocoele
Definition
“A varicocoele is a dilatation of the veins of the
pampiniform plexus”
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
Methods of Treatment
The two main methods are:
1 Surgical ligation
2 Embolisation under X-Ray control
4. Epididymo-Orchitis
Definition
“An inflammation of the tissues of the
epididymis and testis”
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.
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
5. Testicular Tumours
Classification
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.
Divided into:
1 Germ Cell Tumours

2 Other tumours, the commonest of which is
lymphoma, which is the commonest testicular
malignancy in the older patient.
Germ cell tumours can be divided into
1 Seminomas
2 Non-seminomatous germ cell tumours
Classification of Non-Seminomatous Germ
Cell Tumours
UK USA
Malignant teratoma Teratoma

differentiated
Malignant teratoma Embryonal Carcinoma
undifferentiated
Malignant teratoma Teratocarcinoma
intermediate
Malignant teratoma Choriocarcinoma

trophoblastic
Yolk Sac Tumours Yolk Sac Tumours
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)
- b-hCG (human chorionic gonadotrophin)
- LDH (lactate dehydrogenase)
The blood tests are known as tumour markers.
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
THANK YOU

Scrotal Swelling Fadhly

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Scrotal Swelling Fadhly

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Scrotal Swellings

Scrotum can be considered as an

Extending from the inner surface of the capsule is a

• Almost congenital hydrocele communicate with

• The fluid collects because of an imbalance

Examination: • A scrotal swelling which you can

Simple surgical excision of the cyst

Aspirating will not work because the cyst is

As for hydroceles, conservative management is

• A left sided-varicocoele may arise as a result

• Therefore all patients with a varicocoele

The two main methods are:

Signs : A scrotal swelling which you can get above

This is a fluoroquinolone antibiotic

It acts by inhibiting an enzyme called DNA gyrase

You might sensibly start classifying testicular tumours

The classification of malignant tumours is complicated

1 Germ Cell Tumours

Malignant teratoma Teratoma

Malignant teratoma Choriocarcinoma

i.e. the testis is taken out through an incision in

This is because the lymphatic drainage of the testis

Radiotherapy for seminoma

Sometimes a combination of the two is

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