GUS2-K8-scrotal Swelling

‫بسم هللا الرحمن الرحيم‬
Scrotal Swellings
Dr. Syah Mirsya Warli, SpU

Dr. Zahri A. Ranie, SpU
Div. of Urology, Dept.of Surgery
Medical Faculty, University of North Sumatera
Common Causes of Scrotal
Swellings
Hydrocele
Epididymal Cyst
Varicocoele
Epididymo-orchitis
Testicular Tumour
Hydrocele
• Fluid collections within the tunica
vaginalis of the scrotum or a long
spermaticcord.
• Persistent developmental connections a
long the spermatic cord or Imbalance of
fluid produc versus absorption.
• Little risk of clinical consequence.
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).
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
Treatments
• 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.
Differentials
– Orchitis
– Testicular torsion
– Indirect inguinal hernia
– Traumatic injury to the testical
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
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
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
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
But Remember
40% of testicular tumours are
mixed, i.e. they have both
seminomatous and non
seminomatous elements
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

GUS2-K8-scrotal Swelling

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‫بسم هللا الرحمن الرحيم‬

Dr. Syah Mirsya Warli, SpU

Examination: A scrotal swelling which you can

Examination: Scrotal swelling which you

Simple surgical excision of the cyst

Aspirating will not work because the cyst is

As for hydroceles, conservative management is

Signs: Scrotal swelling which you can get

Therefore all patients with a varicocoele

The two main methods are:

Signs: A scrotal swelling which you can get

This is a fluoroquinolone antibiotic

It acts by inhibiting an enzyme called DNA gyrase in

You might sensibly start classifying testicular

The classification of malignant tumours is

1 Germ Cell Tumours

Malignant teratoma Teratoma

Malignant teratoma Choriocarcinoma

The blood tests are known as tumour markers.

i.e. the testis is taken out through an

This is because the lymphatic drainage of

Radiotherapy for seminoma

Sometimes a combination of the two

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