Examination of Scrotal Swelling

Hardra vg
59
History
Age
■ Younger Ages
‣ Funiculitis
■ Any Age
‣ Encysted hydrocele of spermatic cord
‣ Lymph varix
‣ Varicocele
Residence
■ Funiculitis and lymph varix are commoner in Orissa and
adjoining districts.
Complaints
Pain
❖ Funiculitis
❖ Tuberculous thickening of spermatic cord,as an extension upwards
from the epididymis
❖ Malignant extension upward from the testis
❖ Vague dragging pain on prolonged standing in varicocele
❖ Sudden agonising pain over inguinoscrotal region during torsion of
testis. This condition mimics appendicitis on the right side.
Swelling
❖ Main presenting feature during encysted hydrocele of cord, diffuse
lipoma, lymph varix etc.
❖ Questions such as:
■ “How did it first appear?”
■ “Where did it appear first?”
■ “Does it disappeared automatically on lying down?”
will aid in the diagnosis.
● Varicocele
‣ Appears spontaneously from below the inguinal ligament
‣ Disappears spontaneously when the patient lies down with
scrotum elevated
● Funiculitis appears with fever along with chill
● Infantile hydrocele, testicular growth appears from below.
●Lymph varix will spontaneously reduce on lying down although slower
than varicocele.
Any other complaints
● Tuberculous thickening of spermatic cord may be associated with
evening rise in temperature, excessive coughing, haemoptysis etc.
● Rapid onset of varicocele on the left side with hematuria may
indicate carcinoma of kidney on that side.
● Sterility may be complained in case of bilateral undescended testis.
Past History
❖ Previous history of periodic attacks of fever accompanied by pain
and swelling of spermatic cord of scrotum is highly suggestive of
filarial infection.
Personal History
❖ History of gonococal exposure may be obtained in gonococcal
funiculitis.
Local Examination
● Position of patient
‣ Always convenient to examine patient in standing position first
and later in recumbent position
‣ He must not be allowed to bend over during examination
Inspection
Swelling
‣ Position and extent of the swelling are very important. A localised
swelling in the spermatic cord is encysted hydrocele of the cord
whereas a diffuse swelling of the cord may be a lipoma.
‣ Skin over swelling
■ In funiculitis or in certain late cases of torsion of testis the skin
over the swelling will be red and oedematous. This must be
differentiated from strangulated hernia which also shows signs of
inflammation.
● Impulse on coughing
‣ This differentiates a hernia from other conditions in this region. It
must be remembered that lymph varix (lymphangiectasis) also
gives an impulse (thrill-like) on coughing.
‣ Varicocele also gives an impulse on coughing like a fluid thrill.
‣ An undescended testis with associated hernia may also give
impulse on coughing.
Palpation
● Position and Extent
‣ A cystic swelling in the middle of spermatic cord without any
upward extension is an encysted hydrocele of the cord.
‣ A diffuse swelling of the cord may be a lipoma when it is non-
inflammatory and a funiculitis when it is inflammatory.
● Consistency
‣ A localised cystic, fluctuant and translucent swelling is an
encysted hydrocele of the cord.
‣ A lymph varix feels soft, cystic and doughy.
‣ A varicocele is diagnosed by its peculiar feel like a "bag of
worms"
● Reducibility
‣ But a lymph varix and a varicocele become spontaneously reduced
when the patient lies down. This reduction occurs slowly and not
abruptly as in the case of a hernia.
‣ After reduction the external abdominal ring is pressed with a
finger and the patient is asked to stand up.
‣ A varicocele and a lymph varix will gradually fill from below
● Impulse on coughing
‣ This is also a classical sign of a hernia.
‣ A varicocele and a lymph varix also give impulse on coughing, but
the impulse is felt like a thrill and is not the typical expansile
impulse as felt in the case of a hernia.
Percussion and auscultation
○ Percussion is helpful in differentiating a strangulated hernia from
acute funiculitis, the former being resonant as it contains the
intestine.
General Examination
○ The chest should be examined particularly in the case of
tuberculous epididymitis extending upwards.
○ The abdomen should be examined thoroughly in case of malignant
infiltration of the spermatic cord from the testis to exclude
presence of palpable enlarged pre- and para-aortic groups of lymph
nodes.
○ In a case of rapidly growing varicocele in a middle-aged man one
should examine the kidney as very often tumour of the kidney
spreads along the lumen of renal vein (in case of left side) or inferior
vena cava (in case of right side) to obstruct the testicular vein
resulting in a varicocele.
Type of swelling
Congenital swelling- torsion of testis
Inflammatory swelling-cyst of epididymis
Traumatic swelling-Hydrocole
Malignant swelling-Testicular carcinoma
Vascular swelling- varicocele
Painless swelling Painful swelling
Hydrocele. Torsion of testis
Cyst of epididymis
Varicocle
Testicular carcinoma
Hydrocele

❖ It is the collection of fluid between the two layers of tunica vaginalis

of testis.
❖Types:
● Congenital
● Acquired
● Primary
● Secondary
Primary Vaginal Hydrocele

❖ Middle-aged, common in tropical countries.

❖ Testis is not palpable as it usually attains a large size .
❖ Fluctuant.
❖ Initially transilluminant, but long-standing hydrocele is
nontransilluminant (due to thickened dartos, thickened spermatic
fascia, thickened hydrocele sac, infected content, chylous fluid, often
filarial hydrocele, haematocele).
❖ Testicular sensation can be elicited in vaginal hydrocele by
transmitting the pressure sensation through the fluid.
Secondary Vaginal Hydrocele

❖ It is usually small, lax and testis is usually palpable. Exception is,

secondary hydrocele due to filariasis. It can be very large.
❖ Infection: Filariasis
Tuberculosis of epididymis- 30% cases
Syphilis
Injury: Trauma,
Tumour: Malignancy
Complication
❖ Infection
❖Pyocele
❖Haematocele
❖Atrophy of testes
❖Infertility
❖Hernia of hydrocele sac
Treatment
❖ Subtotal excision of the sac
❖ Jaboulay's operation (Partial excision and eversion)
❖ Evacuation and eversion.
❖Lord's plication
❖Sharma and Jhawer's technique
Cyst of Epididymis

❖ It is due to the cystic degeneration of:

● Paradidymis (organ of Giraldes)-is the most common cause
● Appendix of the epididymis; Appendix of the testis
● The vas aberrans of Halle
❖ Even though it is of congenital origin, it occurs in middle age.
❖ It is tensely cystic, contains clear fluid .
❖ Often bilateral.
❖ They are aggregation of number of small cysts and so multiloculated.
❖ They feel like · bunch of tiny grapes' situated behind the body of the
testis.
❖ It is situated behind the body of testis.
❖ Numerous septae they are finely tessellated and so are brilliantly
transilluminant, appear like 'chinese lantern pattern'.
Treatment
❖Avoid excision as much as possible as it results in infertility due to
blockage.
❖In old age, excision can be done.
Varicocele
❖ It is dilatation and tortuosity of the pampiniform plexus of veins and
so also the testicular veins.
❖ Common in tall, thin young men.
❖ Common on the left side; can be bilateral.
❖ Swelling in the root of the scrotum
❖ Dragging pain in the groin and scrotum
❖ "Bag of worms" feeling
❖ Impulse on coughing
❖ On lying down, it gets reduced
❖ Grading of varicocele:
(I) Small
(II) Moderate,
(Ill) Large,
(IV) Severely tortuous
Types
❖Primary/idiopathic-95%: No cause is found. There is incompetence of
valves of the testicular vein.

❖Secondary- due to specific cause like left-sided renal cell carcinoma

with a tumour thrombus in left renal vein causing obstruction to
venous flow of left testicular vein.
Investigations
Semen analysis
Venous Doppler of the scrotum and groin.
Ultrasound abdomen to look for kidney tumor
Treatment

❖Paloma's operation-. Suprainguinal extraperitoneal ligation of the

testicular vein.
❖Inguinal approach (lvanissevich approach): Easier and safer.
❖Subinguinal approach (Marc-Goldstein): It is subinguinal approach at
superficial inguinal ring outside the external oblique aponeurosis
without opening the external oblique aponeurosis. Here cord is easily
identified through a small incision.
❖Scrotal approach: In case of grade IV, veins have to be excised
through this approach.
❖Laparoscopic approach: Presently, accepted
Torsion of Testes
❖ It is an emergency condition of the testis, wherein the testis twists
(rotates) in its axis compromising its blood supply. If not intervened
and rectified within 12-24 hours, testicular gangrene may occur.
❖ Right testis rotates in clockwise direction where as left testis rotates
in anticlockwise.
❖ Occurs in children and adolescents.
❖ Presents with sudden onset of pain in the scrotum, groin and lower
abdomen.
Differential diagnosis
❖Acute epididymo-orchitis-elevation of the scrotum for one hour,
relieves the pain of acute epididymo-orchitis but aggravates in case of
torsion testis (Prehn's sign).

❖Strangulated inguinal hernia: Torsion of incompletely descended

testis resembles strangulated inguinal hernia but the scrotum on that
side is empty
Investigations
❖Total WBC count.
❖Doppler study of scrotum to look for the testicular artery pulsation.
❖Ultrasound abdomen.
Treatment
❖Emergency exploration of the scrotum and untwisting of the torsion
testis is done. Then viability of testis is checked. Once confirmed, the
testis is fixed to the scrotal sac using 2-3 interrupted nonabsorbable
sutures (Prolene).
❖If surgery is done within 12-24 hours, viability of the testis may be
retained. If delayed, testis becomes gangrenous and orchidectomy is
done after taking informed consent.
❖Postoperatively, a repeat Doppler study helps to confirm the viability.
As often the condition is bilateral, other side testis should also be
fixed to prevent the torsion.
Pyocele
❖ Collection of pus in the layers of tunica vaginalis.
❖ Fever, toxicity, tender swelling in the scrotum, with scrotal wall
oedema.
❖ Often in young individuals.
❖ Pus under tension eventually causes infective thrombosis of testicular
vessels, leading to nonviability of the underlying testis or testicular
gangrene.
Treatment
❖Antibiotics are started .
❖Scrotum is explored immediately and pus is evacuated.
❖Viability of the testis is checked.
❖If viable, pus is evacuated and sent for CS, wound is closed with a
drain.
❖If the testis is not viable, then orchidectomy is done (after taking
consent).
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