SCROTAL SWELLINGSCase No:2

PROBLEM ORIENTED CASE BASED LEARNING

Dr.B.Selvaraj MS;Mch;FICSProfessor of Surgery

Melaka Manipal Medical collegeMelaka Malaysia 75150

OVERVIEW

• Various causes(Differential diagnosis) of scrotal swellings• Classical clinical vignette with probable diagnosis• The diagnosis in detail- only one pathology in each

episode• Mind map of the diagnosis• Tabular column of differential diagnosis depicting their

characteristic features to differentiate them from your diagnosis• References and feedback

Causes of Scrotal Swellings ACUTE PAINFUL

• Torsion testis• Acute epididymo-orchitis• Torsion of testicular

appendages

CHRONIC PAINLESS

• Hydrocele• Epididymal cyst• Spermatocele• Chronic epididymo-

orchitis• Testicular tumor• Varicocele

Classical Clinical vignette Torsion Testis

• A 14-year-old boy presents with acute onset of right scrotal and RLQ pain for the past 4 hours. He additionally reports nausea and one episode of vomiting. He denies any similar past pain and reports no history of trauma.• O/E: the skin overlying the right side of the scrotum appears

to be slightly erythematous and edematous. The right testicle appears to be lying significantly higher in the scrotum as compared to the left testicle.• The entire right testicle is exquisitely tender to palpation,

whereas the left one is nontender• He has an absent cremasteric reflex on the right.

Torsion Testis- Etiopathogenesis

• Twisting of testis along with spermatic cordStrangulationNecrosis• Common in neonates and in puberty• Inversion of testis• Strong muscular exertion or blunt trauma can trigger it• Undescended testis undergo torsion frequently• High insertion of tunica vaginalis- bell clapper deformity-predisposes• There are 3 types of torsion- Extravaginal, intravaginal and mesorchial• Extravaginal in neonates, intravaginal in adolescents

Torsion Testis- Types

In Neonates In Adolescents Bell clapper deformity

Torsion Testis- Clinical Features

• Sudden severe pain in hemiscrotum or both sides• Nausea & vomiting• Scrotal skin edematous and erythematous• Testis exquisitively tender• Affected testis at higher level because of twisting Deming’s sign• Normal testis lying horizontally Angel’s sign• Pain not relieved on elevation of scrotum Prehn’s sign• Cremastric reflex absent in affected side

Torsion Testis- Clinical Features

Torsion Testis- Clinical Features

Torsion Testis- Clinical Features

Torsion Testis- Differential Diagnosis

Torsion Testis- Doppler USG

Torsion Testis- Doppler USG

Central testicular blood flow Normal Testis

No Central testicular blood flow but excessive peripheral blood flow

• Ipsilateral side Exploration, detorsion and fixation orchiopexy Detorsion is away from median raphae of scrotum like opening a book• Contralateral side Exploration and fixation orchiopexy• In doubtful cases and nonavailability of Doppler USG

Better to explore rather than unduly delay the treatment• Testicular salvage rate is 100% if surgery is done within 6

hrs and it is 20% if surgery is delayed > 24 hrs

Torsion Testis- Treatment

• Hydatid of testis & epididymis Remnant of obliterated Mullerian ducts• Sudden Swelling and redness of hemiscrotum• Tender Testis• ‘Bluedot sign’ +ve• Cremastric reflex intact

Torsion of Testicular appendages

Torsion of Testicular appendages “Blue dot sign”

• Explore & Excise torsed appendages in early cases• In delayed cases >48 hrs conservative treatment with antibiotics & anti inflammatory drugs

Torsion of Testicular appendages Treatment

• Inflammation of epididymis & Testis due to infection or trauma• Sudden onset of pain in a hemiscrotum• Commonly associated with UTI or trauma• Thickened & Tender epididymis• Pain relief by elevation of hemiscrotum Prehn’s sign• Can be treated conservatively with antibiotics and antiinflammatory drugs

Acute epididymo-orchitis

Acute Epididymo-orchitis Doppler USG

USG Scrotum• Thickened Epididymis• Reactive Hydrocele• Thick scrotal wall

Doppler USG• Excessive blood flow to

Epididymis• Normal testicular

parenchymal blood flow

Testicular Torsion- Mindmap

Scrotal Swellings- Algorithm

Scrotal Swellings Ex & Px

Hx Sx Dx Tx

1. Hydrocele Primary-IdiopathicSecondary- under lying pathology

Painless big swelling; not reducible

No cough impulseGet above swelling+Transilluminant+

ClinicalIn doubt- USG of scrotum

Lord’s operationJaboulay’s operation

2. Epididymal cyst & Spermatocele

Degenaration of epididymis, occlusion of pathway

Swelling in scrotum resembles 3rd testis

Testis palpable separately; Chinese lantern appearance

ClinicalUSG of scrotum

ConservativeExcision

3. Varicocele IdiopathicAbsence of valves in testicular vein

Worm like in upper scrotum; infertility

Disappears on lying down; Bag of worms appearance

ClinicalUSG color doppler

VaricocelectomyInguinal or Retroperitoneal

4. Testicular torsion & Epididymo- orchitis

Abnormal fixation and lie of testisUTI & trauma

Severe pain& swelling scrotumNausea & vomiting

Tender hemi scrotum; cremasteric reflex absent

ClinicalUSG color doppler

Explore,detorse, orchiopexy or orchidectomyConservative

5. Testicular carcinoma

UDT, Kieinfelter’s Germ cell- Seminoma & Non seminomaNon germ cell tumor

Painless heavy swelling

Not reducibleHard in consistencyTestis felt separately

Clinical; No FNACUSG OF scrotum

High orcidectomy with or without RPLND+ RT+CT

D/D for Scrotal Swellings (Compare & Contrast) (Vertical Reading)

References

• Hunt & Marshall’s clinical problems in surgery 2nd edition• Clinical surgery made easy- a

companion to PBL by Mohan De silva 1st edition• 100 cases in surgery 2nd edition• Case files surgery 4th edition• Clinical scenarios in surgery-

decision making 1st edition• Surgery- a case based clinical

review 1st edition

• Surgery Review by Carlos Pestana• Clinical surgery pearls by

Dr Dayananda Babu 2nd edition• NMS casebook surgery 2nd edition• General Surgery- Correlations &

clinical scenarios 1st edition• Surgery review by Makary 3rd edition• Short practice of surgery by Bailey and

Love 26th edition• Shelf life surgery 1st edition

Feedback & Suggestions

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