Topic discussion

Surgical unit 2

Scrotal swelling

Group 3
Causes of scrotal swelling according to site
• Scrotal wall swellings eg. sebaceous cysts , Ca scrotum
• Intrascrotal swellings
1. Hydrocele
2. Testicular tumors
3. Haematocele, pyocele, chylocele
4. Varicocele
5. Epididymal cyst
6. Spermatocele
7. Complete scrotal hernia
Causes of scrotal swelling according to duration
Acute painful Chronic painless
1. Cystic
• Torsion testis • Hydrocele
• Acute epididymo-orchitis • Epididymal cyst
• Spermatocele

2. Solid
• Varicocele
• Chronic epididymo-orchitis
• Testicular tumor
 Hydrocele
Definition
A hydrocele is abnormal accumulation of serous fluid in
some part of processus vaginalis, usually in the tunica.
Classification
• According to aetiology
1. Primary or idiopathic
2. secondary
• Anatomical classification
1. Vaginal hydrocele
2. Infantile hydrocele
3. Communicating or congenital hydrocele
4. Hydrocele of the cord
Aetiology
Produced in four different ways;

1. By connection with the peritoneal cavity via patent processus vaginalis

( congenital )

2. By excessive production of fluid within the sac, e.g. a secondary hydrocoele.

3. By defective absorption of fluid.

4. By interference with the lymphatic drainage of scrotal structures.

2.Secondary hydrocele
• Associated with diseases of testis and epididymis
 Infection eg. Epididymo-orchitis
 Trauma
 Neoplasia
 Lymphatic obstruction
• Remain small and Lax
Clinical features

• Usually presenting with painless scrotal swelling

• Can get above the swelling
• Testis cannot be palpated separately
• Cystic in consistency
• Positive fluctuation test
• Positive transillumination test
Complications
• Rupture
• Herniation of hydrocele sac
• Haematocele
• calcification
Investigation
 For diagnosis
Diagnosis is mainly made by clinical methods.
 For underlying cause
USG scrotum – exclude underlying testicular tumor
 For management
haemogram
BT, CT
B,C,HIV ( infection screening)
 Treatment
Options
1. Operative treatment
2. Non-operative treatment

Operative treatment
• Jaboulay’s operation ( eversion)
• Hydrosectomy/ radical cure
• Lord’s operation ( plication )
• Operation for congenital type of hydrocele
1. Plication; Lord’s operation is suitable when the sac is thin-walled.
Minimal dissection and risk of haematoma is reduced.

2. Eversion; the sac is opened and everted behind the testis, with
placement of the testis in a pouch prepared by dissection in the
fascial planes of scrotum (Jaboulay’s procedure)

3. Excision; can cause a large scrotal haematoma. (not

recommended)
Non operative treatment
• Aspiration
• Injection treatment

For secondary hydrocele

• Treatment of underlying cause
• Aspiration and antifilarial drugs for filiarial hydrocele and
chylocele
Testicular tumor
 Testicular tumor
• 1-1.5 % of malignant tumors in men
• Classification
1. Germ cell tumors 90-95%
(1)seminoma,
(2)non-seminomatous - embryonal cell carcinoma, yolk sac
tumor, teratoma,choriocarcinoma
2. Interstitial tumors 1-2%
Include sertoli cell tumor and leydig cell tumor
3. Lymphoma 3-7%
4. Other tumors 1-2%
Clinical features

• Mostly painless testicular lump.

• Sensation of heaviness can occur if the testis is two or three times normal size.

• Pain and acute enlargement of testis due to haemorrhage into tumor

• Rarely, Symptoms of metastatic disease are predominant

• On examination – an intratesticular solid mass.

Investigations
 For diagnosis
1. USG testis
2. Tumor markers
• βhCG level
• AFP
3. Scrotum exploration and orchidectomy for suspected
testicular tumor

 For staging
1. CXR
2. USG (abdomen)
3. CT ( chest, abdomen, pelvis)
Staging
 Stage Ι - tumor confined to testis and epididymis
 Stage ΙΙ - nodal disease is present but confined to nodes
below the diaphragm
 Stage Ш – nodal disease is present above the diaphragm
 Stage ΙV – non lymphatic metastasis , commonly to the
lungs
Treatment of seminoma
 Stage I disease
• Very sensitive to radiotherapy and adjuvant radiotherapy to para-
aortic lymph nodes ( mainstay of treatment)
• Due to excellent response to platinum based chemotherapy, some
year ago, chemotherapy was added even for stage I disease
• However, current practice is CT and tumor markers based
surveillance protocol with chemotherapy being reserved for
men who demonstrate relapse
 Stage II –IV disease

• BEP chemotherapy is mainstay of treatment

• Bleomycin, Etopocide, Cis-platin

Treatment of non- seminoma tumors
 Stage I disease
• Not respond to radiotherapy
• Patients with negative tumor markers are treated by orchidectomy
alone
• Patients with positive tumor markers are treated by chemotherapy
until markers become negative and then orchidectomy

 Stage II- IV disease

• BEP chemotherapy
• Retroperitoneal lymph node dissection
 Complete scrotal hernia
• Definition – hernia is protrusion of viscus or part of vicsus
through abnormal opening in the wall of its containing
cavity.
• Complete ( scrotal ) hernia – hernia sac descends to the
bottom of the scrotum
• Clinical features
 Swelling in the inguino –scrotal region
 More prominent on standing and straining, less
prominent on lying down
 Cannot get above the swelling
 Reducible
 Expansile cough impulse

 Complications
• Irreducible hernia
• Obstructed hernia
• Strangulated hernia
• Gangrenous hernia
• Inflammed hernia
• Perforation of intestine
Investigation
 For diagnosis
• Diagnosis is mainly made by clinical methods
 For underlying causes
• USG abdomen
• Full blood count, ESR
 For management
• Haemogram, BT,CT, B, C, HIV
Treatment
• Operation is treatment of choice.
• Herniotomy and repair ( open & laparoscopic)
• Truss is not recommended but can be used when
operation is contraindicated or refused.
• Treatment of underlying causes eg. Treatment of chronic
chest infection and BPH
 Varicocele
• Definition – a varicose dilatation of the veins draining to
the testis ( pampiniform plexus)
• Causes – idiopathic, secondary to renal tumor or after
nephrectomy
• Clinical features
 Mostly asymptomatic
 If symptomatic, present in adolescence or early
adulthood ,usually on the left side
 Dragging discomfort that is worse on standing
 Scrotum on the affected side hangs lower than normal
 Transmitted cough impulse
 Swelling separate from testis
 Bag of worms feeling on palpation
 Testis is smaller and softer than its fellow in long standing
cases

• Investigation
USG – helpful in small varicocele
- to exclude renal tumor in old age.
Treatment
• conservative for asymptomatic cases
• In symptomatic cases, first line treatment is embolization
of testicular veins
• Laparoscopic ligation of testicular veins
• Open surgery
• Testicular vein ligation
• Varicocelectomy
Varicocele , bag of worms
appearance
 Haematocele
It has two types.
1. Recent haematocele
• Due to rupture of one of the vessels of tunica causing
bleeding into the sac
• After aspiration of hydrocele
• Precipitated by trauma
• Clinical features
-sudden onset of pain and swelling after history of trauma
-tender, warm , fluctuant , nontranslucent
• Investigation
USG scrotum – to rule out neoplasm and find viability
of testis
• Treatment
– scrotum is explored under GA , the clot is evacuated and
wound is closed with a drain
2.Chronic or old clotted haematocele
• Due to slow , spontaneous haemorrhage into the tunica
vaginalis without any proper history of trauma
• Painless, hard , non tender , non fluctuant swelling with
loss of testicular sesation
• May mimics testicular tumor
• USG scrotum
• Treatment – orchidectomy
 Pyocele
• Collection of pus in the layers of tunica vaginalis
• Can occur in previously normal tunica or in pre-existing
haematocele or hydrocele
• Clinical features
 Fever, toxicity, tender swelling in the scrotum with
scrotum wall edema
 Often occur in young individuals
Investigation
• USG will confirm the diagnosis

Treatment
• Antibiotics
• Exploration of scrotum and drainage of pus
• Viability of testis is checked
• If testis is not viable, orchidectomy is done.
 Chylocele
• Presence of chylous fluid in the tunica vaginalis
• Due to rupture of lymphatic varix with discharge of chyle
into the hydrocele
• Caused by parasite Wuchereria bancrofti
• It is suspected when a case of hydrocele presents with a
periodic history of fever and negative translucency test
• Long standing case, dense adhesion occur
• Treatment – rest and aspiration
-excision of the sac in chronic case
Chylocele
 Epididymal cysts
• Cystic degeneration of epididymis
• Congenital in origin but occurs in middle ages
• Tensely cystic, contains clear fluid
• Bilateral , multiloculated
• Feel like a tiny bunches of grapes
• Lies posterior to and separate from testis
• Transilluminate brilliantly
• Confirmed by USG
• Treatment – excision but infertility may result
• If multilocular cysts require partial or total epididymectomy
Epididymal cyst
 Spermatocele
• Unilocular acquired retention cyst derived from blockage
of some portion of the sperm conducting mechanism of
the epididymis
• Lies in the head of epididymis above and behind the upper
pole of testis
• Soft, cystic, transilluminate
• Fluid contains spermatozoa and resembles ‘barley water’
appearance
• Diagnosis is confirmed by aspiration cytology
• Treatment – small spermatocele can be ignored
- for large one, excision
Spermatocele
 Sabecous cyst
• firm nodule on the skin of scrotum that is caused by
accumulation of sebum resulting from sebaceous gland
blockage
• Small and multiple
• Surgical excision if troublesome
 Carcinoma of the scrotum
• Chimney sweeps’ cancer
• Rare cancer
• Aromatic cyclic hydrocarbons are aetiological
factors
• Growth starts as wart or ulcer
• Treatment – surgery
Thank you!