Scrotal swellings 1

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SCROTAL SWELLINGS Case No:1 PROBLEM ORIENTED CASE BASED LEARNING Dr.B.Selvaraj MS;Mch;FICS Professor of Surgery Melaka Manipal Medical college Melaka Malaysia 75150

Transcript of Scrotal swellings 1

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SCROTAL SWELLINGSCase No:1

PROBLEM ORIENTED CASE BASED LEARNING

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

Melaka Manipal Medical collegeMelaka Malaysia 75150

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OVERVIEW

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

episode• Mindmap of the diagnosis• Tabular column of differential diagnosis depicting their

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

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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

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Classical Clinical Vignette Vaginal Hydrocele

• A 35-year-old male patient presents with right sided scrotal swelling of two years duration. It is a progressively increasing painless swelling.• O/E: the right side of the scrotum shows a swelling of 15 × 10 cm

size which is confined to the scrotum (can get above the swelling). The surface of the swelling is smooth and borders are well-defined. There is no local rise of temperature. The swelling is fluctuant and transilluminant. It is not reducible.There is no cough impulse. The right testis is not felt separately. On percussion it is dull. • The spermatic cord is felt above the swelling and is tender.• The contralateral testis and genitalia are normal. There is no

evidence of any mass or lymph nodes in the abdomen

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Hydrocele- Etiopathogenesis• A hydrocele is an abnormal collection of serous fluid in a part

of the processus vaginalis, usually the tunica vaginalis.• A hydrocele can be produced in four different ways • 1. By excessive production of fluid within the sac in

secondary hydrocele• 2. By defective absorption of fluid in primary hydrocele• 3. By interference with lymphatic drainage of scrotal

structures in filariasis• 4. By connection with the peritoneal cavity via a patent

processus vaginalis in congenital hydrocele

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Primary Vs Secondary Hydrocele Primary Hydrocele

• Defective absorption of fluid• Ex: Vaginal & infantile

hydroceles• Attain moderate to big size• Difficult to palpate testis• Transillumination positive• Consistency tensely cystic• Tx: Jaboulay’s & Lord’s

operations

Secondary Hydrocele• Excessive production of fluid• Ex: Filariasis, tumor, trauma &

epididymo-orchitis• Attain small size• Testis easily palpable• Transillumination negative• Consistency Lax cystic• Tx: Treat underlying causes

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Composition of Hydrocele Fluid• Color—Straw or amber colored.• Composition—Water, fibrinogen, inorganic salts,

albumin and cholesterol crystals• Hydrocele fluid normally won’t clot if it is drained into a

container but will clot immediately even if it comes into contact with a drop of blood• Following swellings contain cholesterol crystals viz.

hydrocele, branchial cyst, and dental and dentigerous cyst

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Primary Hydrocele- Types

• 1.Congenital hydrocele• 2. Funicular hydrocele • 3. Infantile hydrocele• 4. Encysted hydrocele of the

cord• 5. Vaginal hydrocele-

commonest type• 6. Bilocular hydrocele• 7. Hydrocele of the hernial

sac

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Primary Hydrocele- Clinical features

• Moderate to big size swelling• Cough impulse negative• Get above the swelling

positive• Not reducible• Consistency tensely cystic• Transillumination positive• Testis not felt separately

• Congenital hydrocele Diurnal variation +• Bilocular hydrocele Cross

fluctuation + • Encysted hydrocele Traction

test+ • Get above the swelling negative

in Infantile and Bilocular hydroceles• Transillumination negative in

Hematocele, Pyocele, Chylocele and thick sac

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Hydrocele of Canal of Nuck

• Hydrocele of the canal of Nuck is a condition in females.

• The cyst lies in relation to the round ligament and is always at least partially within the inguinal canal.

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Primary Hydrocele- Clinical Pictures

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Primary Hydrocele- Complications • Infection• Pyocele• Hematocele• Atrophy of testis • Infertility• Hernia of hydrocele sac

(rare)• Rupture & calcifications

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Primary Hydrocele- Treatment • Congenital hydrocele- Inguinal herniotomy• Adult vaginal hydroceleSmall sizeLord’s plicationLarge sizeJaboulay’s operation Incision and eversion of sacAfter evacuation, the sac with the testis is placed in a newly created pocket between the fascial layers of the scrotum Sharma and Jhawer’s technique.• Encysted hydroceleInguinal herniotomy + incision and

drainage of the encysted hydrocele

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Primary Hydrocele- Treatment

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Complications of surgery

• Reactionary haemorrhage Hematocele• Infection• Pyocele• Sinus formation• Recurrent hydrocele

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Hydrocele- Mindmap

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Scrotal Swellings- Algorithm

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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 veins

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)

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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• Surgery- Clinical cases uncovered by

Harold Ellis 1st edition• Self- Life Surgery 1st edition

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