SCROTAL SWELLINGSCase No:4

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

• 30 years male patient presented with a swelling in the left side of the scrotum for last 4years. The swelling started in the lower part of the scrotum and subsequently the swelling is slowly increasing in size and grown up to the root of the scrotum. The swelling disappears on lying down position and reappears on standing and walking• Patient complains of dull aching pain in the left side of the scrotum

for last 6 months, the pain is more towards the evening when the swelling enlarges in size• There is no pain abdomen, no urinary complaints

Classical Clinical Vignette Varicocele

• O/E: A mass of dilated vein feeling like a bag of worms is palpable on the left side of the scrotum along the left spermatic cord extending from the upper pole of the testis up to the superficial inguinal ring• No expansile impulse on cough is palpable, instead a thrill is

palpable. On lying down and on elevation of the scrotum the swelling disappears• On asking the patient to stand up the dilated veins

reappeared. The left testicular volume is smaller than the right one. Abdominal examination is normal

Varicocele-Anatomy

• Surgical Anatomy: Pampiniform plexus of veins (15 – 20) draining the testis and epididymis makes the major bulk of the spermatic cord. As they ascend, the number is reduced to 12 and on reaching the superficial inguinal ring they unite to form 4 veins. At the level of deep ring they are 2 in number and in retroperitoneum, it forms single testicular vein.• Left testicular vein drains into left renal vein and right testicular

vein into inferior vena cava

Varicocele-Anatomy

Varicocele

• Dilatation and tortuosity of the pampiniform plexus of veins• Seen commonly in men aged 15-30yrs and rarely after 40yrs.• Occur in 15-20% of all males and 40% of all infertile males.• Normal vein diameter of vessels of plexus- 0.5-1.5mm. Diameter

greater than 2mm- Varicocele.

Varicocele

• It is common on the left side5 reasons.Left testicular vein is longer than right testicular veinLeft testicular vein enters at right angle to the left renal veinLeft testicular artery is arching over left testicular veinA loaded sigmoid colon compressing left testicular veinLeft renal vein is compressed b/w the Aorta and SMA

Varicocele- Etiology

• 1.Idiopathic/Primary – due to incompetency of valves. 98% occur on the left side

• 2.Secondary Pelvic or abdominal mass. Lt renal cell carcinoma with tumor thrombus in left renal vein. Nutcracker syndrome- SMA compressing left renal vein. Other

conditions- Retroperitoneal fibrosis or adhesions

Varicocele- Bag of Worms Appearance

Varicocele- Clinical Features

• The patient may have aching or dragging pain particularly after prolonged standing.• It can be differentiated from an omentocele by the peculiar feel

of the bag of worms.• Many varicoceles are asymptomatic and found incidentally• It is more common on the left side for reasons stated above• Infertility: Varicocele is often associated with infertility. The

scrotal temperature is usually higher in the presence of varicocele and this may impair spermatogenesis

Varicocele- Clinical Features

• Bow sign- hold varicocele b/w thumb and fingers, patient is asked to bow- reduced in size• On lying down it gets reduced; On standing up it reappears• Long standing cases- affected side testis is reduced in size and

softer. Testis size can be measured by Prader orchidometer• No expansile cough impulse present, but thrill present while

coughing

Varicocele- Grading

• Grade I: Small varicocele which is palpable only when patient performs Valsalva maneuver (expiration against a closed glottis).

• Grade II: Moderate sized. Easily palpable varicocele without Valsalva’s maneuver

• Grade III: Large varicocele visible through the scrotal skin.

• Grade IV : Very much dilated and tortuous veins

Varicocele- Investigations

• Venous color doppler of the scrotum and groin- -standing/ valsalva’s manoeuvre• USG abdomen to look for kidney tumours.• Seminal analysis Oligospermia or azospermia

Varicocele- Investigations

Varicocele- Indications for Surgery

• American Urological Society recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present.• A varicocele is palpable.• The couple has documented infertility.• The female has normal fertility or potentially correctable infertility• The male partner has one or more abnormal semen parameters or sperm

function test results.• The indications in adolescents- presence of significant testicular

asymmetry (>20%) demonstrated on serial examinations, testicular pain, and abnormal semen analysis results.

Varicocele- Treatment

• Asymptomatic varicocele—No treatment is required, only scrotal support and reassurance• Symptomatic varicocele—Excision of the pampiniform plexus in the

inguinal canal after ligating them. Testis still has venous drainage via the cremasteric veins• VARICOCELECTOMY- The most common approaches are • Inguinal (groin)-easier and safer. • Retroperitoneal (abdominal) • Suprainguinal extraperitonial( Palomo’s operation)Open & Laparoscopic • Scrotal approach- For Gr 4

Varicocele- Treatment

Varicocele-

• Non-surgical procedure.• Steel coil or silicone balloon catheter is introduced into a vein below

the groin through a nick in the skin.• Passed under X-ray guidance.• Tiny metal coils or other embolizing agents introduced through the

catheter.• No stitches needed. • Patient can go back in 24hrs.• Lower rates of complications. Less effective, higher recurrence(5-11%),

danger that the coil could migrate to the heart and cause death

Coil Embolization,

Varicocele- Coil Embolization,

Varicocele- Complications

• Haemorrhage and scrotal haematoma• Infection Pyocele• Injury to testicular artery• Injury to ilioinguinal nerve and pain• Recurrence—5-10%

Varicocele - 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• Surgery- Clinical cases uncovered by

Harold Ellis 1st edition• Shelf life surgery 1st edition

Feedback & Suggestions

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