Diagnosis of scrotal swellings
- To determine the nature of a scrotal swelling four aspects need to be assessed.
- Can you get above the swelling?
- Can the testis and epididymis be identified separately?
- Does the swelling transilluminate?
- Is the swelling tender?
Swellings not confined to the scrotum
- Hernias
- May be reducible with cough impulse
- Testis is palpable
- Infantile hydrocele
- Irreducible
- No cough impulse
- Testis impalpable
Swellings confined to scrotum
- Epididymo-orchitis
- Testis and epididymis definable
- Testis tender
- Testicular tumour
- Testis and epididymis definable
- Lump within testis
- Testis non tender
- Epididymal cysts
- Testis and epididymis definable
- Lump separate
- Testis non tender
- Vaginal hydrocele
- Testis and epididymis not definable
- Transilluminates brightly
- Torsion testis
- Testis and epididymis not definable
- Testis tender
- Gumma
- Testis and epididymis not definable
- Irregular non-tender lump
Picture provided by Pankaj Rao, Command Hospital Chandimandir, Panchakula,
India
Testicular torsion
- Common surgical emergency in adolescent boys
- Peak incidence in second decade of life
- A high insertion of tunica vaginalis ('Bell clapper testis') predisposes
- Abnormality usually bilateral with contralateral testis also having horizontal lie
- Usually presents with acute scrotal pain
- May present with abdominal pain
- Always examine in the scrotum in boys with abdominal pain
- Urinary symptoms are uncommon
- 50% have had previous episode of pain
- Examination shows tender high-riding testis often with a small hydrocele
Management
- Investigation usually not required
- Testicular torsion is a clinical diagnosis requiring urgent surgical exploration
- Diagnosis usually obvious
- If testis infarcted - needs orchidectomy
- If viability in doubt wrap in warm swab and wait
- If viable both ipsilateral and contralateral side require an orchidopexy
Outcome
- Approximately 60% of testes are salvageable
- Re-examination at 6 months shows about 10% to be atrophic
- Outcome best in those operated on with less than 6 hours symptoms
- Beyond 12 hours salvage of testis less assured.
- Long-term sub-fertility occasionally is a problem
- Possibly due to an auto-immune response affecting both testes
Epididymitis
- Uncommon in adolescents - be wary about making the diagnosis
- Usually has a more prolonged history, less pain and urinary symptoms
- Tenderness is greatest over the epididymis
Idiopathic scrotal oedema
- Usually occurs in boys less than 10 years old
- Presents with scrotal redness and oedema
- Pain is slight and testis feels normal
Torsion of testicular appendix
- Presents with sudden testicular pain but often not severe
- Hydrocele with tender appendage (hydatid of Morgagni) often apparent
- If discovered during scrotal exploration appendage should be excised.
Bibliography
Boucher N R, Anderson J B.
Torsion of the testis. Curr Pract Surg 1995: 7: 77-81.
Shergill I S, Foley C L, Arya M, Bott S R, Mundy A R. Testicular Torsion
unraveled. Hosp Med 2002; 63: 456-459.
Visser A J, Heyns C F. Testicular function after torsion of the spermatic cord. BJU
International 2003; 92: 200-2003. |