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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
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
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 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
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
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
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
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
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
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.
Primary Hydrocele- Clinical Pictures
Primary Hydrocele- Complications • Infection• Pyocele• Hematocele• Atrophy of testis • Infertility• Hernia of hydrocele sac
(rare)• Rupture & calcifications
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
Primary Hydrocele- Treatment
Complications of surgery
• Reactionary haemorrhage Hematocele• Infection• Pyocele• Sinus formation• Recurrent hydrocele
Hydrocele- 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 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)
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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