Regarding Scrotal Problems....

Regarding Patients With Scrotal problems select a diagnosis from the list below for the given case scenario:

A. Varicocele
B. Testicular cancer
C. Epididymo-orchitis
D. Epididymal cyst
E. Inguinal hernia
F. Hydrocele
G. Femoral hernia
H. Hydatid of Morgagni
I. Fournier's gangrene
J. Cardiac failure

1. A 31-year-old man presents as he and his wife have been having problems conceiving. On examination there is a diffuse lumpy swelling on the left side of his scrotum. This is not painful and the testicle, which can be felt separately, is normal.

Diagnosis: Varicocele

2. A 44-year-old man notices a pea-sized lump on his right testicle. On examination a discrete soft mass can be felt posterior to the right testicle.

Diagnosis: Epididymal cyst

3. A 75-year-old man presents with a swelling in his right scrotum. On examination a large, non-tender swelling is found in the scrotum. You cannot palpate above the swelling during the examination.

Diagnosis: Inguinal hernia
(A hydrocele is less likely as you cannot 'get above' the swelling on examination.)

Brief Discussion On Scrotal Swellings:


Epididymal cysts Epididymal cysts are the most common cause of scrotal swellings seen in primary care.

Clinical Features 
 separate from the body of the testicle
 found posterior to the testicle

Associated conditions 
 polycystic kidney disease
 cystic fibrosis
 von Hippel-Lindau syndrome

Diagnosis may be confirmed by ultrasound.

Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.

Hydrocele A hydrocele describes the accumulation of fluid within the tunica vaginalis.

They can be divided into communicating and non-communicating:
 communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
 non-communicating: caused by excessive fluid production within the tunica vaginalis

Hydroceles may develop secondary to:
 epididymo-orchitis
 testicular torsion
 testicular tumours

Clinical Features 
 soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
 the swelling is confined to the scrotum, you can get 'above' the mass on examination
 transilluminates with a pen torch
 the testis may be difficult to palpate if the hydrocele is large

Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.

Management
 infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
 in adults a conservative approach may be taken depending on the severity of the presentation.

Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumor

Varicocele A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Varicoceles are much more common on the left side (> 80%).

Clinical Features:
 classically described as a 'bag of worms'
 subfertility

Diagnosis: ultrasound with Doppler studies

Management : usually conservative
occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility