Benign Scrotal Disease

 

• Hydrocele

  Definition and epidemiology

  • Serous fluid accumulation between the tunica vaginalis and tunica albuginea.
  • Found in older men, or as a congenital problem in infants resulting from a patent processus vaginalis.

  Signs and symptoms

  • Smooth, transilluminable lump, usually antero-inferior to the testicle, which you can get above.
  • If it is large the underlying testis may not be palpable.

  Investigations

  US if there is any diagnostic uncertainty, and for all men age 20-40 to rule out tumour.

  Management

  • Drainage provides temporary relief if symptomatic, but recurrence is common.
  • Plicating the tunica vaginalis (Lord's repair) or inverting the sac (Jaboulay's repair) is curative. Indicated if symptomatic, or if it doesn't resolve in children by age 1-2.

• Haematocele

  • Post-traumatic collection of blood in scrotum.
  • On examination, a tender, tense lump which does not transilluminate.
  • Ultrasound to assess severity and rule out testicular torsion or tumour.
  • Surgical exploration and drainage may be indicated.

• Varicocele

  • Dilated testicular vein, which feel like bag of worms. More prominent on standing.
  • 90% on the left.
  • Usually asymptomatic, but can cause pain and may be linked to impaired fertility.
  • If there is pain, consider treatment with surgical ligation or radiological embolisation. Surgery does not improve fertility, however.

• Epididymal cyst

  • Fluctuant, transilluminable lump attached to testis but feels like a clearly separate structure.
  • Usually asymptomatic and requires no treatment.

• Epididymo-orchitis

  Definition and causes

  • Inflammation of the epididymis (epididymitis) can occur alone or, in >50% of cases, with testicular inflammation (orchitis). Isolated orchitis is rare, and usually due to mumps.
  • Causes: chlamydia or gonorrhea if sexually active, and E. coli if older. Mumps or non-infective causes occur at any age.

  Signs and symptoms

  • Swollen, painful epididymis/testis.
  • UTI symptoms may be present (frequency, urgency, and dysuria).
  • Urethral discharge.
  • In mumps, epididymo-orchitis or orchitis follows parotitis by around 1 week, and may be accompanied by high fever, headache, and vomiting.

  Investigations

  • Urine dip, urine MC+S, and MC+S and/or nucleic acid testing of any urethral secretions.
  • Consider HIV testing.
  • Mumps IgM/IgG if suspected.
  • Doppler ultrasound can help distinguish between epididymo-orchitis and torsion.

  Management

  Start antibiotics before microbiological confirmation, based on clinical suspicion:

  • If STI suspected → doxycycline PO for 10-14 days, plus single dose ceftriaxone IM.
  • If E. coli suspected → ciprofloxacin PO for 10 days.

  Other measures:

  • Advise bed rest and scrotal elevation.
  • If due to STI, arrange contact tracing and advise to avoid sex until treatment completed.

  Refer to urology to rule out testicular cancer if it doesn't resolve with antibiotic treatment.

• Testicular torsion

  Pathophysiolgy and epidemiology

  • Twisting of spermatic cord causing testicular ischaemia. Risk of testicular loss (atrophy and deformity) without rapid treatment.
  • Onset usually <30 years old, most commonly around age 13.
  • Can be intermittent torsion in which pain passes. However, surgery is still advised, especially if testicle(s) have transverse lie.
  • Undescended testes is a risk factor.

  Signs and symptoms

  Symptoms:

  • Sudden onset pain in 1 testis, which makes walking uncomfortable.
  • Abdominal pain.
  • Nausea and vomiting.

  Signs:

  • Swollen, red, tender hemiscrotum.
  • Affected testis often lies higher and transverse.
  • Absent cremasteric reflex.

  Investigations

  Surgical exploration if any suspicion.

  Tests shouldn't delay surgery, but consider:

  • Duplex US to visualise testes and check blood flow with doppler.
  • Urinalysis to rule out infection.

  Management

  Detorsion and fixation with suture (orchidopexy) of both sides, as the other is at increased risk of torsion.