Scrotal swelling

Classifications

1) Congenital  



Congenital hydrocele
Congenital indirect inguinal hernia

2) Inflammatory

Cellulitis of scrotal skin - skin appears red, shinny, warm, tender
Pyocele - pus accumulation within tunica vaginalis, fluctuates, non-transilluminant

Orchitis/Epididymo-orchitis/Epididymitis - tender, non-fluctuent swelling
Funiculitis - tender and thickened spermatic cord

3) Neoplastic

There's no benign testicular tumours!

Malignant 

Primary : Seminoma, Teratoma, Leydig cell tumour, Sertoli cell tumour, Lymphoma
Secondaries from other sites

4) Others

Hydrocele
Hydatid cyst of morgagni
Epididymal cyst (smooth, uni/multi-locular swelling located behind the testis, brilliantly transilluminate)

Spermatocele (above and behind the upper pole of testis, poorly transilluminate)
Encysted hydrocele of the cord


Varicocele

History taking

1) Onset

Sudden onset of scrotal swelling may be hematocele (with h/o of trauma)
Acute onset can be inflammatory causes (Epididymitis, Orchitis, E-Orchitis)
Insidious - usually hydrocele or testicular tumour

2) Progression

Rapid progression - inflammatory swellings or hemorrhage into a cyst/hydrocele

3) Association with pain

Inflammatory swellings are painful.
Acute epididymo-orchitis must be differentiated from Testicular torsion.

The former, as testis is elevated - pain reduces (increases support on testis)
The latter, as testis is elevated - pain worsens (increases the degree of torsion)

4) Association with fever

Low, moderate, high grade
Intermittent, remittent, continuous
Both acute epididymo-orchitis and scrotal abscess presents with fever

5) Urinary symptoms

A positive h/o of UTI is important for acute epididymo-orchitis
Ask for frequency and dysuria

On examination

1) Inspection

Comment whether one side or both sides are involved
Check whether the swelling extends up to the inguinal region, which can be :

Infantile hydrocele
Inguino-scrotal hernia

Ask the patient to cough, look for expansile cough impulse, which can be :

Hernia, Congenital hydrocele

Inspect the skin over swelling, comment on it's colour and rugosity, whether :

Stretched + shinny -> inflammatory
Stretched + normal rugosity -> Hydrocele, testicular tumours

Inspect whether there's any skin lumps.
Any scars, sinuses?

2) Palpation

Try to get above the swelling, it means that the cord is palpable above the swelling. This is to confirm that it's a pure scrotal swelling.

Comment on the position of testis :

Swelling is anterior to testis -> Hydrocele (but usually hydrocele will be too large for the testis to be separately palpable)
Swelling is attached to the top of testis, cystic -> Hydatid cyst of morgagni
Cystic swelling behind the testis, more towards the upper pole -> Epididymal cyst
Swelling above and behind the upper pole of testis -> Spermatocele
Cystic swelling palpable at the root of scrotum -> Encysted hydrocele of cord

(Can be mistaken as direct inguinal hernia - try pulling the scrotal skin down, it'll descend and becomes less mobile)

Testicular swellings can be either tumour or inflammatory
Varicocele - feels like a bag of worms

Tenderness - for any inflammatory swellings (acute pyocele, hematocele, acute epididymo-orchitis), and sometimes, very tensed cyst

Consistency
Soft - Spermatocele
Cystic - Epididymal cyst
Tense - Hydrocele
Firm - Acute epididymo-orchitis
Hard - Testicular tumours

Palpate the contents of scrotum
Feel for the cord and vas deferens.
The vas deferens will be normal but the cord is thickened - testicular tumour
Both vas deferens and cord is thickened and tender - Acute epididymo-orchitis
Skin not pinchable - testicular tumours infiltrated to skin
Varicocele - bag of worms while patient standing, resolves as he lies down

Cough impulse - Felt in case of hernia, palpable thrill in varicocele

Fluctuation positive - all swelling contains fluid

 

Transillumination test

3) Examine the inguinal nodes
4) Examine the abdomen