inguinoscrotal swellings - med.alexu.edu.eg

INGUINOSCROTAL SWELLINGS

Dr. Ahmed EL Damati

Lecturer of General Surgery - Faculty of Medicine - Alexandria University

General Surgery Department

Inguinoscrotal Swellings – Ahmed El Damati

Inguinoscrotal Swellings

Dr. Ahmed EL Damati

Lecturer of General Surgery - Faculty of Medicine – Alexandria University

Intended Learning Objectives:

• To differentiate between common Inguinoscrotal swellings of Surgical importance.

• To recognize the key points of management of each of them form a general practitioner

perspective.

Background:

The differential diagnosis of inguinoscrotal swellings of surgical importance is wide. One of the

key features to reach a diagnosis as well as to safely manage these patients is to evaluate the

context for diagnosis.

As a junior member of the surgical team, you could face this patient in the emergency department,

in the general surgery clinic or as consultation from other specialties.

The main complaint for any patient with inguinoscrotal problems could be pain or swelling.



Anatomy:

The groin is the junctional area between Abdomen & Thigh on either side of pubic bone.

It contains several important anatomical structures including:

1. The spermatic cord containing vas deferens, testicular vessels, nerves, and lymphatics.

2. The femoral vein in the middle compartment of the femoral sheath and its continuation

as external iliac vein.

3. The femoral artery in the lateral compartment of the femoral sheath as a continuation of

external iliac artery.

4. The femoral nerve lateral to the artery outside the femoral sheath.

The scrotum containing the testis, epididymis, and vas deferens and their coverings.

Lymphatic drainage of the testis is the paraaortic lymph nodes at the level of first lumbar

vertebra. Its coverings drain to iliac lymph nodes while scrotal skin drains to inguinal lymph nodes.

Pathology: Inguinoscrotal swelling could be classified under the following pathological

categories:

1. Congenital

2. Traumatic

3. Inflammatory

4. Vascular

5. Malignant

6. Others

Inguinoscrotal hernias will be discussed in another chapter.

We will deliberate here on other differential diagnoses of surgical importance.



The pubic tubercle test:

• The pubic tubercle could be identified by:

1. Direct palpation in thin individuals.

2. Upward attachment of adductor longus muscle.

3. Medial end of the inguinal ligament.

• If the origin of the swelling is above the pubic tubercle → Inguinal swelling.

• If the origin of the swelling is below the pubic tubercle → Femoral swelling.

The scrotal neck holding test:

• The examiner should sit to in-line with the patients scrotal neck.

• He will hold the scrotal neck and assess its relation to the swelling:

1. If scrotal neck is full → Inguinoscrotal swelling.

2. If the scrotal neck is empty (containing only the vas and testicular vessels) and the

swelling is above it → Pure inguinal swelling.

3. If the scrotal neck is empty and the swelling is below it → pure scrotal swelling.



The differential diagnosis includes but is not limited to:

Acute testicular torsion

• It is an actual emergency.

• Tissues around the testicle are not attached well → testes twist around spermatic cord →

cuts off blood flow to testicle → Pain & Swelling.

• 2 distinct mechanism of testicular torsion:

1. Extravaginal (Supravaginal) (most common at perinatal period): spermatic

cord & testis twist along with tunica vaginalis, it occurs at level of

superficial inguinal ring.

2. Intravaginal (most common in older children & adolescents): spermatic

cord & testis twist inside tunica vaginalis, more common variety due to bell

clapper deformity.

Bell-clapper deformity: Inappropriately high attachment of tunica vaginalis

over spermatic cord & failure of normal posterior attachment of testicle to

inner scrotum → allows testicle to move freely within tunica vaginalis →

intravaginal torsion.

• Diagnosis:

∙ Often Clinical: acute scrotal pain and swelling in young male.

∙ Ultrasound can check blood flow to testes.

∙ Torsion must be treated quickly.

• Treatment:

∙ All patients with torsion will need surgery

∙ Spermatic cord → untwisted (de-torsion) to restore blood supply + stitches to prevent

future torsion.

∙ Lasting damage starts after 6 hours of torsion → 3 in 4 patients need orchidectomy if

surgery is delayed > 12 hours.

∙ Incision: Most often scrotal, sometimes through groin.

∙ If testicle cannot be saved → remove testicle & sew stitches around other testicle to

prevent future torsion (This can only be determined surgery).

∙ The patient should be counselled and consented for orchidectomy before exploration.

∙ The anatomical abnormality is bilateral and the contralateral testis should also be fixed.



Acute Epididymo-Orchitis

• Acute inflammatory disease of epididymis & ipsilateral testis.

• Patient will complaint of acute scrotal pain and swelling with cardinal signs of acute

inflammation. Sometimes with urethral discharge or signs of urinary tract infection.

• May be secondary to urinary infection or urethritis

• Possible complication of catheterization or instrumentation of the urinary tract.

• Treatment should be started immediately after diagnosis.

• Antibiotics, analgesics are required.

• May need aggressive treatment with parenteral antibiotics.



Varicocele

Left sided varicocele.

• Dilated & tortuous veins in the pampiniform plexus = varicose veins of the spermatic cord.

• Almost invariably on the left side: Right testicular veins drain into inferior vena cava, but

left drain into left renal vein.

• Small symptomless varicoceles occur in 25% of normal men, on left side.

• When veins become large→ may cause a vague, dragging sensation & aching pain in

scrotum or groin.

• Patients may complaint from swelling in the groin or the scrotal neck.

• Appearance may embarrass adolescents & young men. They need only assurance in most

cases (1ry varicocele).

• Sudden appearance of varicocele in middle or old age may be caused by a renal neoplasm

spreading along renal vein & obstructing testicular vein (2ry varicocele).



• 1ry and 2ry varicocele could be differentiated as follows:

1ry varicocele 2ry varicocele

Age 15 -25 years > 40 years

Onset Gradual Acute

Duration Long Short

Site left Usually left sometimes right

On lying down Disappear Persist

On cough Thrill No thrill

Abdominal examination normal May palpate abdominal mass (neoplasm)

• You cannot feel a varicocele when patient is lying down because veins are empty → you

must always examine scrotum with patient standing up.

• The dilated, compressible veins above testis are then palpable & often visible: feel like a

‘bag of worms’.

• The testis below a large varicocele may be smaller & softer in comparison to normal side.

• The effect of a varicocele on spermatogenesis is controversial.



Hydrocele:

• Scrotal swelling due to fluid collection around testicle.

• Common in newborns, usually disappears without treatment by age of 1 year.

• Older boys and adult men can develop a hydrocele due to inflammation or injury within

scrotum.

• The swelling is cystic fluctuant & could be transilluminated.

• Transillumination:

• Embryologically, processus vaginalis is a diverticulum of the peritoneal cavity. It

descends with the testes into the scrotum via the inguinal canal around the 28th gestational

week with gradual closure through infancy & childhood.

• Structurally, hydroceles are classified into 3 principal types:

1. Communicating (Congenital): patent processes vaginalis → Scrotum may swell

more over time.

2. Non-communicating: patent processus vaginalis is present, but no communication

with the peritoneal cavity occurs.

3. Encysted hydrocele of the cord: the mid portion of the processus remains patent.



Types of hydroceles & differentiation from inguinal hernia

• Adult-onset hydroceles are usually secondary. Late-onset hydroceles may present acutely

from local injury, infections & radiotherapy; they may present chronically from gradual

fluid accumulation. Morbidity may result from chronic infection after surgical repair.

• Primary new-onset hydroceles presenting in late childhood & pre-adolescence are often

noncommunicating and resemble the adult type hydrocele pathology.

• A hydrocele can be produced in 4 different ways:

1. Excessive production of fluid within the sac (2ry hydrocele).

2. Defective absorption of fluid (most 1ry hydroceles).

3. Interference with lymphatic drainage of scrotal structures.

4. Connection with peritoneal cavity via a patent processus vaginalis (congenital).

• Hydrocele could be:

1ry: Idiopathic

2ry to:

o Trauma

o Epididymo-orchitis

o Tumor

o Lymphatic obstruction



• To differentiate between primary and secondary hydrocele:

1ry vaginal hydrocele 2ry vaginal hydrocele

Usually larger & more tense Usually smaller & less tense

Testis Usually not felt Can be felt separately



Scrotal Hematoma / Hematocele

• Collection of blood within tunica vaginalis.

• Bleeding is usually caused by trauma or underlying malignant disease.

• Could present as:

1. Acute Hematocele:

∙ Patient usually but not always gives clear history of injury, or of vague

discomfort in testis, followed by painful, rapid swelling of scrotum.

∙ It is a condition particularly associated with cycling.

∙ Swelling in one side of scrotum is tense, tender & fluctuant, but does not

transilluminate.

∙ Testis cannot be felt separate from swelling.

2. Chronic Hematocele:

∙ If acute episode is ignored & not treated, or if bleeding occurs without

patient’s knowledge, blood in tunica vaginalis will clot. As time passes, clot

that surrounds testis contracts & hardens → hard mass.

∙ Normal testicular sensation may be lost if contracting clot causes ischemic

necrosis of testis.

∙ Difficult to differentiate from testicular tumor → testis may need to be

explored before final diagnosis can be made.



Testicular tumor:

• The classification of testicular tumors could include:

I. Germ-cell tumors

∙ Seminoma

∙ Non-seminomatous germ-cell tumour

Embryonal carcinoma

Teratocarcinoma

Choriocarcinoma

II. Stromal tumors

∙ Leydig cell

∙ Sertoli cell

∙ Granulosa cell

III. Metastatic tumors

• 2 main varieties:

1. Seminoma = carcinoma of seminiferous tubules

2. Teratoma = malignant germ cell tumor

• There are some clinical features to differentiate between 2 types, but usually diagnosis is

made by histopathologist.

• History:

∙ Age:

✓ Teratoma commonly occurs between 20-30 years

✓ Seminoma may occur few years later

✓ Both are very rare in childhood & teenage years

∙ Symptoms:

✓ Commonest presentation = Testicular swelling, not usually painful.

✓ However, occasionally presents acutely with painful, tender testicle (diagnosis is

not always straightforward).

✓ Dull, aching, dragging pain in scrotum & groin occur in some patients, particularly

if testis becomes significantly enlarged.

✓ An important symptom to enquire about is whether testicle feels heavy. This is

almost diagnostic of testicular tumor.

✓ Presentation with distant metastases: general malaise, loss of appetite, wasting,

abdominal pains & dyspnoea.

✓ Many patients will state that their scrotal symptoms followed injury. Ignore this

view unless there is an obvious haematocele.



✓ It is better to explore a testis for benign disease than to miss a tumor.

✓ There is a considerably higher incidence of malignant change in incompletely

descended testis, diagnosis will be difficult.

• Examination:

✓ Pure scrotal swelling.

✓ Scrotal skin should be normal, except in rare circumstance in which tumor

invaded & ulcerated through it.

✓ Size: Tumors noticed by patient when testicle is clearly larger > other side

✓ Surface: usually smooth, but can be irregular or nodular.

✓ Composition: Testicular tumors feel harder > normal testis.

✓ Dull to percussion / Not fluctuant / Not translucent.

✓ Important physical sign: With patient lying on his back, place your fingers

underneath the testicle and lift it up. Compare it with the normal side. A feeling

of heaviness is characteristic of a tumor.

✓ Relations to surrounding tissues: other testis should be normal, but bilateral

tumors occur in 2% of cases.

✓ Spermatic cord & vas deferens should be normal. Once tumor breaks through

tunica albuginea, it infiltrates skin of scrotum.

✓ Tenderness:

o Testicular tumors are not tender except in unusual acute presentation.

o In many instances, normal testicular sensation is lost.

✓ Shape:

o Majority of testicular tumors are not noticed until they occupy the whole

testis. Rarely, you may be able to feel a nodule that is clearly in the testis &

not in epididymis.

o Epididymal nodule is never a tumor.

o Testicular tumors are irregular & variable in shape but are basically

spherical.

• Laboratory investigations: Blood for tumor markers: Alpha-feto protein (AFP) & Human

chorionic gonadotropin (HCG)

∙ AFP is elevated in 75% of embryonal carcinomas & 65% of teratocarcinomas

∙ AFP is not elevated in pure seminoma or choriocarcinoma.

∙ HCG is elevated in 100% of choriocarcinomas, 60% of embryonal carcinomas,

60% of teratocarcinomas & 10% of pure seminomas.

• Imaging:

1. Scrotal ultrasound is helpful in excluding cystic lesions of the intrascrotal contents

and in ruling out infective lesions of the testicle.



2. Chest X-ray must be performed to assess the lungs and mediastinum. If a suspicion

of metastatic lesions in these areas exists, CT scanning of the chest should be

performed.

3. Abdominal CT will identify the presence of enlarged para-aortic lymph nodes within

the abdomen. It will also show any evidence of obstruction of the ureters by a mass of

lymph nodes.

• Staging:

• Management:

∙ Orchidectomy (via groin incision) & histological diagnosis, further treatment

depends on histology & staging:

1. Seminoma

∙ Stage I: radiotherapy to abdominal nodes

∙ Stage II: radiotherapy to abdominal nodes

∙ Stage III: chemotherapy (bleomycin, etoposide, cisplatin)

2. Non-seminoma germ cell

∙ Stage I: RPLND (Retroperitoneal lymph node dissection)

∙ Stage II: chemotherapy + RPLND

∙ Stage III: chemotherapy

• Prognosis: Overall cure rates are over 90% & node-negative disease has almost 100% 5-

year survival.



∙ Lymph drainage:

✓ Lymph from Testis drains to para-aortic LNs in center of abdomen above

umbilicus.

✓ Seminoma commonly metastasize to para-aortic LNs, sometimes producing

palpable abdominal mass.

✓ Inguinal LNs will only be enlarged if tumor spread to scrotal skin (rare).

∙ General examination:

✓ All LNs, especially para-aortic & supraclavicular groups.

✓ Testicular tumors may metastasize to any tissue in the body. Unusual swellings

may be detected on general examination.

✓ Lung metastases are usually peripheral & not detectable on clinical examination

but are readily visible on chest X ray.

∙ Differential Diagnosis:

✓ Testicular swellings likely to be confused with tumors are acute & chronic

epididymo-orchitis & haematocele.

✓ However, if the patient tells you that his testicle feels heavy, you find that testicular

sensation is lost & enlarged testis feels, to you, heavier than other side, diagnosis

of testicular tumor is almost certain.



Saphena Varix:

• Dilation of Great Saphenous Vein at its junction with Femoral Vein in groin.

• It is a common surgical problem & patients may present with groin swelling.

• It is usually compressible.



Femoral Aneurysm

• Bulging & weakness in the wall of femoral artery, located in the thigh.

• It can burst, which may cause life-threatening, uncontrolled bleeding.

• Aneurysm may also cause a blood clot, potentially resulting in leg amputation.



Femoral pseudoaneurysm

• Troublesome groin complication related to femoral arterial access site used for invasive

cardiovascular procedures.

• Occur in 0.1-0.2% of diagnostic angiograms & 0.8-2.2% following interventional

procedures.

• Consider in IV drug users.



Inguinal Lymphadenopathy:

• Could be isolated or part of generalized lymphadenopathy.

• The main feature of lymph nodes is multiplicity.

• The character of the swelling will vary in relation to the background pathology.



Conclusion:

• Clinical context of paramount importance.

• Pain & Swelling are the main symptoms.

• Anatomy and Pathology are keys to reach diagnosis.

• Strangulated Hernia / Torsion / Tumor should not be missed.

• When in doubt explore.

inguinoscrotal swellings - med.alexu.edu.eg

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