This is the second presentation on Scrotal Swellings. I have included unique classical clinical vignette, mind map and a tabular column to clinch the correct diagnosis.

1. SCROTAL SWELLINGS
Case No:1
PROBLEM ORIENTED CASE BASED LEARNING
Dr.B.Selvaraj MS;Mch;FICS
Professor of Surgery
Melaka Manipal Medical college
Melaka Malaysia 75150

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. Primary Hydrocele- Clinical Pictures

12. Primary Hydrocele- Complications
• Infection
• Pyocele
• Hematocele
• Atrophy of testis
• Infertility
• Hernia of hydrocele sac (rare)
• Rupture & calcifications

13. Primary Hydrocele- Treatment
• Congenital hydrocele- Inguinal herniotomy
• Adult vaginal hydrocele
Small sizeLord’s plication
Large sizeJaboulay’s operation Incision and eversion of sac
After 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 hydroceleInguinal herniotomy + incision and
drainage of the encysted hydrocele

14. Primary Hydrocele- Treatment

15. Complications of surgery
• Reactionary haemorrhage Hematocele
• Infection
• Pyocele
• Sinus formation
• Recurrent hydrocele

16. Hydrocele- Mindmap

17. Scrotal Swellings- Algorithm

18. Scrotal Swellings Ex & Px Hx Sx Dx Tx
1. Hydrocele Primary-Idiopathic
Secondary- under
lying pathology
Painless big
swelling; not
reducible
No cough impulse
Get above swelling+
Transilluminant+
Clinical
In doubt- USG of
scrotum
Lord’s operation
Jaboulay’s
operation
2. Epididymal
cyst &
Spermatocele
Degenaration of
epididymis, occlusion
of pathway
Swelling in
scrotum resembles
3rd testis
Testis palpable
separately; Chinese
lantern appearance
Clinical
USG of scrotum
Conservative
Excision
3. Varicocele Idiopathic
Absence of valves in
testicular veins
Worm like in upper
scrotum; infertility
Disappears on lying
down; Bag of worms
appearance
Clinical
USG color doppler
Varicocelectomy
Inguinal or
Retroperitoneal
4. Testicular
torsion &
Epididymo-
orchitis
Abnormal fixation and
lie of testis
UTI & trauma
Severe pain&
swelling scrotum
Nausea & vomiting
Tender hemi scrotum;
cremasteric reflex
absent
Clinical
USG color doppler
Explore,detorse,
orchiopexy or
orchidectomy
Conservative
5. Testicular
carcinoma
UDT, Kieinfelter’s
Germ cell- Seminoma
& Non seminoma
Non germ cell tumor
Painless heavy
swelling
Not reducible
Hard in consistency
Testis felt separately
Clinical; No FNAC
USG OF scrotum
High orcidectomy
with or without
RPLND+ RT+CT
D/D for Scrotal Swellings (Compare &
Contrast)
(Vertical
Reading)

19. 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

20. Feedback & Suggestions

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