The most important finding to elicit about a swelling arising from the scrotum is whether on examination it is possible to get above the swelling. This is critical in differentiating a scrotal swelling from an inguinoscrotal swelling. Common causes of scrotal swellings are hydrocoele, epididymal cyst, varicocoele, epididymo-orchitis and testicular tumours. We will cover all the above conditions in this chapter except epididymo-orchitis, which is covered in a separate chapter in this book.
A hydrocoele is a collection of fluid within the tunica vaginalis. Hydrocoele can be acquired or congenital; secondary to a patent processus vaginalis (PPV). Acquired hydrocoeles can be idiopathic or secondary to tumour, trauma or infection. The tunica vaginalis normally produces 0.5 ml of fluid per day and the fluid collects because of an imbalance between fluid production and absorption. Hydrocoele usually presents as a painless swelling in the scrotum and it can be unilateral or bilateral. The swelling can become painful or uncomfortable if it gets to be large or in the presence of infection. The onset may be gradual or sudden, and one must always be suspicious of an underlying testicular tumour in sudden-onset cases, especially when the testicle is impalpable. Hydrocoeles that decrease in size and reappear later should raise the possibility of a congenital hydrocoele with a PPV, especially in the younger age group.
Examination will usually reveal a scrotal swelling. The testes may be impalpable in a large hydrocoele; if the testis is easily palpable and separate from the swelling, then a diagnosis of an epididymal cyst should be entertained. The swelling is usually fluctuant and transilluminates well, suggesting the presence of clear fluid within the sac. Investigations should include an ultrasound scan if there is concern regarding the underlying testicle and to rule out the possibility of testicular cancer.
Hydrocoele can be managed conservatively if it is asymptomatic and not a cosmetic problem. In patients who have medical co-morbidities and are unfit, aspiration with or without injection of a sclerosing agent such as tetracycline or sodium tetradecyl sulfate can be carried out. This can sometimes lead to infection and the hydrocoele can also recur. Surgical treatment would include ligation of the PPV through an inguinal approach if the hydrocoele is congenital, or incision and drainage of the hydrocoele fluid along with eversion or excision of the tunica vaginalis if the hydrocoele is acquired. Small hydrocoeles can be dealt with by plication of the sac after drainage of the fluid. There is a risk of bleeding with haematoma formation, infection and recurrence of the hydrocoele with any procedure.
This is a cystic swelling arising from the epididymis and usually presents as a painless scrotal swelling. It can become uncomfortable as it enlarges in size. The testis is usually felt as a separate entity from the cyst. An epididymal cyst can also transilluminate well. Conservative management is advised if the cyst is small and asymptomatic. Aspiration is generally not advised, as these cysts are usually multiloculated. If the cyst is large and causing discomfort, surgical excision is usually recommended and the patient is counselled about the possibility of infection, bleeding and recurrence of the cyst.
Varicocoele is dilatation of the veins of the pampiniform plexus. It is more common on the left side and usually presents with a dragging or aching discomfort in the groin or scrotum. It is important to know that the left testicular vein drains into the left renal vein and therefore varicocoeles on the left side should raise the possibility of a left renal tumour. It is important that all patients with a left varicocoele undergo a renal ultrasound. Varicocoeles usually present with some discomfort and swelling that gets worse during the day and settles at night; this is because the veins engorge during the day as a result of gravity. The enlarged veins feel like a bag of worms on palpation. There is little evidence to suggest that varicocoeles may have a role to play in infertility, although treating the varicocoele may improve seminal parameters, which in turn may help with assisted methods of contraception.
It is reasonable to manage a varicocoele conservatively if the patient is not too bothered by his symptoms. The options of management are either surgical or embolization performed by the radiologist. Surgical options include open surgery, i.e. high (retroperitoneal) or low (inguinal) ligation of the vessels. Laparoscopic ligation of the vessels is also an option. In all these techniques the vas is preserved while the rest of the cord structures are ligated, including the testicular artery. The testes tend to pick up their blood supply from the dartos muscle and the incidence of testicular atrophy is small. Complications of operative intervention are recurrence and the possibility of hydrocoele formation on the ipsilateral side.
Any patient aged under 50 years presenting with a swelling arising from the body of the testes should be considered to have a testicular tumour until proven otherwise. Primary neoplasms arising from the testes are germ cell tumours (GCTs). They are classified into seminomas and non-seminomas. Non-seminomas include teratoma, embryonal carcinoma, choriocarcinoma and yolk sac tumours. It is important to know that about 40% of testicular tumours are mixed, having both seminomatous and non-seminomatous elements, and these tumours should really be treated as non-seminomas.
Seminomas have a bimodal distribution with two peak age incidences, one at about 30-40 and the other at about 60 years. Non-seminomatous GCTs have a peak age incidence of between 20 and 30 years. They usually present with a painless scrotal swelling or sometimes with a history of trauma. Occasionally they present with metastatic disease, either with an abdominal mass secondary to para-aortic lymphadenopathy, mediastinal mass and lung or brain metastases. There is a swelling in the body of the testes on examination that is usually hard, craggy and painless. There may be an associated hydrocoele.
An ultrasound of the testes is usually diagnostic. Tumour markers such as a-feto protein (AFP), β human chorionic gonadotrophin (βHCG) and lactic dehydrogenase (LDH) should be checked as soon as the diagnosis is suspected or made. They are not of much diagnostic value, but are extremely important for follow-up purposes. An inguinal orchidectomy is performed to obtain a pathological diagnosis. A scrotal approach is not advocated because of the danger of altering the lymphatic drainage if a scrotal incision is made. Once a diagnosis is made, then staging is commenced in the form of a chest X-ray and CT of the abdomen. The staging system is beyond the scope of this chapter. Seminomas are usually radiosensitive, whereas non-seminomatous GCTs respond to chemotherapy. Sometimes a combination of the two or even surgical excision of metastatic tumour may be required. It is important to remember that the prognosis for patients with these tumours is reasonably good, even if they are metastatic on initial diagnosis.