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Examination of Inguinoscrotal and Scrotal Swelling
https://t.me/med1917
431
A
B
Figs 18.1A and B: Undescended testis in two patients.
(A) Bilateral and testes are not present even in groin—
Cryptorchidism. Note the underdeveloped empty scrotum.
(B) It is unilateral (right sided) with visible testis (swelling)
in the inguinal region.
Its extent is from scrotum to groin. Skin over the
swelling may be stretched with loss of rugosity in long
standing hydrocele. Rugosity will also be lost in
syphilitic orchitis, tuberculous epididymitis and
testicular tumours. Skin may be stretched often in
scrotal oedema. Filarial scrotal oedema is non-pitting
whereas scrotal oedema due to other causes is pitting
in nature. One has to remember that common cause
of hydrocele is filarial. Clinician should be able to
Fig. 18.2: Typical look of torsion testis – right sided.
differentiate hydrocele from scrotal oedema. Ulcer
in the scrotal skin may be due to scrotal carcinoma
which will be having raised and everted edge, slough
in the floor. All features of an ulcer explained in Chapter
2: ‘Examination of an Ulcer’ should be mentioned.
T esticular tumour occasionally can fungate through
scrotal skin (can be anywhere but usually anterolateral)
and present as an ulcer. Syphilitic gummatous ulcer
is located always on front (anterior) of the scrotum
which is adherent to testis due to syphilitic orchitis.
It is punched out with wash leather slough. Tuberculous
epididymitis causes ulceration on the posterior aspect
of the scrotum with an undermined edge. Only in
anteverted testis positions are reversed. Testis may
protrude out as a granulating mass in severe infection
called as hernia testis. Hydrocele fluid may protrude
out of the tunica vaginalis testis through dartos as
hernia of the hydrocele. Scrotal skin gangrene is a
feature of Fournier’s gangrene. Multiple discharging
sinuses in the scrotal skin are the features of the
gonococcal urethritis with discharging urine – watering
can perineum. Multiple sebaceous cysts are common
in scrotum. Scrotum may show whitish vesicle
containing lymph due to filariasis (lymph scrotum)
which may rupture causing lymphorrhagia.
Sinus in the scrotum can develop due to infection,
postoperative cause or tuberculosis. Urinary fistulas
in the scrotum can occur (Fig. 18.3).
Impulse on coughing: Inguinal hernia shows expansile
impulse on coughing. V aricocele and lymph varix also
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Fig. 18.3: Discharging sinus in the scrotum.
SRB’s Clinical Surgery
Palpation
Palpation of the Swelling
Position and extent: Exact location of swelling on
inspection is important whether it is in the inguinal/
inguinoscrotal/scrotal. Encysted hydrocele of the cord
is located usually in the middle of the cord near the
root of the scrotum occasionally in the groin. It will
not extend proximally above. Lipoma of the cord,
funiculitis (inflammation of vas deferens, filarial—
common), ectopic testis in superficial inguinal pouch
are other groin swellings to be considered. Skin should
be held to see the fixity (Fig. 18.5).
Fig. 18.4: Left sided varicocele.
show impulse on coughing but with fluid thrill (Fig.
18.4).
Groin should be inspected for swelling (inguinal
nodes), ulceration, and fungation. Ulceration can occur
in groin due to secondaries in the lymph nodes, bubo,
tuberculosis, etc.
Fig. 18.5: Skin should be held to find out the skin
fixation.
Get above the swelling: In standing position cord is
palpated for structures by placing thumb in front and
fingers behind the root of the scrotum. In hydrocele
one can get above the swelling – means only cord
structures are felt and nothing else. In inguinoscrotal
hernia, one cannot get above the swelling. Cord with
additional structures are also felt. This is important
test to confirm scrotal swelling (Figs 18.6A and B).
Reducibility: Inguinal and inguinoscrotal hernia is
reducible. By taxis hernial contents are gently reduced
and emptied into the abdominal cavity. Hernia gets
reduced abruptly and rapidly . Hydrocele is not reducible. Exception is congenital hydrocele which commu-
Examination of Inguinoscrotal and Scrotal Swelling
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433
is positive), transilluminant. L ymph varix is soft, cystic
and doughy. Varicocele is soft, with typical feel of
‘bag of worms’. Hydrocele is smooth and soft (firm
if it is tensely cystic).
Fluctuation: This is essential test for hydrocele. Upper
part of the scrotum is held between thumb and fingers
of one hand to steady the swelling; thumb and fingers
of other hand are held at lower pole. Intermittent
pressure from lower fingers will push apart the fingers
over upper part and vice versa. Test is repeated in
opposite direction. It is important to elicit fluctuation
in two directions. It is also important to fix the swelling
prior to eliciting the fluctuation (Figs 18.7A and B).
A
B
Figs 18.6A and B: (A) One can get above the swelling
in hydrocele. (B) In inguinoscrotal swelling getting above
the swelling is not possible.
nicates with abdominal cavity . Congenital hydrocele
is usually associated with tuberculous ascites.
Varicocele and lymph varix also gets reduced while
lying down but slowly and gradually.
Impulse in coughing: Hernia shows expansile impulse
on coughing. Varicocele and lymph varix also show
impulse on coughing like a fluid thrill but it is not
expansile.
Like any other swelling, size, shape, surface, warm-
ness, tenderness, consistency should be checked.
Encysted hydrocele is fluctuant, cystic (Paget’s test
A
B
Figs 18.7A and B: Fluctuation should be elicited in two
directions in hydrocele after fixing the swelling using fingers.
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SRB’s Clinical Surgery
In a small swelling Paget’s test is used. In bilocular
hydrocele, i.e. swelling in the groin and hydrocele
with band-like narrowing near external ring, fluctuation
can be elicited across external ring above and below
– cr oss fluctuation (Other swellings which are cross
fluctuant are—psoas abscess, ranula, and compound
palmar ganglion). Hydrocele, encysted hydrocele,
epididymal cyst, spermatocele, abscess are fluctuant
swellings in the scrotum.
Transillumination/translucency: It is done in a dark
room using a pen torch. Pen torch is placed laterally
in the anterior part of the scrotum. Never place it posteriorly as testis will interfere with proper illumination.
Red glow of translucency is seen in the scrotum which
is better appreciated using roll of thick paper or
X-ray sheet placed on the opposite side (medially)
especially with day light. Hydrocele becomes nontransilluminant due to thick dartos, thick unclear fluid,
thick sac, haematocele, chylocele, pyocele. In epididymal cyst, it is brilliantly transilluminant (Figs 18.8A
and B).
Traction test: It is the test for encysted hydrocele of
the cord. Swelling is located above the testis which
is mobile but becomes immobile once testis is pulled
down from the swelling. It is used to differentiate it
from epididymal cyst.
Palpation of Testis
Position: T estis may be in normal position with testis
in front, epididymis behind and globus major upwards.
In anteverted testis, epididymis lies anteriorly and body
posteriorly. In inverted testis , testis lies upside down
with globus major inferiorly. In incompletely inverted
testis, testis lies horizontally . Inverted or incompletely
inverted testis precipitates torsion testis. Often these
changes are bilateral.
Size: Normal size is 3.75 cm above downwards;
2.5 cm from anterior to posterior; 1.8 cm side-to-side.
It weighs 10-15 gram. Atrophied testis is smaller in
size. It may be due to undescended testis or due to
earlier mumps attack or developmental defect. Atrophy
may be unilateral or bilateral. Larger testis may be
due to tumour or filarial orchitis or syphilitic gumma.
Weight of the organ in relation to size should be
assessed. It is done by balancing the testis on the palm
of the hand. T estis is heavier in testicular tumour and
haematocele. It is lighter in gummatous testis even
though size is large (Fig. 18.9).
A
B
Figs 18.8A and B: Hydrocele which is transilluminant.
Fig. 18.9: Anatomy of testis.
Examination of Inguinoscrotal and Scrotal Swelling
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Testicular sensation: It is sickening sensation / pain
felt in the abdomen (at the level of umbilicus – T10)
by the patient when a mild pressure is applied (gentle
squeezing) over the testis. It is absent in testicular
tumour, syphilis (Gumma), leprosy , chronic haematocele. Both side testes should be palpated. T rue testicular
pain is located in the lower abdomen at the level of
internal ring in accordance with Brown’s law. In
suspected malignancy of testis, it should be avoided
or gentle to prevent possible spread by squeezing into
veins and lymphatics.
435
Palpation of Epididymis
It is firm uniform structure along the posterior aspect
of the testis with upper head - globus major, middle
body, lower tail - globus minor. Tuberculosis commonly involves epididymis mainly globus minor
(tail) initially (due to retrograde spread along vas
deferens). Head is involved by haematogenous spread.
Epididymis tail is thickened, nodular and often tender.
Later when entire epididymis is involved, epididymis
will be enlarged, craggy, firm. Eventually coagulation
necrosis → softening → cold abscess occurs on the
posterior aspect of the scrotum → sinus/ulcer formation
behind. Firm, irregular enlarged epididymis is common
in filariasis. Acute epididymo-orchitis is smooth, soft
tender swelling posteriorly due to bacterial or viral
(mumps) causes. After prostatectomy retrograde
bacterial infection can cause acute infection.
Palpation of Spermatic Cord
Cord is palpated for vas deferens. Vas deferens is
palpated at the root of the scrotum between thumb
and index finger together on both sides (Fig. 18.10).
Normally it slips between fingers like whipcord. Vas
is thickened and tender in epididymo-orchitis—acute
or chronic due to funiculitis. It is thickened and beaded
in tuberculosis of vas. It is thickened and tender in
filariasis. Soft, doughy feeling is felt in lymph varix;
Filarial Epididymo-orchitis—both testis and
epididymis involved; thickened tender vas
Tuberculosis Epididymitis—involving epididymis only;
rather late, testis is involved only rarely;
beaded vas
Syphilis Orchitis—only testis is involved; rather
late epididymis rarely may get involved;
vas deferens not involved
Fig. 18.10: Method of palpation of vas.
like ‘bag of worms’ in varicocele of spermatic cord.
Rarely testicular tumour spreads along the spermatic
cord causing it nodular and hard.
Palpation of Lymph Nodes
Scrotal skin drains into inguinal lymph nodes; testis
and epididymis drains into pre- and para-aortic lymph
nodes at the level of origin of testicular artery –
transpyloric nodes. Inguinal and iliac nodes may be
enlarged in scrotal skin conditions and also when
testicular tumour infiltrates the tunica and scrotal skin.
Testicular tumour spreads to para-aortic nodes and
then to left sided supraclavicular nodes.
Systemic Examinations
Abdomen Examination
Respiratory system examination is important as
secondaries can occur in testicular tumours. In
tuberculosis primary focus may be in lungs.
Investigations
• Blood—smear for microfilariae; syphilis; ESR.
• Urine for culture, AFB (early morning specimen).
• Chest X-ray to see lung secondaries from testicular
tumour as ‘cannon ball’ type; to see pulmonary
tuberculosis.
• Tumour markers in testicular tumour—α-feto
protein (AFP); βHCG.
• US of scrotum to see haematocele, pyocele,
secondary hydrocele, varicocele, testicular tumour.
It is very useful in all scrotal diseases (FNAC is
contraindicated in testicular tumour. Scrotal
approach is also contraindicated).
• CT abdomen to see nodal metastases and liver
secondaries.
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Fournier’s Gangrene
SRB’s Clinical Surgery
It is also called as idiopathic gangrene of the scr otum.
It is a vascular gangrene of infective origin, caused
by Haemolytic streptococci , microaerophilic streptococci, staphylococci, E. coli, Clostridium welchii.
There will be fulminant inflammation of the scrotal
skin and subcutaneous tissues resulting in obliterative
arteritis of the arterioles of the scrotal skin leading
into cutaneous gangrene.
Clinical features: Condition is common in old age;
presents with sudden pain, redness, blackening in the
scrotum, fever, severe toxicity; Very fast spreading
cellulitis of scrotal skin occurs extending to the groin
and often to anterior abdominal wall; extensive skin
sloughing occurs leaving normal testis exposed.
Sometimes toxicity is so severe that they may go for
renal failure and other complications; sometimes the
condition may worsen rapidly leading to death. Minor
perineal injury, infection of anal fissure, drainage of
periurethral abscess may precipitate the condition (Figs
18.11A and B).
A
Hydrocele
It is the collection of fluid between the two layers
of tunica vaginalis of the testis.
Types (Fig. 18.12)
1. Congenital.
2. Acquired: (a) Primary and (b) Secondary.
Aetiology: Defective absorption of hydrocele fluid
by the tunica vaginalis, probably due to damage to
the endothelial wall by low grade infection. Excessive
production of fluid—as in secondary hydrocele;
Interference with drainage of the fluid by lymphatic
vessels of the cord; Communication into the peritoneal
cavity are other causes. Hydrocele fluid is amber
colored with specific gravity of 1.022 to 1.024. It
contains water, salts, albumin, and fibrinogen. Per se
hydrocele fluid does not clot, but gets activated if it
comes in contact with the blood, fibrinogen and clots
firmly. Often fluid contains cholesterol and tyrosine
crystals (Fig. 18.13).
Cysts which contains cholesterol crystals (1)
V aginal hydrocele; (2) Branchial cyst; (3) Dentigerous
cyst.
B
Figs 18.11A and B: Fournier’s gangrene.
Primary Vaginal Hydrocele
It occurs in middle aged, common in tropical countries.
T estis is not palpable, usually attains a large size (unlike
secondary hydrocele which are small except in filarial
hydrocele). Fluctuant (It is elicited by fixing the
hydrocele with hand and feeling for the fluid
movements using fingers placed in two perpendicular
Examination of Inguinoscrotal and Scrotal Swelling
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directions. Note: A relaxed muscle can demonstrate
fluctuation in one direction even though there is no
fluid in it); initially transilluminant (elicited in front
of the swelling side-to-side), but long standing
hydrocele is non-transilluminant (due to thickened
dartos, thickened spermatic fascia, thickened hydrocele
sac, infected content, chylous fluid, often filarial
hydrocele, haematocele). One can get above the
swelling. Testicular sensation can be elicited in vaginal
hydrocele by transmitting the pressure sensation
through the fluid (Figs 18.14 to 18.16).
Swellings which are brilliantly transilluminant
1. Vaginal hydrocele
2. Epididymal cyst
3. Cystic hygroma
4. Ranula
5. Meningocele
437
Fig. 18.12: Types of hydrocele.
Fig. 18.13: Hydrocele fluid.
A B
Figs 18.14A and B: Large hydrocele in two patients. Note
penis is buried in the scrotum. It is often difficult to differentiate
hydrocele from hernia. Get above the swelling and impulse
on coughing are the two clinical methods used to differentiate.
Fig. 18.15: On table transillumination in hydrocele –
brilliant transillumination.
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Fig. 18.16: Vaginal hydrocele.
Infantile Hydrocele
SRB’s Clinical Surgery
Here tunica and processus vaginalis (hydrocele) are
distended up to internal ring, but sac has no connection
with the general peritoneal cavity.
Congenital Hydrocele
Here processus vaginalis communicates with the
peritoneal cavity . As this communicating orifice is too
small, bowel and/or omentum do not descend and so
hernia usually will not develop. While lying down,
fluid disappears gradually and while standing fluid
recollects. Hydrocele cannot be emptied by digital
pressure due to ‘inverted ink bottle’ effect. Ascites,
tuberculous peritonitis are the aetiologies for the same
in an adult (Fig. 18.17).
Encysted Hydrocele of the Cord
It is a smooth, soft, oval, fluctuant, transilluminant
swelling associated with the spermatic cord in inguinal
or inguinoscrotal region. Impulse on coughing,
reducibility is absent. Testis is felt normal. It is due
to persistent patent small portion of the tunica vaginalis
in the cord but is closed above and below . On gentle
traction to the testis, the swelling becomes less mobile
(traction test). Differential diagnosis: Epididymal
cyst, inguinal hernia.
Hydrocele en Bisac (Bilocular Hydrocele)
Hydrocele has got two intercommunicating sacs, one
above and one below the neck of the scrotum. Upper
one lies superficial or in the inguinal canal or may
insinuate itself in between the muscle layers—cross
fluctuant. Other condition wher e cr oss fluctuation is
elicited: (1) Plunging ranula; (2) Compound palmar
ganglion; (3) Psoas abscess.
It occurs in females, in relation to the round ligament,
always in the inguinal canal.
Hydrocele of the Hernial Sac
It is due to adhesions of the content; fluid secreted
will collect in the hernial sac and forms hydrocele
of the hernial sac. It occurs in 5% of inguinal hernia
cases.
Fig. 18.17: Hydrocele in a child. It mimics hernia. It is due
to patent processus vaginalis. Treatment is like hernia –
herniotomy only through inguinal approach.
Secondary Hydrocele
Causes: Infection: filariasis; tuberculosis of epididymis; syphilis. Injury: trauma, post-herniorrhaphy
hydrocele. T umour: malignancy. Secondary hydrocele
rarely attains large size. It is usually small, lax and
testis is usually palpable (unlike primary hydrocele).
Exception is secondary hydrocele due to filariasis.
Post-herniorrhaphy hydrocele: It is a secondary
hydrocele occurring after the surgery for inguinal
hernia. It is due to the damage to lymphatic vessels
of the tunica vaginalis and is 0.2% common. It is treated
like any hydrocele but usually after about 6 months.
Filarial hydrocele and chylocele: It occurs commonly
in coastal region and in and around the Equator. It
Examination of Inguinoscrotal and Scrotal Swelling
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Fig. 18.18: Chylocele.
usually occurs after repeated attacks of filarial
epididymitis. Hydrocele is usually of large size and
the sac is thickened. Fluid contains fat, rich in
cholesterol, derived from ruptured lymph varix into
the tunica. It is often difficult to differentiate from
primary hydrocele. In chylocele, chylous fluid collects
in tunica vaginalis which may show microfilaria (Fig.
18.18).
Complications of Hydrocele
Infection; pyocele (suppurated hydrocele); haematocele; atrophy of testis; infertility; rupture; hernia of
the hydrocele sac through dartos (Fig. 18.19).
Inguinal hernia; epididymal cyst; spermatocele;
testicular tumour; scrotal oedema.
Conditions which cause loss of testicular sensation
Testicular tumour
Lepra orchitis
Syphilitic orchitis
Chronic haematocele
439
Haematocele
It is collection of blood/clot in the tunica vaginalis
testis. It may be due to trauma or bleeding in an existing
hydrocele. Blood gets clotted, organised and later may
be calcified. Eventually it causes testicular atrophy.
T ypes: Recent haematocele—It is due to rupture of
one of the vessels in the tunica causing bleeding into
the sac. It often may be due to aspiration of a hydrocele.
It may be precipitated by trauma also.
Clinical features: Sudden onset of pain, swelling after
a history of trauma; tender, warm, fluctuant, but nontransilluminant; occasionally aggressive testicular
tumour mimics presentation of acute recent haematocele. US of scrotum is done in such suspected cases
to rule out neoplasm and also to find out the viability
of testis.
Complications: Chronic (old clotted) haematocele;
infection; pyocele.
Chronic or old clotted haematocele—It is usually
due to slow , spontaneous haemorrhage into the tunica
vaginalis without any proper history of trauma. It is
painless, hard, nontender, nonfluctuant, often calcified
swelling, with loss of testicular sensation. Because
of the constant pressure testicular function and so
testicular sensation is lost. It mimics testicular tumour
in many aspect (Fig. 18.20).
Pyocele
It is collection of pus in the layers of tunica vaginalis.
It is often suppurative hydrocele. It can occur in a
previously normal tunica or in a preexisting haematocele or hydrocele which gets infected.
Fig. 18.19: Hernia of hydrocele can occur
through dartos muscle.
Fig. 18.20: Haematocele.
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SRB’s Clinical Surgery
Features: Fever, toxicity, tender swelling in the
scrotum, with scrotal wall oedema; often in young
individuals, it may be difficult to differentiate this from
the torsion testis; pus under tension eventually causes
infective thrombosis of testicular vessels, leading to
nonviability of the testis or testicular gangrene (Figs
18.21A and B).
A
Cyst of the Epididymis
It is due to the cystic degeneration of: (1) Paradidymis
(organ of Geraldes)—is the commonest cause; (2)
Appendix of the epididymis (hydatid of Morgagni);
(3) Appendix of the testis; (4) The vas aberrans of
Haller. Even though it is of congenital origin, it occurs
in middle age. It is tensely cystic, contains clear fluid;
often bilateral; they are aggregation of number of small
cysts and so multiloculated. They feel like ‘bunch
of tiny grapes’ situated behind the body of the testis.
Because of numerous septae they are finely tessellated
and brilliantly transilluminant, giving a ‘Chinese
lantern pattern’.
Cyst of an appendage of the testis is a unilateral
globular rare cystic swelling in the superior pole of
the testis which may develop torsion.
Spermatocele
It is a unilocular acquired retention cyst derived from
blockage of some portion of the sperm conducting
mechanism of the epididymis. It is situated in the head
of the epididymis, above and behind the body of the
testis. Swelling contains barley water like fluid which
contains spermatozoa. It is soft, cystic and transilluminant. It is often considered by the patient like having
additional testis. Aspiration cytology confirms the
diagnosis. It is often called as ‘third testis’.
B
Figs 18.21A and B: Pyocele is
suppurative hydrocele.
Epididymal cyst Spermatocele
Congenital Acquired retention cyst
Behind and above the testis Behind the body of the
testis
Multilocular Unilocular
Bunch of grapes appearance Looks like 3rd testis
Clear fluid as content Barley water fluid
contains sperms
Brilliantly transilluminant Transilluminant
Excision should be avoided Can be excised
in young
Varicocele
It is dilatation and tortuosity of the pampiniform plexus
of veins and so also the testicular veins. Normally
there will be plenty of plexus of veins (pampiniform)
in the scrotum, which all join together to form about
4-8 veins in the inguinal canal. Above, in the abdominal
cavity, in the posterior abdominal wall all join to form
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