SCROTAL SWELLINGSCase No:3

PROBLEM ORIENTED CASE BASED LEARNING

Dr.B.Selvaraj MS;Mch;FICSProfessor of Surgery

Melaka Manipal Medical collegeMelaka Malaysia 75150

OVERVIEW

• Various causes(Differential diagnosis) of scrotal swellings• Classical clinical vignette with probable diagnosis• The diagnosis in detail- only one pathology in each

episode• Mind map of the diagnosis• Tabular column of differential diagnosis depicting their

characteristic features to differentiate them from your diagnosis• References and feedback

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

Classical Clinical vignette Epididymal Cyst

• A 45 years old male patient presented with a swelling in right side of the scrotum for last 3 years which is increasing very slowly in size. There is no pain over the swelling.• O/E: There is a soft cystic swelling in relation to the head of

the right epididymis. The swelling has a lobulated surface and feels like a bunch of grapes. • Testis can be felt separately from the swelling• The swelling is brilliantly transilluminant and has Chinese

lantern pattern appearance

Epididymal Cyst- Etiopathogenesis

• These are cysts in connection with the epididymis divided into the following types:• 1. Degeneration cysts occur due to cystic degeneration of the

epididymis Epididymal cyst• 2. Retention cysts due to obstruction of the sperm conducting

mechanism Spermatocele Ex: after vasectomy

Epididymal Cyst- Clinical Features

• Most epididymal cysts occur in males over the age of 40 years• An epididymal cyst usually contains clear fluid• The variety that contains slightly grey, opaque, ‘barleywater’-like

fluid and few spermatozoa is sometimes termed a Spermatocele • They are often multiple or multilocular and are frequently

bilateral and feels like bunch of grapes• Brilliantly transilluminant “Chinese lantern pattern”• Testis palpable separately• Cysts are connected to the head of the epididymis, so lie above

the testis 3rd testis

Epididymal Cyst- Clinical Features

Epididymal Cyst- Clinical Features

Epididymal Cyst Vs Spermatocele

Epididymal Cyst - Treatment

• Single large cyst Excision of cyst• Recurrent or multilocular cyst Excision + partial or

total epididymectomy• No role for aspiration because cysts are multilocular• Spermatocele if big aspiration or excision; If small no

intervention

Epididymal Cyst - Mindmap

Scrotal Swellings- Algorithm

Scrotal Swellings Ex & Px

Hx Sx Dx Tx

1. Hydrocele Primary-IdiopathicSecondary- under lying pathology

Painless big swelling; not reducible

No cough impulseGet above swelling+Transilluminant+

ClinicalIn doubt- USG of scrotum

Lord’s operationJaboulay’s operation

2. Epididymal cyst & Spermatocele

Degenaration of epididymis, occlusion of pathway

Swelling in scrotum resembles 3rd testis

Testis palpable separately; Chinese lantern appearance

ClinicalUSG of scrotum

ConservativeExcision

3. Varicocele IdiopathicAbsence of valves in testicular vein

Worm like in upper scrotum; infertility

Disappears on lying down; Bag of worms appearance

ClinicalUSG color doppler

VaricocelectomyInguinal or Retroperitoneal

4. Testicular torsion & Epididymo- orchitis

Abnormal fixation and lie of testisUTI & trauma

Severe pain& swelling scrotumNausea & vomiting

Tender hemi scrotum; cremasteric reflex absent

ClinicalUSG color doppler

Explore,detorse, orchiopexy or orchidectomyConservative

5. Testicular carcinoma

UDT, Kieinfelter’s Germ cell- Seminoma & Non seminomaNon germ cell tumor

Painless heavy swelling

Not reducibleHard in consistencyTestis felt separately

Clinical; No FNACUSG OF scrotum

High orcidectomy with or without RPLND+ RT+CT

D/D for Scrotal Swellings (Compare & Contrast) (Vertical Reading)

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• Shelf life surgery 1st edition

Feedback & Suggestions

Thank Youhttps://www.youtube.com/watch?v=hZovqzif3ck