Scrotal swellings

1. Scrotal swellings
Prof Mostafa Sakr

2. • (A) Painful Scrotal Swellings
• Testicular torsion
• Epididymitis (chronic: specific or non-specific)
• Hematocele
• Rupture testis
• Complicated Hernia
• Some testicular tumors (10%)
• Torsion of testicular appendix

3. • (B) Painless Scrotal Swellings
• Testicular tumours
• Varicocele
• Hydrocele
• Spermatocele
• Hernia
• Syphilitic gumma

4. • Diagnosis of scrotal swellings
• To determine the nature of a scrotal swelling
aspects need to be assessed.
– Can you get above the swelling?
– Can the testis and epididymis be identified
separately?
– Does the swelling transilluminate?
– Is the swelling tender?

5. • A. Swellings not confined to the scrotum
(inguinoscrotal)
• Hernias
– May be reducible with cough impulse
– Testis is palpable
• Infantile hydrocele
– Irreducible
– No cough impulse
– Testis impalpable
•

6. • B. Swellings confined to scrotum
• Testicular tumours:
• Incidence: 2/100.000
• Special characteristics:
• Curable cancer
• It has sensitive markers: (alpha-fetoproteins,
beta-HCG )
• iii- Lymphatic drainage follows the blood supply
to para-aortic lymph nodes.

7. • Classification:
• I- Germ cell tumor
• -Seminoma 30% (Classic, Anaplastic, Spermatocytic)
• -Embryonal carcinoma 30%
• -Teratoma 35% (Differentiated, intermediate,
undifferentiated)
• -Chorion epithelioma 1%
• -Mixed tumor 15%
• B- Non germ cell tumor:
• Leydig-cell tumour, Sertoli-cell tumour and others.

8. • Etiology:
• Premitive or immature cells (totipotential) 
Abnormal differentiation  spermeogensis,
embryogensis, vetillogenesis.

9. • Predisposing factors:
• l.Cryptorchidism
• 7-10% of patients with testicular tumors have prior
testicular maldescent.
• 2. Trauma
• Repeated minor trauma was suggested as a
predisposing factor.
• 3. Hormonal imbalance
• 4. Atrophy
• Post-mumps orchitis atrophy is a potential causative
factor

10. • Pathology:
• The tumor starts as in situ growth, spread
locally to peritubular tissue, then destroy
testicular structure and lately the tumor
invades the tunica albuginea which resists the
malignant invasion.

11. • Metastasis:
• Tumor of the testis proper spread along the
lymphatic vessels to paraaortic lymph nodes..

12. • Seminoma:
• Differentiation into line of spermeogensis.
• Cell of origin:
• The germinal epithelium of seminiferous tubules.
• Gross description:
• Cut surface is grayish white, lobulated homogenous without hemorrhage
or necrosis. The tumor has no capsule. However, the tumor is distinct from
the normal tissue.
• Microscopic:
• Monotonus sheets of uniform cells with delicate connective tissue. The
cells have clear or granular cytoplasm with large central hyperchromatic
nucleus. Malignant foreign body giant cells or syncytiotrophoblast are
common, granulomatous reaction may be present, (the degree of
anaplasia differentiate anaplastic from classic type.

13. Cut section in Seminoma.

14. • Spermatocytic type (4-8%):
• The tumor is large yellowish soft slightly
mucoid. The cells are variable in size, the
cytoplasm is more deeply stained. The nucleus
is deeply granular with condensed chromatin-
like spermatogonia. Stroma is scanty,
lymphatic infiltration and granulomatous
reaction are present. This tumor has better
prognosis.

15. • Teratoma
• Cell of origin: Totipotential cells. It gives elements
of more than one germ layer.
• Gross: Large swelling, its cut surface reveals cysts
with mucinous material. Solid tissue, muscle,
cartilage, bone are interposed between cysts.
• Microscopicaly:
• Ectoderm—squamous epith, normal tissue
• Endoderm—gastrointestinal, respiratory tissue
• Mesoderm—bone, cartilage and muscle tissue.

16. • Chorion epithelioma
• Cell of origin: Totipotential cell  Differentiation into
the line of vetillogensis
• It is highly malignant tumor.
• Gross: Testis is hemorrhagic
• Microscopically: cytotrophoblast, uniform medium
sized cells, distinct cell border and single uniform
nucleus. Around these cells, the syncytiotrophoblast
form its cap in villous-like structures. There are
multinucleated cells with many hyperchromatic
irregular nuclei in vaculated eosinophillic cytoplasm.

17. • Embryonal carcinoma
• Differentiation into line of embryogenesis
• Cell of origin:Totipotential cells.
• Gross description:
• It is the smallest germ cell tumr. Cut surface is variegated
appearance with grayish white smooth or granular bulging
soft tissue, it has no capsule. There are extensive
hemorrhage and necrosis.
• Microscopic:
• Cells are of variable size and arrangement. Some are large
pleomorphic with distinct cell borders. Nuclei are also
pleomorphic, mitotic figures are common.

18. • Embryonal carcinoma
• Differentiation into line of embryogenesis
• Cell of origin:Totipotential cells.
• Gross description:
• It is the smallest germ cell tumr. Cut surface is variegated
appearance with grayish white smooth or granular bulging
soft tissue, it has no capsule. There are extensive
hemorrhage and necrosis.
• Microscopic:
• Cells are of variable size and arrangement. Some are large
pleomorphic with distinct cell borders. Nuclei are also
pleomorphic, mitotic figures are common.

19. • Clinical manifestations (common to all tumors):
• The earlier the diagnosis and treatment, the better is
the prognosis.
• Symptoms and signs:
• 1. Painless testicular swelling
• 2. Dull aching pain in the testis or in 10% acute pain
• 3. 10% manifest with metastasis; e.g. neck mass,
respiratory problems, gastrointestinal, bone fractures,
CNS manifestations etc.
• 4. Gynecomastia 5% (hormonal imbalance).

20. • Examination:
• Start with the normal side, tumor is usually
painless, hard, and heavy or the testis is
expanded. It may spread to epididymis. Small
hydrocele may be present (secondary).
Sonography is accurate, examination of the
abdomen is essential.

21. • Diagnosis:
• -It is based on clinical examination and
ultrasound showing heterogenous
vascularized or huge mass. No preoperative
biopsy needed to avoid soiling of scrotal skin
with malignant cells.
• -Preoperative tumor markers.

22. • Staging system:
• Stage l: confined to testis
• Stage ll: spread to regional node
• Stage lll: beyond retroperitoneal area.
• Metastatic Survey:
• Chest X-ray CT scan
marker
Tumor

23. • Marker Oncofetal:
• Alpha-Fetoprotein
• Beta-HCG
• CEA (carcinoembryonic antigen)
• Cellular enzymes (LDH, PLAP)

24. • Treatment:
• Urgent high inguinal orchiectomy
• Followed by:
• 1- Seminoma—irradiation 2500 rads in 3
weeks
• 2- Nonseminomatous germ cell tumor +
retroperitoneal lymph nodes dissection.

25. D. D.
• Epididymo-orchitis
– Testis and epididymis definable
– Testis tender
• Testicular tumour
– Testis and epididymis definable
– Lump within testis
– Testis non tender
• Epididymal cysts
– Testis and epididymis definable
– Lump separate
– Testis non tender

26. • Vaginal hydrocele
• - Testis and epididymis not definable
• - Transilluminates brightly
• Torsion testis
• - Testis and epididymis not definable
• - Testis tender
• Gumma
• - Testis and epididymis not definable
• - Irregular non-tender lump

27. • Testicular torsion
• Definition
• It is a surgical emergency due to twisting of
the cord, leading to obstruction of venous
blood supply to the testes leading to
secondary edema and congestion which will
cause arterial obstruction and necrosis and
gangrene of the testes.

28. • Etiology
• If the testis has a narrow mesentery, it will move freely
around its axis like a clapper bell thus being liable to
torsion. The abnormality is usually bilateral. It occurs
usually at puberty or if a tumor develops in the testis
due to increase in the testis size.
•
• Differential diagnosis
• Strangulated inguinal hernia, acute epididymoorchitis,
scrotal abscess, hematocele and mump's orchitis.

29. • Types
• I. Neonatal Testicular torsion
• (Extravaginal torsion, Torsion of the cord)
•
• Mechanism
• In neonates, the gubernaculum has still not
completely been attached to the scrotal wall, and the
testes and the gubernaculum freely rotate inside the
scrotum, thus the entire testes, epididymis and tunica
vaginalis twist together in a vertical axis on the
spermatic cord above.

30. • Clinical picture
• The infant is restless, reluctant to feeding.
• Hard, large scrotal mass, -ve transillumination.
•
– Treatment: It is controversial
• No treatment the testis is already necrotic.
• Surgical orchiectomy with contra lateral
orchiopexy to avoid sympathetic orchipathia of
the other side and protect against its delayed
torsion.

31. • II. Pubertal testicular torsion
• (Intravaginal torsion)
•
• Age of incidence 12—18 years
•
• Precipitating factors of torsion
• Contraction of the cremasteric muscle.
• Straining or lifting heavy objects.
• Coitus or masturbation.
•

32. •
• Clinical picture
• Sudden onset acute testicular pain and swelling.
• Severe tenderness.
• Nausea and vomiting.
• Transverse lie of the testis.
• Scrotal elevation will increase pain.
• Secondary hydrocele may develop.

33. • Treatment
• Manual detorsion (done from medial to
lateral) is not recommended as it is not a final
solution and torsion may recur, also may be
incomplete so the pain is relieved but the
testis is still ischemic.
• Surgical exploration
• Affected testis if viable detorsion and orchiopexy, if
not viable do orchiectomy.
• Contralateral testis orchiopexy.

34. • III. Torsion of testicular appendages
• The most common appendage susceptible to torsion is the
appendix testes.
• Clinical picture
• Similar to pubertal testicular torsion.
• The twisted appendix may be palpable before scrotal
swelling development as a 3—5 cm tender mass above the
upper pole of the testis with a characteristic blue dot sign
on the overlying skin.
• Local anesthesia may be given for proper examination.
• Treatment  Surgical excision.

35. • Hydrocele
• It is abnormal quantity of peritoneal fluid
between the visceral layers of the tunica
vaginalis.
obliterated except around
• Procesus vaginalis
testis.
• Usually painless, unless underlying disease is
painful.

36. • Types
– Communicating
– Encysted
– Funnicular
– scrotal
• May be primary or secondary.
• Diagnosis:
– Testis not felt.
– Can get above it.
– Transluminant.
– U/S.
• Treated by Excision and Eversion

37. • Epididymitis
– Uncommon in adolescents - be wary about
making the diagnosis
– Usually has a more prolonged history than torsion,
less pain and with urinary symptoms
– Tenderness is greatest over the epididymis

38. • Idiopathic scrotal oedema
– Usually occurs in boys less than 10 years old
– Presents with scrotal redness and oedema
– Pain is slight and testis feels normal.