Focused History Examination Differential Diagnosis Hx of PAIN due to: - Funiculitis (young age) - Tuberculous thickening of cord - Malignancy of Testis (Upward extention) - Varicocele (Prolonged standing, vague dragging pain) - Torsion (sudden in onset, ⚠️ Appendicitis must be ruled out (Rt. Groin pain)) Hx of SWELLING: - Key Qs during Hx Taking: e.g.: “How/Where did it appear?” Etc. to get a diagnostic clue. e.g. Rapid Left sided Varicocele with hematuria indicates Kidney Carcinoma.

2. INGUINOSCROTAL
SWELLING
Presented by:
DR AWAIS IRSHAD

3. LEARNING OBJECTIVES:
 Focused History
 Examination
 Differential Diagnosis

4. FOCUSED HISTORY:
 Hx of PAIN due to:
- Funiculitis (young age) - Tuberculous thickening of cord
- Malignancy of Testis (Upward extention) - Varicocele (Prolonged standing, vague
dragging pain)
- Torsion (sudden in onset, ⚠️ Appendicitis must be ruled out (Rt. Groin pain))
 Hx of SWELLING:
- Key Qs during Hx Taking: e.g.: “How/Where did it appear?” Etc. to get a diagnostic
clue.
e.g. Rapid Left sided Varicocele with hematuria indicates Kidney Carcinoma.

5. FOCUSED HISTORY Contd:
 PAST Hx: Previous occurrence of these symptoms suggestive of filarasis (Wuchereria
bancrofti)
 PERSONAL Hx: Previous sexual contact in gonococcal funiculitis.

6. EXAMINATION (Local):
 Positions: 1. Standing 2. Recumbent
 INSPECTION: 1. Position and extent of swelling e.g.:
Spermatic Cord: Localized (encysted hydrocele) , Diffuse (Lipoma)
2. Skin over swelling e.g.:
Redness indicates Funiculitis or Late torsion of cord. D/D from Strangulated hernia
with inflammation.
3. Impulse on coughing : To differentiate hernia from other conditions e.g.:
Expansile in Hernia, Thrill-like in varicocele and lymph varix.

7. EXAMINATION (Local) Contd:
 PALPATION: Position and Extent e.g.:
- Cystic swelling in the middle of spermatic cord is hydrocele whereas diffuse swelling is
Lipoma(N.inflammatory) , funiculitis is inflammatory.
- Common positions of Ectopic testes and undescended testis are Superficial inguinal pouch
and Inguinal canal respectively.
Consistency e.g.:
- Hydrocele: Fluctuant, translucent - Varix: Soft, doughy
- Varicocele: Bag of worms.
Reducibility e.g.:
- The patients stand up while pressing the Sup. Inguinal Ring , Hernia does not
reappear where varicocele and lymph varix do fill from below.

8. EXAMINATION (Local) Contd:
- Impulse on coughing: Typical expansile impulse only in case of hernia
 PERCUSSION is helpful in differentiating Strangulated hernia from funiculitis, with the
former being resonant.
** Examine the Testis, epididymis and spermatic cord at the end of Local examination.
**

9. EXAMINATION (General):
 Chest: Tuberculous epididymitis
 Abdomen: Malignancy, palpate pre and para-aortic nodes
 Kidney: Rapid varicocele , Renal Tumour, Lt Sided: Renal vein , Rt Sided: IVC
involvement respectively.

10. ETIOLOGY OF INGUINOSCROTAL SWELLING:
 Inguinal Hernia
 Hydrocele
 Lymph Varix
 Lipoma
 Malignancy
 Testicular Torsion
 Abscess

11. DIFFERENTIAL DIAGNOSIS (D/Ds):
 Encysted Hydrocele: Distention of the funicular process(The part of the tunica
vaginalis that covers the spermatic cord.) with fluid. Fluctuation and Translucency test
will be positive. Cough impulse absent. Traction test.
 Varicocele: Dilation of pampiniform plexus, Lt. side commonly affected due to Right
angle b/w Lt. spermatic and renal veins. Feels like bag of worms. Rapid onset suggests
Carcinoma of kidney. Thrill-like cough impulse.
 Lymph Varix : Dilation of lymphatic vessels due to filariasis (Lymphatic filariasis is
caused by infection with parasites classified as nematodes (roundworms) ).
 Lipoma of the cord: Irreducible soft swelling with no impulse
 Inflammation “ “ “: Most often due to due TB. Tenderness, indurated seminal vesicles
on RE.
 Malignancy of testis: Hardening of the cord, deposits in regional lymph nodes

12. DIFFERENTIAL DIAGNOSIS (D/Ds) Contd:
 Undescended/Ectopic testis: Scrotum of the involved site would be empty. Ectopic
testes is well-developed whereas Undescended testes is not.
 Torsion of the testis: Mimics strangulated hernia which is resonant, torsion is dull on
percussion.
 Retractile testis: Strong contraction of the cremaster muscle may pull the testis from
the scrotum into superficial inguinal pouch. Common in children. ‘Chair Test’ is
performed to bring the testis back into the scrotum.

13. REFERENCES:
 A Manual of Clinical Surgery by S.Das, 13th Edition.
 Google Images, Credits are to original authors.

14. Thank You for your
attention, you are very
kind.