This document provides an overview of various inguinal and scrotal swellings including hernias, hydrocele, varicocele, spermatocele, orchitis, orchitis-epididymitis, testicular torsion, and Fournier's gangrene. Key details are provided on the epidemiology, causes, risk factors, clinical presentation, investigations, and management of each condition. Examples of different types of hernias, hydroceles, and cases of Fournier's gangrene are also described.

1. PRESENTED BY Mr VICTOR SIMWINGA
*

2. *
* OBJECTIVES
REVIEW ANATOMY OF INGUINAL REGION AND SCROTUM
BLOOD SUPPLY
INNERVATION SUPPLY
EPIDEMIOLOGY
EXAMPLES OF INUGUINAL SCROTAL SWELLINGS
RISK FACTORS
CAUSES
CLINICAL PRESENTATIONS
 INVESTIGATIONS
MANAGEMENT

5. EXAMPLES OF INGUINAL AND SCORTAL SWELLINGS
Hernias
Hydrocele
Varicocele
Spermatocele
 Orchitis
 Orchitisepididymitis
Testicular torsion
Fournier's gangrene

6. INGUINAL HERNIA
* A hernia is the protrusion of the abdominal contents beyond the normal confines of the
abdominal wall.
* Consists of three parts: the sac, contents of the sac and covering of the sac.
* Hernial coverings are formed from the layers of the abdominal wall through which the
hernia sac passes.
Epidemiology
* Groin hernia is 25 times more common in men than women.
* Indirect inguinal hernia is commonest hernia in men and women.
* Femoral hernia s more common in females (10:1); umbilical and
* incisional hernias are also common in females (2:1)
Clinical Presentation
* Patient presents with dragging pain and swelling in the groin which is better seen while
coughing and standing; felt together with an expansile impulse (momentary increase or
occurrence of the swelling during the act of coughing).

9. * AETIOLOGIES
 Straining.
 Lifting of heavy weight.
Chronic cough (tuberculosis, chronic bronchitis, bronchial asthma, emphysema).
 Chronic constipation (habitual, rectal stricture).
Urinary causes
Old age—BPH, carcinoma prostate.
Young age—stricture urethra.
Very young age—phimosis , meatal stenosis.
Obesity.
Pregnancy and pelvic anatomy (especially in femoral hernia
in females).
 Smoking.
 Ascites.
 Appendectomy through McBurney’s incision may injure the
ilioinguinal nerve causing right sided direct inguinal hernia

10. Diagnosis
* Invagination test :It were using an index finger the hernia is reduced & pt is asked to
cough & if the cough impulse is felt at tip of the finger then hernia is called Indirect
inguinal hernia
* If the cough impulse is not felt on the palm of the finger is called direct inguinal
hernia.
* Occlusion test: Occlude the deep inguinal region using the index finger, if the hernia is
at the tip it is called indirect hernia & at the palm of the index finger it is called direct
hernia.
* An inguinal hernia is medial to the pubic turbecle whilst femoral hernia is lateral to the
pubic turbecle.
* Transillumination test: in hernia light can’t protrude to the other side.
* Chest X-ray to rule out bronchitis
* Abdominal ultrasound to rule BPH and Ascites

11. TREATMENT
*Herniostomy: involves resectioning the hernia
sac without repairing the posterior wall of the
hernia canal.
*Herniorrhaphy: resection hernia sac & repair
the wall
*Mesh repair: resect the hernia sac & repair the
posterior wall with a mesh wire.

12. *

13. ORCHITIS
This is the inflammation of the testicles. Which
can be caused by either bacteria or a virus.
Epidemiology
Affects men than women
Highest risk is age between 15-29yrs
Uncommon in prepubertal males

14. RISK FACTORS
People who engage in high-risk sexual behavior may be more likely to
develop orchitis. High-risk sexual behavior includes:
• having sexual intercourse without condoms
• having a history of STIs
• having a partner who has an STI
• Congenital urinary tract abnormalities can also increase risk of orchitis. This
means if one is born with structural problems involving bladder or urethra
CAUSES
• Most commonly, mumps causes isolated orchitis.
• Other rare viral etiologies include coxsackievirus, infectious
mononucleosis,varicella, and echovirus.
• Bacterial causes usually spread from an associated epididymitis in sexually
active men or men with BPH: – bacteria include Neisseria gonorrhoeae,
Chlamydia trachomatis, Escherichia coli, Klebsiella pneumoniae,
Pseudomonas aeruginosa, and Staphylococcus and Streptococcus species. –
Bacterial orchitis rarely occurs without an associated epididymitis.

15. SYMPTOMS
Pain in the testicles and groin is the primary symptom of Orchitis.
Tenderness in the scrotum
Painful urination
Painful Ejaculation
A swollen scrotum
Blood in semen
Abnormal Discharge
An Enlarged prostate
Swollen lymph node in the groin
Fever
Clinical Presentation
Testicular examination reveal the following
Testicular enlargement
Induration of the testis
Tenderness
Erythematous scrotal skin
Edematous scrotal skin
Enlarged Epididymis
On rectal examination, there is a soft boggy prostate(prostatitis)
.

17. LABORATORY INVESTIGATIONS
*Laboratory tests are often not helpful in making the diagnosis of
Orchitis
• Diagnosing mumps Orchitis can be comfortably made based on
history and physical examination alone. Diagnosing mumps Orchitis can
be confirmed with serum immunofluorescence antibody testing.
• In sexually active males, urethral cultures and gram stain should be
obtained for Chlamydia trachomatis and Neisseria gonorrhoea.
• Urinalysis and urine culture can also be obtained.
IMAGING INVESTIGATIONS
• Color Doppler ultrasonography has become the imaging test of choice
for the evaluation of an acute scrotum Orchitis .
• Because Orchitis often presents as acute oedema and pain of the
testicle, ruling out testicular torsion is critical. A finding of a normal-
sized testicle with decreased flow is suggestive of torsion, whereas a
finding of an enlarged epididymis with thickening and increased flow is
more suggestive of epididymitis/Orchitis

18. TREATMENT
*There’s no cure for viral Orchitis, but the condition can go away on
its own.
Supportive treatment maybe applied:
Bed rest.
Hot or cold compress.
 Scrotal elevation.
Bacterial Orchitis is treated with antibiotics, anti- inflammatory
medications, Commonly antibiotics include ceftriaxone, doxycycline,
azithromycin or ciprofloxacin
 cold packs

19. *

20. Orchiepididymitis
What is it?
• Epididymitis is the inflammation of the epididymis.
• If the inflammation spreads to the testicle spreads to the scrotum it
is called Orchiepididymitis.
INCIDENCE
 The mean age of these patients was 40.2 ± 17.3 years.
 Young adults are predominantly affected, with a frequency peak
between 20 and 40 years of age.
Structural urologic abnormalities are common in children and in
men older than 40 years with acute epididymitis.

21. RISK FACTORS
• Sexual intercourse with more than one partner and not using
condoms
•Being uncircumcised
•Recent surgery or a history of structural problems in the urinary tract
•Regular use of a urethral catheter
CAUSE
•Among sexually active men aged <35yrs e.g Transmission Chlamydia
trachomatis or Neisseria gonorrhoea
•Men who are the insertive partner during anal intercourse: e.g
Escherichia coli and Pseudomonas aeruginosa
•Men aged >35 years
–Sexually transmitted epididymitis is uncommon
–Bacteriuria secondary to obstructive urinary disease is more common.

22. SYMPTOMS
•Heavy sensation in the testicle area
•Painful scrotal swelling
•Fever
•Chills
•Testicle pain gets worse with pressure
•Lump in the testicle
•Blood in the semen
•Discharge from the urethra
•Pain or burning during urination or ejaculation
•Discomfort in the lower abdomen or pelvis
CLINICAL PRESENTATIONS
 Tenderness and induration occurring first in the epididymal tail and then spreading
• Elevation of the affected hemiscrotum
• Normal cremasteric reflex
• Erythema and mild scrotal cellulitis
• Reactive hydrocele (in patients with advanced epididymo-orchitis)
• Bacterial prostatitis or seminal vesiculitis (in postpubertal individuals)
• With tuberculosis, focal epididymitis and a draining sinus

24. LABORATORY INVESTIGATIONS
• Urinalysis: Pyuria or bacteriuria (50%); urine culture indicated for prepubertal and elderly
patients
• Complete blood count: Leukocytosis
• Gram stain of urethral discharge, if present
• Urethral culture, nucleic acid hybridization, and nucleic acid amplification tests to
facilitate detection of Neisseria gonorrhoea and Chlamydia trachomatis
• Performance of (or referral for) syphilis and HIV testing in patients with a sexually
transmitted etiology
• The use of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to
differentiate epididymitis from other causes of acute scrotum is under investigation
IMAGING STUDIES
 Voiding cystourethrogram (VCUG)
•Retrograde urethrography
•Abdominal/pelvic ultrasonography
•Radionuclide scanning and scintigraphy
•In tuberculosis epididymitis, chest radiography, computed tomography, or excretory
urography.

25. TREATMENT
• Empiric treatment is indicated before laboratory results are available
• Goals of treatment of acute epididymitis caused by C. trachomatis or N.
gonorrhoea:
–Microbiological cure of infection
–Improvement of signs & symptoms
–Prevent transmission to others
–Reduce potential complications
• Recommended Regimens: –Ceftriaxone 250mg IM in a single dose PLUS –
Doxycycline 100mg PO BID x 10 days For epididymitis most likely caused by
enteric organisms: –Levofloxacin 500mg PO once daily x 10 days OR – Ofloxacin
300mg PO BID X 10 days.
PROPHYLAXIS
• Practicing safe sex
• Treating sexual partners as a contact to epididymitis.
•Repeat screening for STI ~ 2 months after initial testing for re-infection.
•Abstain from sex until the individual & sex partners have completed treatment.

26. *

27. FOURNIER GANGRENE
Age – 30 – 60 years
 Sex – 10 times more common in males
 Social habits – More common in male homosexuals (more prone for
Rectal injury)
 Mortality - 20–30%
Fournier gangrene is defined as a polymicrobial necrotizing fasciitis of the perineal,
perianal, or genital areas.
INCIDENCE

28. Layers (from without
inwards)
1. Skin
2. Dartos muscle
3. External spermatic
fascia
4. Cremasteric fascia
5. Internal spermatic
fascia
RELEVANT ANATOMY OF THE SCROTUM

29. RISK FACTORS
 Diabetes mellitus
 Alcoholism
 Malignancies
 Cirrhosis Liver
 Chronic steroid use
 HIV infection
 Malnutrition
 Morbid Obesity
 Poor anogenital hygiene
CAUSES
 Initially described as idiopathic
 Now in more than 75% cases inciting cause in known
 Necrotizing process commonly originates from infection in anorectum, urogenital tract or skin of genitalia
 Ano-rectal causes
– Infection in the perineal glands
– Manifestation of colorectal injury,
 Uro-genital causes
– infection in the bulbourethral glands
– Urethral injury
– Iatrogenic injury
– Lower urinary tract infection
 Dermatologic causes
– Ulceration from scrotal pressure
– Trauma to scrotum or perineum
 CAUSATIVE BACTERIA
 Polymicrobial infection of aerobes & anaerobes
 Minimum of four isolates per case
 Most common aerobe – E. coli
 Most common anaerobes – Bacteroides
 Others – Streptococcus,
-MRSA – Methicillin Resistant Staphylococcus aureus,
-Klebsiella
-Pseudomonas,
- Proteus &
- Clostridium.

30. *CLINIICAL MANIFESTATIONS
 Begins with insidious onset of pruritus and discomfort of external
genitalia
 Prodromal symptoms of fever and lethargy, which may be present
for 2-7 days before gangrene
The hallmark of Fournier gangrene is out of proportion pain and
tenderness in the genitalia
 Increasing genital pain and tenderness with progressive
erythema of the overlying skin
 Dusky appearance of the overlying skin; subcutaneous
crepitation; feculent odor
Obvious gangrene of a portion of the genitalia with purulent
discharge from wounds
As gangrene develops, pain subsides (Nerve necrosis)

32. Laboratory studies
Blood culture & sensitivity
Grouping & X-match
Pus swab for M/C/S
 Urea ,creatinine Electrolytes
 Radom Blood Sugar
 Urine M/C/S
 Coagulation profile for DIC
Imaging studies
U/SS -Can be used to detect fluid or gas in soft tissue. “Sonographic
hallmark” – Presence of gas in scrotal tissue
 C.T. Scanning -Defines extent more specifically,
-Identifies underlying causes e.g. Small perineal abscess

33. Medical Management
ABCDE- Approach
Treated as an in-patient always.
 IV fluids and catheterisation—for monitoring of urine output
 Broad-spectrum antibiotics are given to cover both gram-positive and gram-negative
aerobes and anaerobes
(ciprofloxacin+ clindamycin + metronidazole)
( ampicillin + gentamicin + metronidazole or clindamycin)
Vancomycin for MRSA
 Tetanus prophylaxis
 Nutritional support
Surgical Treatment
Repeated aggressive debridement
 Fecal diversion
 Urinary diversion
 Once patient recovers and wound granulates well ,skin grafting may be done
Orchidectomy is not necessary as testicles are normal and viable
 Testis can be placed in the pouch in medial aspect of the thigh

34. *MALE WITH DEBRIDED FOURNIER’S GANGRENE
FEMALE WITH DEBRIDED FOURNIER’S GANGRENE

35. *Debrided Fournier’s Gangrene

36. HYDROCELE
Hydrocele is a collection of fluid around one or both testicles and
cause swelling of scrotum or groin area.
INCEDENCE
 It commonly occurs in men older than 40 years
1 in 10 male infants has a hydrocele at birth, but most hydrocele
disappear without treatment within the first year of life.

37. TYPES OF HYDROCELE
i) Non communicating
ii) Communicating
Non communicating
A non communicating hydrocele occurs when the sac closes, but your
body doesn’t absorb the fluid. The remaining fluid is typically
absorbed into the body within a year
Communicating
A communicating hydrocele occurs when the sac surrounding your
testicle doesn’t close all the way. This allows fluid to flow in and out.

39. ETIOLOGIES
 Idiopathic
Inflammation of infection of the epididymis or testicles.
In rare cases, may be caused by cancer of testicle or left kidney.
Men over the age of 40

40. Clinical manifestation
*Swelling of scrotum
*Pain sometime
* Redness of scrotum
* Feeling of pressure at base of penis present.
*Testicular torsion
* Infertility

42. DIAGNOSTIC EVALUATION
History taking
*Physical examination
*Transillumination: It is a test used to identify abnormalities in an
organ or body cavity. The test is performed in a dark room, with a
bright light shined at a specific body part to see the structures
beneath the skin.
*Ultrasound of scrotum done to rule out presence of fluid
*Blood test done to rule out infection

43. *

44. TREATMENT
Surgery: If your new infant has a hydrocele, it
will probably go away on its own in about a
year. If your child’s hydrocele doesn’t go away
on its own or becomes very large, he might need
surgery by a urologist
Needle aspiration done.
Sclerotherapy done to reduce re accumulation.
In adults, hydroceles typically go away within
six months

46. VARICOCELE
Dilatation and tortuosity of the pampiniform plexus and so also of the testicular veins.
Incidence
Seen commonly in men aged 15-30yrs and rarely after 40yrs.
Occur in 15-20% of all males and 40% of all infertile males.
Normal small vessels of plexus- 0.5-1.5mm.
Diameter greater than 2mm- Varicocele Seen commonly on the left side – For 5
reasons.
 longer
 enters at right angle to the renal vein
 left testicular artery arching over it
 a loaded sigmoid colon.
 compressed b/w the aorta and SMA

47. CAUSES
1.IDIOPATHIC/PRIMARY
– due to incompetency of valves, 98% occur on the left side.
2.SECONDARY
pelvic or abdominal mass.
 renal cell carcinoma with tumor thrombus in left vein.
 Nutcracker syndrome-
 SMA compressing left vein.
 Common conditions RCC
 Retroperitoneal fibrosis or adhesions

48. CLINICAL MANIFESTATION
 Swelling
 Dragging /aching pain in the groin and scrotum
 “ bag of worms” feeling
 Scrotum on the affected side hangs down.
 On lying down , it gets reduced.
 Bow sign- hold varicocele between thumb and fingers , patient is asked to bow-
reduced in size
 Cough impulse present
 Long standing cases- affected side testis is reduced in size and softer.
 Fertility problems

50. INVSTGATIONS
 Venous doppler of the scrotum and groin-
 Standing/ valsalva’s manouevre.
 U/S abdomen to look for kidney tumours.
 Semen analysis

51. GRADING
1.SMALL - identified only by bearing down i.e, an increase in abdominal pressure.
2.MODERATE - identified by palpation w/o bearing down.
3.LARGE - easily identifed by inspection alone.
4.SEVERELY TORTUOUS

52. TREATMENT
3 SURGICAL AND 1 NON SURGICAL
PROCEDURE.
VARICOCELECTOMY-
The most common approaches are
inguinal (groin)-easier and safer.
retroperitoneal (abdominal)
infrainguinal/subinguinal (below the groin),
suprainguinal extraperitonial( Palomo’s operation),
Scrotal approach- grade 4.
Done in spinal.
2-3 inch incision.
Ligate the offending
veins.
Avoid strenuous
exercise for several
days after surgery.
Apply scrotal
support

53. Complications
20% chance of recurrence.
5% chance of hydrocele
Damage to testicular artery.
Infection.
hematoma

54. Spermatocoele
Benign cystic accumulation of sperm
Arises from the head (caput)of the epididymis-on superior aspect.
Lesions are benign – retention cysts
Usually uniclocular
Contain barley water like fluid spermatozoa

55. CAUSES
remains undefined
In a mouse model - occluded by agglutinated germ cells.
Physical trauma, inflammation Epidydimal scarring obstruction spermatocoele
In utero exposure to diethylstilbestrol (DES)

56. Clinical features
Symptoms
Typically asymptomatic
Incidental findings examination
Usually a painless mobile swelling postero superiorly
Associated symptoms scrotal heaviness and dull discomfort
Signs
Smooth and spherical
Fluctuant
Transillumination on examination

57. Investigation
 Uncomplicated asymptomatic spermatocele no investigation needed
 scrotal pain , urine analysis to rule out epididymitis.
 FNAC-dead sperm Ultrasonography
 Cystic lesions that arise from the epididymal Head
 Less commonly- intratesticular lesion attached to the mediastinum testis.
 Hypoechoic with posterior acoustic enhancement and cannot be differentiated from
an epididymal cyst .
 Occasionally, may have internal echoes within the cyst.
 Scrotal USS - spermatocele visible to the left of a normal testis
 Color Doppler -"falling snow" appearence (internal echoes moving away from the
transducer)
Histologic Findings -fibromuscular wall that is lined by cuboidal epithelium

58. Medical Therapy
No specific medical therapy .
Oral analgesics i.e ibuprofen
If an underlying epididymitis - give antibiotics i.e ceftriaxone
Observation is usually used for
simple, small asymptomatic Spermatoceles
Surgical Therapy
Spermatocelectomy
The primary operative intervention is Via a transscrotal approach
Relative contraindications
- Systemic anticoagulation
-family incomplete
Performed on an outpatient basis
With either regional or general
anesthesia

59. Complications
chemical epididymitis epididymal damage infertility
Bleeding
infection
spermatocele
recurrence
scrotal wall thickness.

60. TESTICULAR TORSION
Testicular torsion refers to the torsion of the spermatic cord structures and
subsequent
loss of the blood supply to the ipsilateral testicle
Normal anatomy
• The tunica vaginalis does not completely surround the testis and epididymis, which
are attached to the posterior scrotal wall

61. PATHOPHYSIOLOGY
Torsion occurs as the testicle rotates between 90° and 180°,
compromising blood flow to and from the testicle.
• Complete torsion usually occurs when the testicle twists 360° or more;
incomplete or partial torsion occurs with lesser degrees of rotation.
The degree of torsion may extend to 720°.
• The twisting of the testicle causes venous occlusion and engorgement
as well as arterial ischemia and infarction of the testicle.
• The degree of torsion the testicle endures may play a role in the
viability of the testicle over time.
• In addition to the extent of torsion, the duration of torsion prominently
influences the rates of both immediate salvage and late testicular
atrophy. Testicular salvage is most likely if the duration of torsion is less
than 6-8 hours.
• If 24 hours or more elapse, testicular necrosis develops in most
patients.

62. TYPES OF TESTICULAR TORSION
Intravaginal torsion
Is the more common type, occurring most frequently at puberty.
It results from anomalous suspension of the testis by a long stalk of spermatic cord,
resulting in complete investment of the testis and epididymis by the tunica
vaginalis.
• This anomaly has been likened to a bell-clapper
Extravaginal torsion
• Most often occurs in newborns without the “bell clapper” deformity.
• It is thought to result from a poor or absent attachment of the testis to the scrotal
wall, allowing rotation of the testis, epididymis, and tunica vaginalis as a unit and
causing torsion of the cord at the level of the external ring.

63. HISTORY
 Severe unilateral scrotal pain
• Previous episodes, spontaneous resolution
• Related to activity, trauma, during sleep
• Nausea, vomiting, abdominal pain, fever
PHYSICAL EXAMINATION
Prenatal torsion, firm, hard, scrotal
mass, which does not transilluminate
in an otherwise asymptomatic
newborn male. The scrotal skin
characteristically fixes to the
necrotic gonad.
• Older patient, swollen, tender, highriding
testis with abnormal transverse
lie and loss of the cremasteric reflex

65. DIAGNOSIS
CLINICAL SUSPICION
• Nuclear scintigraphy
– Radiation, limited availability
• Ultrasound
– Altered echotexture (B-mode)
– Vascular flow (Color / Spectral / Power Doppler)
• Infrared scrotal Spectroscopy
ULTRASOUND FOR TESTICULAR TORSION
Sensitivity 86%, specificity 100% experienced provider using color /
power doppler1
• Gray-scale findings on ultrasound depend on how much time has
passed since the torsion occurred.
• The gray-scale findings of acute and subacute torsion are not
specific and may be seen in testicular infarction caused by
epididymitis, epididymo-orchitis, and traumatic testicular rupture or
infarction.

66. ULTRASOUND FOR TESTICULAR TORSION CON’T
Early stages, scrotal contents may have a normal sonographic
appearance.
• After 4 to 6 hours, the testis becomes swollen and hypoechoic,
• After 24 hours, the testis becomes heterogeneous as a result of
hemorrhage, infarction, necrosis, and vascular congestion
• The epididymal head appears enlarged and may have
decreased echogenicity or may become heterogeneous.
• The spermatic cord immediately cranial to the testis and
epididymis is twisted, causing a characteristic torsion knot or
“whirlpool pattern” of concentric layers
Large, echogenic or complex extratesticular masses caused by
hemorrhage in the tunica vaginalis or epididymis may be seen in
patients with undiagnosed torsion

67. TREATMENT
 Definitive treatment: surgical detorsion and orchioplexy
• Manual detorsion : medial to lateral; “opening a book”
– May need to rotate 2-3 times for complete detorsion Roberts

68. *