scrotal swelling

2. SCROTAL
SWELLING
Alia Syarmila Bt Yusuf

4. Anatomy of the scrotum
varicocele
hydrocele
haematocele

5. Skin problems
Infections
Testicular inflammation & tumor
Scrotal hernia

6. Anatomy of scrotum
• It is the small muscular sac that contains and protects the testicles, blood
vessels, and part of the spermatic cord.
• It is divided internally into two compartments by a septum, and each
compartment contains a testicle.
• The scrotum protects the testicles from temperature changes. In order to
insure normal sperm production, the scrotum keeps the testes at a
temperature slightly cooler than the rest of the body by contracting or
expanding.

9. Structure of scrotum:
wall of the scrotum
• Skin: Skin of scrotum is thin, wrinkled and pigmented.
• Superficial fascia: The superficial fascia of scrotum is continuous with the fatty and
membranous layers of fascia of anterior abdominal wall. The fatty layer in this region is
replaced by a smooth muscle known as dartos muscle. The membranous layer of fascia in
the scrotal region is known as Colle’s fascia. It is continuous in front with the Scarpa’s fascia
(membranous layer of fascia of anterior abdominal wall).

11. Structure of scrotum:
wall of the scrotum
• Spermatic fasciae: lies beneath the superficial fascia and are derived from the three layers of
anterior abdominal wall.
• External spermatic fascia: Derived from the aponeuorsis of external oblique muscle.
• Cremasteric fascia: Derived from the internal oblique muscle. This fascia contains both the
connective tissue and muscle fibers, which form the cremaster muscle.
• Internal spermatic fascia: Derived from the fascia transversalis.
• Tunica vaginalis: It lies within the three spermatic fasciae, covering the anterior, medial and
lateral surfaces of each testis. The tunica vaginalis is in fact the lower expanded part of
processus vaginalis, from which it is shut off just before birth. The tunica vaginalis is thus a
closed sac, which is invaginated from behind by the testis on each side.

12. Blood supply & drainage
• Testicular ar.
• anterior scrotal artery
• posterior scrotal artery
• The venous blood drains through the testicular veins into the inferior vena
cave.

14. Anatomy of the scrotum
varicocele
hydrocele
haematocele

15. Varicocele
State of varicosity of the testicular vein
A varicocele is a dilatation of the pampiniform venous plexus and the internal
spermatic vein.
Varicocele is a well-recognized cause of decreased testicular function and occurs in
approximately 15-20% of all males and in 40% of infertile males. air
teens/ young adults
If occur in older men, underlying retroperitoneal disease should be sought ,
including renal ca. extending into left renal vein.
Left side is affected in 95% of cases, WHY?

16. L spermatic v. is more vertical
where it connects to left renal v.
L Renal v. can be compressed by
colon
L testicular v. is longer than right
Lacks of terminal valve

17. Clinical features
• Asymptomatic
• Dragging pain in the affected site
• Inspection
• Usually unilateral
• Cough impulse may be positive

18. Clinical features
• Palpation
• Standing position
• Bag of worms
• Able to get above mass
• Testes can be felt separately
• Non-transilluminate

19. Complication
• Infertility
• Interference of the normal temperature of the scrotum

20. Management
• Surgical
• Palomo operation
• Laparoscopic ligation of the
spermatic v. on the pelvis side
wall
• Non surgical
• Transfemoral radiological
embolization of the testicular v.

21. Anatomy of the scrotum
varicocele
hydrocele
haematocele

22. Hydrocele
Collection of serous fluid in tunica vaginalis

23. Anatomy
• Tunica vaginalis – potential space that encompass the anterior 2/3 of testicle
• Epididymis – coiled tubular structure on the posterior testes

25. Hydrocele
Anatomical
classification
Vaginal
infantile
Congenital
Hydrocele of the cord
aetiology
Primary
Secondary

26. Anatomical classification of
hydrocele

29. Hydrocele
Anatomical
classification
Vaginal
infantile
Congenital
Hydrocele of the cord
aetiology
Primary
Secondary

30. Aetiology
Primary Secondary
Patent processuss vaginalis Interfere lymphatic drainage
Defective absorption of fluid Excessive production of fluid
Importance: usually benign and
presence since childhood
Importance: local pathologies
(testicular tumors, torsion, orchitis,
trauma, post inguinal repair)

31. Clinical features
☼ Inspection :
☼ usually unilateral
☼ cough impulse (-)
☼ large/small
☼ globular in shape
☼ prominent vein on scrotal skin

32. Clinical features
☼ Palpation:
☼ Able to get above mass
☼ Hard to differentiate the testes
☼ Smooth surface
☼ Soft unless calcified, mixed with blood,
large lump
☼ Trans illumination (+) unless infected,
mixed with blood calcified

34. complication
Rupture
Infertility
Calcification
Haematocele

35. management
Non surgical Surgical
Watch and wait Lord`s plication
Aspiration USS guided Jaboulay`s operation

37. Lord's technique of hydrocele surgery:
the hydrocele sac is reduced by plication sutures.

38. • The edge of the
hydrocele sac is
oversewn for
haemostasis or the
edges are sewn
together behind the
spermatic cord
Jaboulay's technique

39. Anatomy of the scrotum
varicocele
hydrocele
haematocele

40. haematocele
A scrotal haematocele is a collection of blood within the scrotal
sac, but outside of the testicle.

41. A haematocele normally
occurs following trauma to
the scrotum, or on occasion
following surgery.
Some think that a varicocele
is a risk factor for
developing a haematocele

42. Skin problems
Infections
Testicular inflammation & tumor
Scrotal hernia

43. Skins problems
Sebaceous cyst

44. Sebaceous cyst of the scrotum
• It is also called epidermal cyst.
• These cysts are common in younger age group.
• do not attached to the underlying surface.
• It is present on the skin surface over the scrotum.
• It is freely movable, smooth and soft to firm in consistency.
• Sebaceous cysts are painless unless they become infected.

46. complication
• Inflammation
• Infection
• Rupture
• Discomfort
• Malignancy

47. treatment
• If a sebaceous cyst is small and causing no problems, it may safely be left alone.
• For inflamed cysts, a corticosteroid injection may be injected into the cyst to reduce
inflammation.
• For infected; Such a cyst is treated with antibiotics and then excised to prevent
recurrent infections.
• Surgical Management
• The medium to big sized cyst, containing sebum or pus, needs to be drained. This
may be done by making a small surgical nick on its surface and subsequent draining.
• Alternatively, the cyst may be excised surgically along with its capsule. This method
is particularly chosen when the cyst has a tendency of recurrence.

50. Skin problems
Infections
Testicular inflammation & tumor
Scrotal hernia

51. Infections
Fournier`s gangrene
Epididymitis
Orchitis

52. Fournier`s gangrene
• Fournier's gangrene is a form of necrotizing fasciitis of the genital and
perineal region.
• significant pain and tenderness, scrotal and genital swelling, discoloration or
frank necrosis, crepitus and at times, foul-smelling discharge
• Bacteriologically, these infections are usually polymicrobial, with aerobes,
anaerobes, gram-positive, and gram-negative organisms

54. Risk factors
• Diabetes mellitus
• Trauma or surgery of the perigenital region
• Urethral extravasation of urine
• Urethral injury
• Paraphimosis
• Rectal injury

55. features
•Local swelling, redness, tumor,
crepitus (gas formation).
•In progredient disease, dark
hemorrhagic necrotic areas
develop
•Fever, signs of sepsis

57. treatment
• Antibiotic Therapy for Fournier's Gangrene:
• A combination with cephalosporin (third generation), gentamicin and
metronidazole i.v. is necessary to treat the mixed infection with aerobe and
anaerobe bacteria.

58. treatment
• Surgical Debridement:
• Deep incisions and excisions of gangrenous tissue until healthy tissue is reached.
Necrotic areas should be completely removed (radical surgery).
• Orchiectomy is rarely necessary.
• To speed up wound healing, secondary wound closure is sometimes possible.

59. epididymitis
Acute or chronic inflammation of the epididymis
• Bacterial epididymitis
• Epididymitis secondary to UTI: E. coli, Proteus, Klebsiella, Pseudomonas, Staphylococci
• Epididymitis secondary to STD: Chlamydia, Neisseria
• TB
• Nonbacterial infectious epididymitis: viral, fungal or parasitic etiology
• Noninfectious epididymitis: trauma, autoimmune, amiodarone-induced or idiopathic
• Chronic epididymitis: duration longer than six weeks
• Chronic epididymyalgia

61. features
• Testicular pain: tenderness of the epididymis
• Tender and swollen spermatic cord
• Swollen Scrotum, reddening and fever with
advanced inflammation
• Intact cremasteric reflex, Prehn's sign is not
reliable, should be positive (lifting of the testis
alleviates the pain).

62. Treatment
• Bed rest
• Elevation and cooling of the testes
• Anti-inflammatory drugs such as Diclofenac
• For the sudden relieve of strong pain: nerve
block of the spermatic cord at the external
inguinal ring with a long-acting local anesthetic
such as bupivacaine
• Antibiotic

63. Surgical treatment
• Epididymectomy: indicated in epididymitis refractory to antibiotic treatment or
chronic epididymitis. Local complications are frequent (recurrent infections,
impaired wound healing, loss of testicle)
• Orchiectomy: indicated in epididymo-orchitis, abscess formation and in
epididymitis refractory to antibiotic treatment as an alternative to
epididymectomy.

64. Orchitis
• Orchitis is the inflammation of the testicles. It can be caused by
either bacterial or viral infection.
• Both testicles may be affected by orchitis at the same time.
However, symptoms are restricted to just one testicle in most men.
• Testicular inflammation of this kind is often associated with the
mumps virus.

66. Risk factor
• Mumps
• history of STDs
• partner who has a sexually transmitted infection
• Congenital urinary tract abnormalities can also increase your risk of
orchitis.

68. Features
• Pain in the testicles and groin is the
primary symptom of orchitis.
• tenderness in the scrotum
• painful urination
• painful ejaculation
• swollen scrotum
• blood in the semen
• abnormal discharge
• enlarged prostate
• swollen lymph nodes in the groin
• fever

69. Treatment
• Asymptomatic
• Antibiotic

70. Skin problems
Infections
Scrotal hernia
Testicular inflammation & tumor

71. Scrotal hernia

73. Aetiology
• An indirect inguinal hernia is most likely
the cause.
• Indirect inguinal hernia, protrudes through
the inguinal ring and is ultimately the result
of the failure of embryonic closure of the
internal inguinal ring after the testicle
passes through it.

75. Skin problems
Infections
Scrotal hernia
Testicular inflammation & tumor

76. Testicular tumour

77. • Testicular cancer often begins with changes in the germ cells, or the cells in the testicles that
produce sperm.
• Testicular cancer is sometimes referred to as a germ cell tumor.
• Testicular cancer is the most commonly diagnosed cancer in men ages 15 to 35, but it can occur at
any age.
• It is also one of the most treatable cancers, even if it has spread to other part
• There are two main types of testicular cancer:
• Seminomas
• Seminomas are slow-growing testicular cancers. They are usually confined to the testes,
but the lymph nodes may also be involved
• nonseminomas.
• Nonseminomas are more common form of testicular cancer. This type is faster growing
and may spread to other parts of the body.
• Teratomas
• Originating from the totipotent cells. The tumour varies in size but maintains the shape
of testes and often feels slightly irregular.

79. Risk factor
• family history of the disease
• Personal history
• abnormal testicular development
• Caucasian descent
• undescended testicle
• Age

81. Presentation
• Painless lump/swelling of a testicle
• lower abdominal or back pain
• development of breast tissue
• Pain or discomfort, with or without swelling, in a testicle or the scrotum
• Change in the way a testicle feels or a feeling of heaviness in the scrotum
• Sudden build-up of fluid in the scrotum
• Swelling of one or both legs
• shortness of breath

82. diagnosis
• Ultrasound
• Orchiectomy/surgical pathology tests
• Blood tests/tumor markers.
• Alpha-fetoprotein (AFP)
• Beta human chorionic gonadotropin (beta-hCG)
• Lactate dehydrogenase (LDH)
• Placental alkaline phosphatase (PLAP)
• CT scan
• MRI scan
• PET scan

84. Treatment
• Surgery is used to remove one or both testicles and some surrounding lymph nodes to both
stage and treat the cancer.
• Radiation therapy
• Chemotherapy
• Observation, or "watchful waiting," may be an option if the cancer is in an early stage and
there are no symptoms.
• In very advanced cases of testicular cancer, high-dose chemotherapy may be administered,
followed by a stem cell transplant. Once the chemotherapy has destroyed the cancer cells, the
stem cells are administered to the patient, and these cells develop into healthy blood cells.

85. prognosis
• Seminoma:
• 90-95% survive 5 years
• Teratoma:
• depend on the histological type and varies between 60-90 % 5 year survival

86. Thank you