Seminar presentation made by students from Widad University College.

1. Date of presentation:
27th Dec 2019

2. ADD A FOOTER 2
Differential diagnosis
Clinical feature
History
Physical examination
Investigation
Management
Complication
Case Scenario

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4. DIFFERENTIAL DIAGNOSIS OF
INGUINOSCROTAL SWELLING
BENIGN
NON-
INFECTIOUS
HERNIA
HYDROCELE
EPIDIDYMAL
CYST
VARICOCELE
INFECTIOUS
EPIDIDYMOORCHITI
S
LYMPHADENITIS
PSOAS
ABSCESS
MALIGNANT
TESTICULAR
TUMOR

6. INGUINAL
SWELLING
REDUCIBLE
ABOVE
INGUNAL
LIGAMENT
INGUINAL
HERNIA
BELOW
INGUINAL
LIGAMENT
FEMORAL
HERNIA
IRREDUCIBLE
TRANSILLUMINATING
HYDROCELE OF
CORD
NON
TRANSILLUMINATING
PSOAS ABSCESS
LYMPHADENITITS
UNDESCENDED
TESTIS
SAPHENOUS
VARIX

7. HESSELBACH’S TRIANGLE
Medially: Lateral border of rectus
muscle
Laterally: Inferior epigastric vessels
Inferiorly: Inguinal ligament
Contains a depression referred
to as the medial inguinal fossa,
which direct inguinal hernia
protrude through the abdominal
wall

8. Deep Inguinal ring = Above the midpoint of inguinal
ligament
Superficial Inguinal ring = Superior the pubic
tubercle

10. Lies in the medial border of femoral sheath.
Borders:
• Anterosuperiorly: Inguinal ligament
• Posteriorly: Pectineal ligament (anterior to
superior pubic ramus)
• Medially: Lacunar ligament
• Laterally: Femoral vein
The entrance of femoral canal is the femoral
ring
(About 1.2 cm lateral to pubic tubercle)
= Femoral hernia

12. SCROTAL
SWELLING
CANNOT GET
ABOVE
HERNIA
INFANTILE
HYDROCEL
E
CAN GET
ABOVE
TESTIS NOT PALPATED
SEPARATELY FROM
EPIDIDYMIS
NON
TRANSILLUMINATI
NG
TENDER
TORSION
EPIDIDYMO
-ORCHITIS
NON TENDER
VARICOCELE
TUMOR
TRANSILLUMINATI
NG
HYDROCEL
E
EPIDIDYMA
L CYST
TESTIS PALPATED
SEPARATELY FROM
EPIDIDYMIS
NON
TRANSILLUMINATIN
G
TENDER
EPIDIDYMO
-ORCHITIS
NON TENDER
TUMOR
TB
EPIDIDYMIS
TRANSILLUMINATIN
G
CYST OF
ORCHITIS

16. Processus vaginalis is an embryonic
development of outpouching of the
peritoneum.
Present from around 12th week of
gestation.
In males: It precedes the testis in their
descent down within the gubernaculum,
and closes.

18. 2 groups:
1. Superficial inguinal lymph nodes
I. Horizontal
• Along lower border of inguinal
ligament
II. Vertical
• Along great saphenous vein
2. Deep inguinal lymph nodes
• Along medial to femoral vein under
cribriform fascia

20. • Types of hernia in inguinal region:
1. Indirect inguinal hernia
• Lateral to inferior epigastric
vessels
• Pass through inguinal canal
2. Direct inguinal hernia
• Medial to inferior epigastric
vessels
• Bulging from the posterior wall
of inguinal canal
3. Femoral hernia
• Pass through femoral ring

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DEMOGRAPHIC DATA
• Male
• Post-puberty age
• Teratoma 20-30y/o, Seminoma 30-40y/o
• Older men with retroperitoneal disease: RCC
HOPI
• Duration of swelling
• Onset of swelling (sudden or gradual)
• Presence of pain
• Increased intra-abdominal pressure:
chronic cough, straining, chronic constipation
• Fever, chills and malaise
• Back pain (if para-aortic nodes infiltrated with metastases)
• Poor hygiene
• Hx of trauma
PAST MEDICAL HX
• Hx malignancy in contralateral testis
• Symptoms of UTI or STD
• Cryptorchidism
• HIV infection
• Gonadal Dysgenesis
• Torsion
• Orchitis
• Infertility
• Klinefelter’s Syndrome
• Infantile Hernia
• Testicular Microlithiasis
• Immunocompromised e.g Diabetics
• Source of infection: urethral stone / stricture /
fistulae/ruptured appendicitis, colonic CA, diverticulitis,
peri-rectal abscess
PAST SURGICAL HX
• Inguinal hernia repair
• Vasectomy
• Orchidopexy
• Appendicectomy
FAMILY HX
• Malignancy in family
SOCIAL HX
• Smoking
• Alcoholics
• Occupation (heavylifting)
• BMI (obesity)  IN GENERAL EXAMINATION

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27. ADD A FOOTER 27
HYDROCELE VARICOCELE EPIDIDYMA
L CYST
HERNIA TESTICULAR
TUMOR
EPIDIDYMO
ORCHITIS
SCROTAL
ABSCESS
FOURNIER
GANGRENE
Characteristic Soft
Smooth
Fluctuant
Bag of worms Soft
Smooth
Nodule
Fluctuant
Soft
Smooth
Hard Nodular
Irregular
Erythematou
s overlying
skin
Erythematous
Fluctuant
Warm
Blackish
discolouratio
n
Tenderness No No No No; yes if
strangulated
No Yes Yes Yes
Can get above Can Can Can Cannot Can Can Can Can
Relationship to
testis
Continuous Separate Separate Continuous Continuous Separate Separate Separate
Reducible No No No Yes No No No No
Cough impulse -ve -ve -ve +ve -ve -ve -ve -ve
Transilluminatio
n
+ve -ve +ve -ve -ve -ve -ve -ve
Extra Unilateral or
bilateral
Compressible
Disappear on
supine
More common
on left
Often
multiple in
the head of
epididymis
Valsava
maneuver
Febrile
Pain relieved
on elevation
of the testis
(Prehn’s
sign)
Symptoms of
infection
Presence of
crepitus
Symptoms of
infection

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Hydrocele  Abnormal collection of peritoneal fluid between the parietal and visceral layers of
the tunica vaginalis enveloping the testis.
 Can form along the spermatic cord and is a differential for lumps in the groin
 Asymptomatic fluid collection around the testicles (processus vaginalis)
Varicocele  Abnormal dilatation of the pampiniform venous plexus within the spermatic cord.
 90% of varicoceles are found on the left side as the spermatic vein drains directly
into the left renal vein
 Dull aching, left scrotal pain
 Testicular atrophy – compare both sides
 Decreased fertility
Epididymal
cysts (spermato
celes)
 Benign fluid-filled sacs arising from the epididymis.
 Often multiple in the head of epididymis
Epididymo-
orchitis
 Inflammation of the epididymis & testis
 Pain may be relieved on elevation of the testis (Prehn’s sign).
Scrotal abscess  Scrotal fluctuant & may be palpable
Fournier
Gangrene
 Necrotizing fasciitis of the perineum and genital region frequently due to a
synergistic polymicrobial infection

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Inguinal Hernia  All inguinal hernia should be assessed for strangulation or obstruction.
Indirect Hernia Direct Hernia
Via deep inguinal ring along the inguinal canal Via transversalis fascia (Hesselbach’s triangle)
Patent/reopen processus vaginalis
Enter scrotum
Weak abdominal wall/muscle
Does not enter scrotum
Narrow neck more liable to strangulate Broad neck
impulse on finger Invagination Test Impulse on pulp
cough impulse on index finger Zieman’s Test Cough impulse on middle finger
do not bulge out Deep Ring Occlusion Test Bulge out

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Invagination test
(supine position)
Invert the scrotum with index/little finger
Enter inguinal canal along the course of the cord up to spfcl ing. ring
Ask pt to cough
Impulse palpable:
On tip: indirect hernia
On pulp: direct hernia
Zieman’s test
(supine position)
Index finger: deep inguinal ring (indirect hernia)
Middle finger: superficial inguinal ring (direct hernia)
Ring finger: saphenous opening(femoral hernia)
Ask pt to cough/do vasalva maneuver
Ring occlusion test Ask pt to reduce hernia (in supine)
Occlude the deep inguinal ring (mid-inguinal point) with thumb
Hold the thumb in position & ask pt to stand
Ask pt to cough
+ve: no bulging of hernia (indirect hernia)
-ve: bulging (direct hernia)
Other Percussion: dull(omentum) resonance(enterocele)
Auscultation: bowel sound

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hydrocele
varicocele
Scrotal abscess
epididymoorchitis
Testicular tumor

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Epididymal cystFournier gangrene
Testicular torsion

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35. BLOOD / URINE IX
• Full blood count (leukocytosis,
platelet, Hb level)
• Urine specimen for culture &
sensitivity (presence of
organism)
• Nucleic acid amplification
testing (NAAT) (from urine
specimen or urethral swab;
presence of gonococcal /
chlamydial)
• Tumor marker (AFP rise in 50-
70% NSGCT, hCG rise in 40-
60% NSGCT & 30% seminoma)
IMAGING IX
• Ultrasound – nature of the
swelling, testis involvement in
hydrocele; dilated veins in
varicocoele, epididymal cyst,
thickened epididymis in
epididymoorchitis
• Abdominal X-ray (small bowel
obstruction in femoral hernia)
• Chest X-ray (classical cannon
ball metastases)
• CT chest, abdomen & pelvis (to
detect metastases & respond to
treatment)

36. Hydrocoele - anechoic
Well defined anechoic lesion with posterior
enhancement Hypoechoic in testicular tumor
Varicocoele

38. Stage I – tumour is confined to the testis and epididymis
Stage II – nodal disease is present but is confined to nodes
below the diaphragm
Stage III – nodes are present above the diaphragm
Stage IV – non lymphatic metastatic disease (most typically
within the lungs)

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40. INGUINAL HERNIA
• Herniotomy
• Open suture repair
• Open flat mesh repair
• Open plug / device / complex mesh repair
• Open preperitoneal repair
• Laparoscopic inguinal hernia repair
• Emergency inguinal hernia surgery
FEMORAL HERNIA
• Low approach (Lockwood)
• The inguinal approach (Lotheissen)
• High approach (McEVEDY)
• Laparoscopic approach

41. • Congenital – herniotomy
• 3 main surgical technique :
- Lord’s Plication (a series of uninterrupted absorbable sutures is used to
plicate the redundant tunica vaginalis, the tunica bunches at its attachement
to the testis)
- Eversion (the sac is opened and everted behind the testis, with placement of
the testis in a pouch prepared by dissection in the fascial planes of the
scrotum)(Jaboulay’s procedure)
- Excision (unless great care is taken to stop the bleeding after excision of the
wall, haemorrhage fro the cut edge is liable to cause a large scrotal
haematoma. This approach is not recommended)

42. EPIDIDYMAL CYST
• Excision (single large cyst; interfere with
the transportation of sperm from the testis
on that side and young men should be
counselled regarding this)
• Partial or total epididymectomy (recurrent
or multilocular cyst)
VARICOCOELE
• Not indicated in asymptomatic varicocoele
• When discomfort is significant
- Percutaneous embolisation of the gonadal
veins
- Surgical ligation of the testicular vein
- Recurrence up to 20%

43. • Percutaneous CT-guided drainage
• Antibiotic therapy
- Primary : antistaphylococcal
- Secondary : broad spectrum antibiotic

44. - All patients should drink plenty of fluid
- Scrotal support and analgesia
- Antibiotic (at least 2 weeks in acute, 4-6 weeks in chronic)
• Oral Doxycycline 100-200 mg OD
- Drainage (if suppuration occurs)
- Epididymectomy or orchidectomy (may be considered if no resolution)

45. • Scrotal exploration and orchidectomy for suspected testicular tumor
• By staging & histological diagnosis (after orchidectomy)
- Stage I tumor
Seminoma : adjuvant radiotherapy for para aortic nodes, platinum-
based chemotherapy
NSGCT : BEP chemotherapy (bleomycin, etoposide, cis-platinum)
- Stage II-IV tumors
BEP chemotherapy for both seminoma NSGCT
Dissection of retroperitoneal lymph node

47. Hernia • Strangulated – blood supply is impaired
• Obstructed – irreducibility associated with
intestinal obstruction
Hydrocele • Rupture
• Infertility
• Calcification
• Hematocele (usually after aspiration)
Epididymal cyst • Rarely cause complication, but a twisting of
the cyst on its stalk (a torsion) can occur
Varicocele • Infertility

48. Psoas abscess • Sepsis
Lymphadenitis • Abscess formation
• Cellulitis
• Fistulas (seen in lymphadenitis that is due to
tuberculosis)
• Sepsis
Epididymo-orchitis • Scrotal abscess and pyocele
• Testicular infarction: Cord swelling can limit
testicular artery blood flow
• Fertility problems
• Testicular atrophy
• Cutaneous fistulization from rupture of an
abscess through the tunica vaginalis (seen
especially in tuberculosis)
• Recurrence, chronic epididymitis, and orchialgia

49. Testicular tumor Spreading to other organs:
1. Local spread: tunica vaginalis and along spermatic cord
2. Lymphatic spread: para-aortic nodes, mediastinal and
supraclavicular nodes
3. Blood-borne spread: lungs and liver
Prognosis:
Seminoma
Stage I, II, III  95% 5-year survival after orchidectomy,
chemo and radiotherapy
Stage IV  75% 5-year survival
Teratoma
Stage I, II  85% 5-year survival
Stage III, IV  60% 5-year survival

51. A 22 year old man presents with right scrotal mass for 2 months duration. He
noticed that enlarged scrotum because of being able to feel the heaviness.
1. What are the positive points in this case?
• Right scrotal swelling
• 2 months duration
• Feeling heaviness
2. What are the possible differential diagnosis?
• Right testicular tumor
• Hydrocele
• Hematocele
• Epididymo-orchitis
• Epididymal cyst
• Sarcoidosis
3. What further question to ask?
• Onset of scrotal swelling: Sudden onset occur in trauma and inflammatory cases meanwhile
gradual onset occur in tumor
• Associated symptoms:
• Pain: indicates inflammatory conditions like epididymitis
• Fever: for UTI and paraneoplastic syndrome
• Dysuria: can occur in patient with epididymo-orchitis
• Heaviness: usually seen in patient with hydrocele or tumor
• History of trauma to scrotum: hematoma and hematocele

52. On further questioning, he denied any pain, no history
of trauma to the scrotum, no urinary symptoms such as
frequency and hematuria, no other palpable swelling on
any part of the body. However, he had history of
undescended testis (cryptorchidism) when he was a
baby.
4. What is the likely diagnosis and give reason?
The likely diagnosis is right testicular tumor. This is because patient
with history of cryptorchidism has 10 times risk of developing
testicular tumor.

53. 5. Give proper explanation on how to do local examination of the
scrotum of this patient?
a) Before starting the examination:
• Approach the patient professionally. Explanation is necessary as the patient needs to be
undressed for proper exposure.
• Give reassurance that the procedure won’t cause discomfort and get verbal consent for
examination.
• Scrotal examination can be done in both standing and supine position.
• Examination should be started from normal side first.
b) Inspection:
• Examine all sides of the scrotum during inspection
• Note the enlarged scrotum of affected site
• Scrotal skin may appear normal in tumor cases
c) Palpation
• Lift the scrotum and properly inspect the posterior side. Gentleness is required
throughout examination and avoid excessive pressure that could cause deep aching
sensation.
• Rolling the scrotal skin softly between fingers of one or both hands.
• Individually examine each testicle between the fingers of the one hand for nodules,
masses or tenderness.
• Gently palpate the epididymis, spermatic cord and vas deferens between the thumb and
index finger close to the base of penis. This is termed as “can get above swelling”. The
tumor is usually inseparable from the testis. Hard, irregular, nodular lesion with absence
of testicular sensation.
• Take note that any swelling within the scrotum should be transilluminated for further
evaluation. Testicular tumor usually has negative transillumination test.

54. 6. List the appropriate investigations along with the
expected findings?
a) Scrotal ultrasound
• majority of the lesions appear as an interstitial hypoechoic lesion with
heterogenous density and irregular in shape
b) CT thorax, abdomen, pelvis
• To look for distant metastases
c) CT brain
• Required in advanced stage lesion
d) Chest X-ray
• Cannon ball metastases can be seen as pulmonary deposits
e) Tumor markers
• Not sensitive enough to confirm the diagnosis but can be used to monitor
for treatment response in follow up period. Examples include:
• βHCG: 30% of pure seminomas
• βHCG and αFP: 90% of non-seminomas

55. 7. How to treat this patient?
a) Surgery
• High inguinal orchidectomy
• If patient has enlarged retroperitoneal nodes, proceed with
retroperitoneal lymph node dissection
b) Post orchidectomy chemotherapy and radiotherapy
(depending on histological type)
c) Psychology
• Discussion regarding testicular prosthesis
• Counselling and screening for male siblings in family

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Manipal Manual Of Surgery, 2th edition, K. Rajagopal Shenoy
Doctrina Perpetua, Guides on Clinical Surgery 2nd edition, 2018
Excellence In Clinical Case Presentation In Surgery And Paediatrics 1st Edition 2012

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