1) A 30-year-old man presented with right testicular swelling without pain or urinary symptoms. Examination found an enlarged right testis without tenderness or transillumination. 2) The document provides guidance on evaluating scrotal swellings, including asking about onset/progression, site, associated symptoms, and examination of the testis and epididymis. 3) Common causes of scrotal swelling discussed are hydrocele, epididymal cyst, and varicocele. Hydrocele is fluid between the testis layers, epididymal cyst is a fluid sac in the epididymis, and varicocele is dilated spermatic veins.

1. Testicular swelling
Mohammed AlHinai

2. • A 30 yr. old young man was referred to urology OPD for evaluation of right
scrotal mass, which was noticed one week back. There was no h/o trauma,
fever or urinary symptoms. Clinical examination showed enlarged right testis
without any fluctuation or transillumination. Epididymis and cord were found
to be normal
Differential diagnosis

3. Approach to patient with scrotal swelling
Ask about swelling as general :
• Onset and progression
• Site if Unilateral or bilateral
• Associated symptoms like pain, itch, bleeding, discharge, skin change.
• predisposing factors like trauma, insect bite, infection.
• Systemic symptoms like fever, weight loss, malaise.
Other history including marital history, sexual activity and family history.

4. Examination of testis :
During the examination,
you need to answer some
questions

5. answer to these four questions:
1- can you get above the swelling? 2- can you identify the testis and epididymis?
3- is the swelling translucent? 4- is the swelling tender?

6. Hydrocele
• Hydrocele is a collection of peritoneal fluid between the parietal
and visceral layers of the tunica vaginalis which arise from an
imbalance of secretion and reabsorption of fluid from the tunica
vaginalis.
• Presentation :
- small, soft collections that still allow palpation of the scrotal
contents to massive, tense collections of several liters that make
examination impossible.
- Pain in case of large hydrocele.
- Hydrocele fluid in the scrotal sac transilluminates well.
• A 45 yrs old male patient with left sided scrotal swelling of one years duration. It is a progressively
increasing painless swelling. On examination the right side of the scrotum shows a swelling of 9 * 7
cm size which is confined to the scrotum. The surface of the swelling is smooth and borders are
well-defined. There is no local rise of temperature. The swelling is fluctuant and transilluminant. It
is not reducible. There is no cough impulse. The right testis is not felt separately.
Classify according to
underlying etiology

7. Feature Primary hydrocele Secondary hydrocele
Cause Idiopathic Trauma , infection ,
malignancy
Rate of development Slow Rapid
Size Large Small
Appearance Tense Lax
Testis Not palpable May be palpable
Primary abnormality Defective absorption Excessive secretion
Fluid Clear , amber color May be clear, purulent ,
blood stained
Diagnosis
• Clinically by history and physical examination
• Scrotal US to confirm the diagnosis
Management :
• Don’t require intervention if asymptomatic.
• If symptomatic, surgical procedure by excision of the
hydrocele sac.
• Simple aspiration might be done but risk for recurrence.
Scrotal US show fluid
collection around testis

8. epididymal cyst
• An epididymal cyst is a fluid filled sac in the head of the
epididymis.
• An epididymal cyst that is larger than 2 cm and filled with sperm
is called a spermatocele.
• Presentation :
- Usually asymptomatic.
- Present as painless cyst behind the testis.
- Fluctuant and transilluminant mass.
• A 40 yrs old man was seen in the urology OPD for left scrotal mass. Patient had first noticed the
swelling 6 months back while taking bath. There was no change in the size of swelling since then.
Clinical examination showed fluctuant and transilluminant mass behind the left testis which was
non tender. Left testis is palpable. Right testis and cord were also normal
Well-circumscribed anechoic
lesion in the epididymal head
that does not demonstrate
internal vascularity
• Diagnosed clinically but might need scrotal US to confirm.
• If asymptomatic, no intervention require.
• If symptomatic, excise the cyst.
• Avoid needle aspiration as risk of recurrence and infection.

9. Varicocele
• Varicocele is dilatation of the pampiniform plexus of spermatic
veins caused by increased intravascular pressure which more in
left vein as The left internal spermatic (gonadal) vein is one of
the longest veins in the body, entering the left renal vein at a
perpendicular angle.
• Presentation :
- Asymptomatic in early stage.
- Dull, aching, usually left-sided scrotal pain, typically noticeable
when standing and relieved by recumbency.
- Atrophy of left testicle and decreased fertility as induction of
apoptosis by increased scrotal temperature.
• 50 yrs old male present with scrotal swelling for 1 month. in examination, the swelling more
obvious during valsala maneuver.

10. • Diagnosed clinically but might need scrotal US to confirm if small
size.
• Require semen analysis to assess the fertility.
• If normal testicular size and semen parameters, no intervention
require and monitoring with semen analysis every one to two yrs.
• If there is evidence of testicular atrophy or abnormal semen
parameters, immediate intervention to prevent further damage by :
- Surgical ligation (prefer) by ligating the gonadal vein so that
retrograde blood flow can no longer reach the plexus of veins in the
scrotum.
- percutaneous venous embolization but there is risk of embolization
coils migrating to the lungs and other organs and higher overall
recurrence rates.
Scrotal US show Dilatation
of pampiniform plexus veins
with serpentine appearance
percutaneous venous embolization