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EXAMINATION OF SCROTAL SWELLING

History :
Determine the duration, mode of onset and progress.
(Swelling following trauma is a haematocele – Swelling developed into its full size and
remain stationary for long time.
Hydrocele – (Collection of fluid in the tunica vaginalis started a small swelling without pain
or with pain and slowly increases in size over a time.
History of recurrent attaches of pain and fever indicates filarial infection of the testis
causing secondary hydrocele.
Local Examination :
Inspection – Patient is in standing position
1. Number, shape, size, site, extent,
2. Surface, skin over the swelling, colour of the swelling, borders, surrounding area
3. Visible pulsations, visible cough impulse
Palpation – Localised temperature, tenderness
Unable to get above the swelling
Inspective findings are confirmed
Consistency (Soft, fluctuation positive, transillumination positive)
Testis is palpable on the posterior part of the swelling.
Size – 5 cm vertically, 4 cm horizontally, surface – smooth, non-tender
Examination of the opposite testis – Size 5 cm vertically, 4 cm horizontally, 3
cm in thickness, surface- smooth, non-tender.
Epidydimis is normal in size and not tender
Cord is not thickened
Inguinal lymph nodes on both sides are not palpable.
CASE SHEET :
A 27 Years male patient named Ramanarao came from Visakhapatnam, occupation
Labour with a complaint of swelling on left or right side of scrotum from 1 year duration.
Pain --- one month duration.
History of present complaint :
Patient noticed enlargement of the right side of the testis which gradually increasing
in size and attained the present size.
No h/o trauma, no history of decreasing in the size of the swelling.
No h/o disappearance of the swelling on lying down position, no h/o of recent
rapidity of growth.
Patient compliance of dragging type of pain, intermittent in nature which is more on
standing position relieved on lying down position, radiates to lumbar region.
Bowels and micturation normal.
Past history : Note any medical or surgical history that require physician or surgeon
attendance.
Personal history : Marital history, children
Smoking, alcohol.
Any chronic diseases like diabetes, hypertension, tuberculosis etc.,
Family history : Any person having similar complaint
Any chronic illness in the family
Physical examination :
Built and nourishment, anaemia, jaundice, oral cavity
Pulse – 72/min, regular volume and tension normal, vessel wall – (below 45 years –
not thickened, above 45 years- thickened
Respiratory rate -18/min. regular, abdomino thoracic in type.
B.P. – 120/80 mm of Hg
Systemic examination
CVS – 1st and 2nd heart sounds heard. No advantious sounds
CNS - Patient conscious, answering questions. Pupils – Normal size and normally
reacting to light.
No neurological deficit – Gait is normal
Local examination of scrotum-
On inspection :
A single vertically placed oval swelling measuring vertically 15 cm, horizontally 10 cm,
present on the right side of the scrotum, extending from the root of the scrotum to its
bottom.
Surface is uneven (even) skin over the swelling healthy, colour is normal, lateral border and
inferior border are well defined.
Medial and superior borders are ill-defined.
Surrounding area is normal.
No visible pulsations, no visible cough impulses.
Penis is deviated to left side.
Median raphy is deviated to left side.
On palpation : No local raise of temperature, not tender.
Inspectory findings size, shape, site, extent are confirmed.
I am able to get above the swelling (It indicates the swelling belongs to scrotum and testis)
Surface is smooth, all borders are well defined.
Consistency is soft, fluctuation - positive, transillumination - positive.
Reducibility : Swelling is not reducible (Congenital hydrocele and vericocele are reducible).
Palpable impulse : No impulse palpable on cough (Hold the root of the scrotum with the
thumb and finger and ask the patient to cough. In case of congenital hydrocele, vericocele
and lymph varix impulse may be felt like a thrill)
Examination of the testis – Note its position, testicular sensation (which is a sickening pain
felt by the patient when gentile pressure is applied on the testis) Size, shape, surface,
consistency mobility.
Testis is palpable on the posterior part of the swelling.
Size is vertically 5 cms, horizontally 4cms, surface – smooth and non-tender consistency is
uniformly soft.
Examination of the opposite scrotum : Testis is normal in size and shape and non-tender.
Epidydimis is palpable on the upper pole of testis and is non-tender. (In case of primary
hydrocele testis is rarely felt in a tense vaginal hydrocele owing to the depth of the fluid
which surrounds the testis on its anterior, lateral and medial aspects.
The epididymis lying on its posterior aspect. In case of secondary hydrocele the testis and
epididymis may be palpable as the quantity of fluid is small and is with less tension.
Cord is normal in size and non-tender.
Bilateral inguinal lymph nodes are not palpable.
Abdomen normal.
Conclusion : Scrotal swelling as I am able to get above the swelling.
Soft in consistency, fluctuation - positive, transillumination – positive
Provisional diagnosis : Hydrocele of the tunica vaginalis of right testis.
Causes of scrotal swelling :
1. Skin – Boil, erysipelas, soft sore, hard chancre, sebaceous cyst, wart, papilloma and
epithelioma.
2. Subcutaneous Tissue – cellulitis, lymph scrotum, elephantiasis(filarial), extravasation
of urine, generalized oedema of nephritis.
3. Tunica Vaginalis -Vaginal hydrocele, haemotocele, pyocele or suppurated hydrocele,
chylocele and secondary hydrocele.
Other types of hydrocele, such as congenital and infantile hydrocele,
hydrocele of the cord, hydrocele of the hernia sac, give rise to inguinoscrotal,
inguinal or scrotal swellings according to their extension.
4. Testis –Torsion, hernia testis, acute orchitis syphilitic orchitis.
5. New growths, usually malignant – teratoma and seminoma.
6. Epididymis – Acute epididymitis (gonococcal, B. coli, postprostatectomy), subacute
epididymo-orchitis (filarial),
7. Chronic epididymitis(tuberculous), cyst of the epididymis and spermatocele.
8. Spermatic cord- torsion, varicocele and lymphangiectasis ( or lymph varix).
9. Urethra – Periurethral abscess and extravasation of urine.
10. Pubic Bone –inflammatory and other pathological conditions.
Hydrocele of the tunica vaginalis or Viginal hydrocele :
It is caused by collection of fluid in the tunical vaginalis of the testis which is yellow in colour
with specific gravity varies from 1015 to 1025 contain inorganic salts, and about 6% of
albumin (fibrinogen) cholesterol.
Diagnosed by (a) Getting of the swelling (b) soft or cystic inconsistency (c) fluctuation
positive (d) transillumination.
If the sac is thickened translucency may be difficult to obtain in the –
Usually the testis can not be felt separate from the swelling since it is surrounded by fluid all
round except posteriorly.
Pyocele : General signs and local signs of acute inflammation are present.
(Localised temperature, tenderness, edema of the skin, erythematous.)
Chylocele : Collection of chylous fluid in the tunica vaganalis, the fluid may contain micro-
filaria.
The condition is suspected when in addition to the clinical picture of hydrocele with history
of periodic fever and translucency testis negative.
Diagnosis is confirmed by aspirating milky fluid.
Obstruction of lymph vessels leads to dilatation and when the tension is high they rupture.
Chyle or lymph escapes depending upon the site of obstruction.
The chyle may come out with urine (chyluria) or collect in body cavities like tunical vaginalis
(chylocele), peritoneal cavity (chylous ascitis) pleural cavity (chylothorax).
Secondary hydrocele it is always associate with all cases of acute or subacute epididymo-
orchitis and sythilitic orchitis, 30% cases of tuberculous epididymitis and 50% cases of new
growths (Malignancy)
The amount of fluid is usually small and the swelling is lax, so that it is easy to palpate the
testis.
Complications of hydrocele:
1. Rupture
2. Trauma, giving rise to haematocele
3. Infection leading to pyocele
4. Hernia of the hydrocele sac.
5. Calcification of the sac wall
6. Atropy of the testis in a longstanding tense hydrocele.
Causes of Inguinoscrotal swelling
1. Inguinal hernia is by far the commonestcause of an inguinoscrotal swelling.
2. Hydrocele – The different forms that may give rise to an inguinoscrotal swelling are :
(i) Congenital hydrocele (commonly associated with tuberculous ascites) which may
either be complete or incomplete, i.e., funicular (ii) Infantile hydrocele; (iii)
Hydrocele. Complete congenital hydrocele : In this condition the whole of the
funicular process is patent throughout but the communication with the abdomen is
too narrow to admit the bowel or omentum.
The swelling appears on prolonged standing and gradually disappear during sleep due to the
fluid will trickle to and fro through this narrow opening at the level of internal ring.
Funicular hydrocele : This incomplete congenital, the tunical process being shut off from the
tunica vaginalis just above it. (The sac will empty during sleeping and appears on prolonged
standing like congenital hydrocele)
Infantile hydrocele : It does not necessarily occurring in infants but occur at any age.
In this condition the finical process is closed at the internal ring but patient upto the bottom
of the testis with tunica vaginalis.
The swelling looks like hydrocele but extent to the inguinal region like hernia.
It is not reducible on lying down position or by compression because there is no
communication with the peritoneal cavity.
Hydrocele of the cord : In this condition a portion of the tunical process persist, the upper
part and lower part is completely obliterated.
The central part which is patent becomes is tended fluid giving rise to inguinal, inguinal
scrotal or scrotal swelling depending on which part of the tunical process is patent.
The swelling is oval, cystic, fluctuant and translucent.
It is free from the testis and can be pull down sufficiently to get above the swelling when
traction is obtained to the testis. (Traction test)
In connection with the spermatic cord – (i) Varicocele(ii) Funiculitis (iii) Lymph varix
or lymphangiectasis or diffuse hydrocele of the cord (iv) Diffuse lipoma of the cord(v)
Haematocele of the cord (vi) Inflammatory thickening of the cord extending upwards from
the testis and epididymis (vii) Malignant extension from the testis.
Varicocele is a condition of tortuosity of the veins of pampiniform plexus.
It usually affects left side because the left spermatic vein is longer than the right, enter the
left renal vein at a right angle and is crossed by the colon which may compress when loaded.
Patient have aching or dragging pain after prolonged standing.
It gives impulse on coughing like fluid thrill.
The swelling appears when patients stands and disappears when he lies down.
Rapid onset of varicocele may suggest a carcinoma of the kidney.
Finiculitis (inflammation of the cord) – Commonly caused by filariasis.
Diffuse lipoma of the cord – Swelling is irreducible and having no cough impulse.
Testis :
A) Undescended testis with hernia gives rise to either an inguinal or inguinal scrotal
swelling.
The condition is recognized by the absence of testis in the scrotum along with features of
hernia.
3. In connection with the testis –(i) undescended testis associated with a hernia (ii)
Torsion of the testis.
Causes of inguino scrotal swellings
1. Inguinal hernia
2. Hydrocele
a. Congenital hydrocele
b. Infantile hydrocele
c. Encysted hydrocele of the cord
3. In connection with spermatic cord
a. Varicocele
b. Funiculitis
c. Lymphvarix
d. Diffuse lipoma of the cord
e. Inflammatory thickening of the cord
f. Malignant extension of the testis
4. In connection with the testis
a. Undescended testis associated with hernia
b. Torsion of the testis
c. Causes of inguinal (groin swellings) :
d. (A) Inguinal swellings above the inguinal ligament –
e. (i) Inguinal hernia-
f. (a) Bubonocele (b) Direct hernia (c) Interstitial hernia
g. (ii) Enlarged lymph nodes (external iliac and inguinal)
h. (iii) Abscess-acute or chronic
i. (iv) Encysted hydrocele of the cord
j. (v) Hydrocele of the hernia sac
k. (vi) undesceded, ectopic and retractile testis
l. (vii) Aneurysm of the external iliac artery.
m. (B) Below the inguinal ligament –
n. (i) Femoral hernia
o. (ii) Sephenavarix (Dilatation and tortuity of sephano femoral junction)
p. (iii) Psoas abscess