inguinoscrotal swellings

1. Inguinoscrotal swellings
Dr Thana Ram Patel
Assistant Professor
Department of General Surgery
Dr SN medical college , Jodhpur

2. Surgical anatomy

20. Inguinoscrotal swellings
• Causes
• Course
• manifestations

21. causes

23. course

28. manifestations

29. management
I. Diagnosis
• History
• Clinical exams
• Investigation
• Definition
• Differential diagnosis
• Evaluation (algorithm)
II. Intervention (treatment)

30. History

32. Clinical exams

38. investigations

42. Evaluation

47. interventions
• Treat disease

48. diseases
• Hernia
• Varicocele
• Hydrocele
• Epididymorchitis
• Testicular tumors

49. Inguinal hernia

61. Femoral hernia

64. hydrocele
• Types of Hydrocele
• Primary: Unknown etiology and on examination
the testis is not palpable separately.
• Secondary: Known etiology and testis is felt
separately
• Causes of Secondary Hydrocele:
• Infections: filaria, TB and syphilis
• Injuries: Trauma, post-herniorrhaphy
• Tumor: Malignancy

65. Variants of hydrocele
• Congenital hydrocele The processus vaginalis is present so there is direct
communicating of the tunica vaginalis with the pelvic cavity. The communicating
orifice at the deep inguinal ring is too small for the development of
• Funicular hydrocele Here the processus vaginalis remains patents up to top of the
testis where it is shut off from the tunica vaginalis
• Vaginal hydrocele (most common) There is abnormal accumulation of serous fluid
within the tunica vaginalis
• Bilocular hydrocele (Hydrocele en basic ) Here the hydrocele has two
intercommunicating sacs—one above and one below the neck of the scrotum.
Upper sac has no connection with the processus vaginalis and it is in fact the
herniated tunica vagina
• Infantile hydrocele The fluid collects within the tunica vaginalis and procesus
vaginalis which are continuous but the vaginalis is not communicating with the
peritoneal cavity
• Hydrocele of the canal of nuck This is female counterpart of the hydrocele of the
cord. It is seen in relation to the ground ligament
• Hydrocele of the cord Here the central portion of the processus vaginalis is
patient, but its upper and lower parts are obliterra

66. manifestations
• Hydrocele fluid is amber colored
• Contains—water, salt, albumin, fibrinogen,
cholesterol and tyrosine crystals
• Hydrocele fluid when comes in contact with
blood fibrinogen gets activated and clot
formation occurs resulting in hematoma
• Other cysts containing cholesterol crystals:
Branchial cysts, dentigerous cysts
• Hydrocele shows transillumination+

68. • swellings showing transillumination:
• Vaginal hydrocele
• Epididymal cyst
• Cystic hygroma
• Ranula
• Meningocele

69. • Surgeries Done for Hydrocele
• Congenital - herniotomy
• Lord’s plication for small and thin sac
• Partial excision and eversion of sac –
Jaboulay’s method

71. Varicocele - snapshot
• A 34-year-old man presents to the fertility clinic
for evaluation of infertility. His him and his wife
have been trying to have children for 2 years. His
wife was recently evaluated and found to be
normal and healthy. The patient denies any pain
in his testicular region. However, he reports
occasional feelings of heaviness in his scrotum.
On physical exam, his scrotum looks distended.
Valsalva maneuvers result in a "bag of worm"-like
finding upon palpation of the testicle

72. • Most common on left side
• Most common in young tall men

74. mainifesations
• Bag of worms like feel on palpation
• The veins empty in supine position (so examination is
always done in standing position)
• Infertility: Varicocele increases the temperature in the
scrotum and this decreases spermatogenesis .
• Varicocele may be secondary to renal cell carcinoma of
the left kidney. The growth from renal cell carcinoma
blocks the renal vein by venous permeation. So sudden
onset of varicocele (left side) in middle aged man should
arouse suspicion of a renal cell carcinoma of the left side.
• In renal cell cancer, the varicocele does not decompress in
the supine position

75. treatment
• Varicocele testis is treated by ligating the
pampiniform plexus of veins by any of the
three following approaches:
• Retroperitioneal (Palomo) approach: (open or
laparoscopic) - Very commonly done by Lap
surgeons (Palomo Operation)
• Inguinal approach (Invanissevich approach)
• Transcrotal approach

76. Epididymal cyst
• Congenital and derived from embryonic remnant
around the epididymis
• May be due to cystic degeneration of
1. Müllerian duct remnant: appendix of testis
(sessile hydatid of Morgagni)
2. Wolffian duct remnants:
2a. ƒ
Paradidymis or organ of giraldes
2b. ƒ
Appendix of epididymis (pedunculated hydatid
of morgagni)
3. Vas aberrans of Haller

77. • Filled with clear crystal fluid
• Multilocular cysts and tense cyst
• Occur in middle age
• Often bilateral
• Cysts are situated behind testis
• Fluctuation is difficult to elicit and
transillumination is Positive Chinese Lantern
Appearance on transillumination

79. spermatocele
• Acquired condition - Due to retention of
portion of sperm conducting duct of
epididymis

80. • Filled with fluid of barley water color and contains
spermatozoa
• Unilocular cyst and soft cyst
• Any age
• Unilateral
• Swelling is located at head of epididymis , above and
behind the body of testis. The testis can be felt
separately from the swelling. Occasionally the swelling
may enlarge and appear as three testicle
• Fluctuation test is positive but difficult to elicit
Transillumination is negative

81. Acute Epididymo orchitis
• Chlamydia - Most common infective organism in
sexually active young male:
• E. coli - Most common infective agent in children,
older men and homosexuals
• Acute epididymitis and acute epididymo orchitis
are inflammation of the epididymis and testis due
to infective pathology
• Infection reaches the epididymis through the vas
from urethra. Sometimes it may be blood-borne

82. manifestations
• Fever, painful, swollen, red, tender scrotum
• The epididymis and the testis are both swollen
• The acute painful condition has to be differentiated
from torsion of testis
• Pyuria is associated with epididymo-orchitis, not with
torsion of testis
• Treatment
• Antibiotics
• Rest
• Lots of fluid

83. Tuberculosis of testis
• The disease first effects the epididymis while
causing orchitis.
• The body of testis may remain uninvolved for
years, but the
• contralateral epididymis often becomes diseased
• Treatment is antituberculosis treatment (ATT)
• If this does not resolve, epididymectomy is
indicated.
• Note: Syphilis will not affect the epididymis
while causing orchitis.

84. UNDESCENDED TESTIS
• Location of testis in Fetal life:
• In lumbar region: 2nd month IU life
• In iliac fossa: 3rd month IU life
• At the deep ring: Till 7th month
• Traverses canal: In the 7th month
• At superficial inguinal ring: 8th month
• Scrotum: 9th month

85. • TESTIS
• Complications of incomplete descent
• T—Torsion of testis
• E—Epididymo-orchitis
• S—Sterility – if bilateral
• T—Trauma
• I—Indirect hernia
• S—Seminoma

86. • Approximately 70–77% of cryptorchid testis will
spontaneously descend, usually by 3 months of
age
• More common in preterm, small for gestational
age, low birthweight (LBW) and twin neonates
• More common on right side
• Secondary sexual characteristics are normal
• Gold standard investigation to detect UDT:
Diagnostic laparoscopy

87. treatment
• “Definitive treatment of the undescended testis should occur before 1
year of age”
• Subdartos pouch formation: Dissect between the skin of scrotum and
dartos muscle and create a pouch and now keep the testis internally into
the pouch.
• Ladd and gross technique: Scrotal sac is enlarged by finger dissection and
testis is mobilized and left in the scrotum with a nonabsorbable suture
holding the testis through the scrotum to the medial side of thigh. (stitch
can be removed after 10–14 days)
• Ombredann’s technique: the mobilized testis is placed in opposite
scrotum sac by passing through the median septum.
• Keetley-Torek technique: He mobilized the testis and brought out the
testis out through the scrotum on to the medial aspect of thigh where he
created a pocket in the thigh between the skin and fascia lata and left the
testis inside it. Margins of scrotal skin and thigh incisions are
approximated. A second surgery is performed after 3–6 months and we
bring the testis into scrotum

88. Ectopic testis
• Ectopic testis
• Lock Wood Theory
• Gubernaculum has 5 tails:
• •• Scrotal tail: Main one
• •• Inguinal tail: Attached in front of the inguinal canal**
• •• Perineal tail: Attached to perineum
• •• Pubic tail: Attached to pubic tubercle
• •• Femoral tail: Attached to saphenous opening.
• •• Superficial inguinal pouch: Most common site of ectopic
• testis due to pull of inguinal tail
• •• The testis lies lateral to superficial ring between external
• oblique aponeurosis and fascia scarpa**

89. Torsion testis
• Most common in adolescent (10–25 years)
• Sudden onset of Pain in the testis.
• Preceded by vigorous activities just before
(Example sexual activity)
• One important predisposing factor is “Bell
Clapper deformity”
• Testicle lacks normal attachments and hangs
horizontally.
• Typically bilateral

90. • Important differential diagnosis: Epidydimo-orchitis
• Tests to Differentiate
• Prehns sign: On elevation of testis by palm
• Pain increases: In torsion
• Pain decreases: In epidydimo-orchitis
• Angel’s sign: It is a sign on the normal side (unaffected side).
• Opposite testis lies horizontally because of the presence of
mesorchium. (The predisposing factor for torsion is same on both
sides)
• Deming’s sign: It is a sign on the affected side where the affected
testis is positioned high because of the twisting of the cord and
spasm of muscles

91. • Investigation of choice: Color Doppler - detects the decreased blood
flow to testis in torsion.
• Tc 99m pertechnetate scan also demonstrates decreased blood flow
• In the 1st hour the torsion can be treated by manipulation (but later
on surgery has to be done to fix the testis )
• If not correctable by manipulation or more than one hour has
passed then surgery has to be done. Surgery must be done within
• 4 hours. Otherwise the testis will be dead
• Both the affected and unaffected testis should undergo
orchidopexy because the anatomical variation responsible for
torsion is likely to be bilateral

92. Testicular tumors
• Testicular cancer is mainly of two types
• Germ cell tumors (GCT) ~ 95%
• Nongerminal neoplasms ~ 5% (include leydig cells, sertoli cells and
gonadoblastoma)
• Germ cell tumors are of two types
1. Seminomas (more common, better prognosis)
2. Non seminomas:
• Chorio carcinoma
• Embryonal cancer
• Endodermal sinus (Yolk sac ) carcinoma
• Teratoma
• Nonseminomas are more malignant than seminomas
• Most common testicular tumor above 50 years of age is Lymphoma

93. • Predisposing factors for testicular GCTs are
• Cryptorchidism
• Testicular feminization syndrome
• GCT of one testis is a risk factor for the other
testis
• Testicular cancer in a sibling
• Klinefelter syndrome is associated with
mediastinal GC T
• Administration of estrogens (e.g. DES) to the
mother during pregnancy is associated

94. Cryptorchidism and Testicular Cancer
• Of the predisposing factors, cryptorchidism has the
strongest association with testicular cancer
• Increased risk is seen for both the testis, i.e. the cryptorchid
testes as well as the normally descended testis
• Abdominal cryptorchid testes are at a higher risk than
inguinal cryptorchid testes
• Seminoma is the most common type of testicular cancer
seen in a cryptorchid testis
• Placement of the cryptorchid testis into the scrotum
(orchidopexy) does not alter its malignant potential,
however it facilitates examination and tumor detection

95. • Seminomas represent about 50% of all germ cell tumors of testis
• Median age is 4th decade (Nonseminomas are most frequent in the 3rd
decade).
• Seminomas follow a more indolent course.
• Most seminomas (70%) present with stage I disease (limited to testis),
• About 20% with stage II disease (with retroperitoneal metastases),
• And 10% with stage III disease (spread beyond retroperitoneum)
• Seminomas as well as nonseminomas typically metastasize through
lymphatics (except Choriocarcinoma which demonstrates early
hematogenous spread)
• Seminomas are one of the most radiosensitive tumors (Nonseminomas
are insensitive to radiation).
• “Lymphoma is the most common testicular tumor in a patient over the
age of 50 and is the most common secondary neoplasm of the testis.”

96. Tumor markers in testicular cancers
• β-hCG: Concentration is increased in both
seminoma and nonseminoma
• AFP: Concentration is increased in only
nonseminoma
• LDH: It is increased in both, it is not as
specific as either of AFP orβ-hCG

97. • CHEVASSU MANEUVER
• Biopsy is taken via inguinal approach (As transcrotal
biopsy or FNAC is not advised in testicular cancers due
to risk of violating the tumor principle. )
• Via inguinal canal cord and testis are exposed
• A soft clamp is applied to the cord at deep ring to
prevent dissemination through blood
• Frozen section biopsy taken from that area of suspicion
• If positive, high orchidectomy is done.
• High orchidectomy means removal of cord structures
about 2 cm proximal to deep ring along with testis.