munir suwalem

1. SCROTAL SWELLING AND
PAIN IN CHILDREN
Presented by
Dr munir suwalem
S.H.O
Peadiatric surgery
B.M.C
Benghazi - libya

2.  The Scrotum is a cutaneous pouch which
contains the testes and parts of the spermatic
cords. It is divided on its surface into two lateral
portions by a ridge or raphé,
 which is continued forward to the under surface of
the penis, and backward, along the middle line of
the perineum to the anus
 the scrotum consists of two layers ,the outer layer
is integument and the inner layer is dartos
tunic, which divides the scrotal pouch into two
cavities for the testes,

3.  Vessels and Nerves.—
 The arteries supplying the coverings of the testes
are: the superficial and deep external pudendal
branches of the femoral, the superficial perineal
branch of the internal pudendal, and the cremasteric
branch from the inferior epigastric. The veins follow
the course of the corresponding arteries.
 The lymphatics end in the inguinal lymph glands.
 The nerves are the ilioinguinal and lumboinguinal
branches of the lumbar plexus, the two superficial
perineal branches of the internal pudendal nerve, and
the pudendal branch of the posterior femoral
cutaneous nerve.

4.  The function of the scrotum appears to be to
keep the temperature of the testes slightly
lower than that of the rest of the body.
 the temperature should be one or two
degrees Celsius below body
temperature (around 37 degrees Celsius or
99 degrees Fahrenheit);
 higher temperatures may be damaging
to sperm count.

5. CLASSIFICATION
 scrotalswelling is usually
classified as:
 Painful or painless
 Acute or chronic

6.  Acute scrotal swelling with pain
 Torsion of spermatic cord
 Torsion of appendix testis
 Acute epididymitis-orchitis
 Trauma
 Insect bite
 Thrombosis of spermatic vein
 Fat necrosis
 inguinal Hernia(incarcerated)
 Folliculitis
 Henoch-Schönlein purpura

7.  Scrotal swelling without pain
 Tumor
 Idiopathic scrotal edema
 Hydrocele
 Inguinal
Hernia
 Henoch-Schönlein purpura

8.  Chronic scrotal swelling
 Hydrocele
 InguinalHernia
 Varicocele
 Spermatocele
 Sebaceous cyst
 Tumor

10. EPIDEMIOLOGY
 Prevalence
 Inguinal
hernias and hydroceles are the
most common causes of scrotal swelling.
 Testiculartorsion occurs in 1:4000 boys.
 Varicoceles are present in 15% of male
adolescents and adults.

11. EPIDEMIOLOGY
 Age
 Hernias can occur at any age but are more
common in premature infants.
 Testicular torsion most commonly occurs
between the ages of 12 and 18 years.
 Idiopathic scrotal edema affects children < 14
years.
 Acute inflammation of the epididymis or testis,
including mumps orchitis, can occur at any age
but is uncommon before adolescence.
 Varicoceles are usually asymptomatic and are
usually detected between 10 and 15 years of
age.

12. MECHANISM
 Acute scrotal swelling with pain
 Torsion of the testicle
 Twisting of the spermatic cord, with
resulting compromise of the blood supply
to the testis
 Torsion of the appendix testis
 When the appendix testis
torses, inflammation and swelling of the
testis and epididymis ensue, causing
testicular pain and scrotal erythema.

14. MECHANISM
 Acute epididymitis-orchitis usually after UTI
Results from an anomaly of the urinary tract,
either congenital or acquired:
 Renalduplications and posterior urethral valves
are among the more common anomalies.
 Withintermittent catheterization, the condition
can occur from retrograde passage of bacteria
back from ejaculatory ducts at the level of the
prostate to the testis and epididymis.

15. MECHANISM
 Henoch-Schönlein purpura
 Systemic vasculitis that can cause abdominal and
joint pain , May involve the scrotal wall in a minority
of cases
 Trauma
 A similar appearance can follow a difficult breech
delivery
 Severe blunt trauma affecting the scrotal contents
 Scrotal skin disease
 Insect bites, folliculitis, and allergic dermatitis may
cause erythema and edema of the scrotal wall.

16. MECHANISM
 Scrotal swelling without pain
 Hernias and hydroceles
 Most are caused by persistent patency of the
processus vaginalis
 Layers of the processus vaginalis condense
late in gestation or early postnatally.
 Obliteration of the processus vaginalis only
around the testis leads to an indirect inguinal
hernia with protrusion of fluid (or other contents)
through the internal ring to the end of the pouch
and potentially to the scrotum.

17. MECHANISM
 Communicating hydrocele occurs when fluid
travels through a processus vaginalis into the
tunica vaginalis around the testis.
 Scrotal hydrocele occurs after complete
obliteration proximally with patency distally.
 Hydroceles of the cord occur when the
processus vaginalis obliterates proximally and
distally, leaving a patent area in the midportion
with retained fluid.

18. MECHANISM
 Varicoceles
 A predilection for the left side exists,
reflecting anatomy of the left gonadal vein
entering the left renal vein at a right
angle.
 The right gonadal vein enters the vena
cava directly at an angle, precluding
reflux of venous blood.

19. HISTORY
 Acute scrotal swelling with pain
 Torsion of the testicle
 Acute onset of constant, severe scrotal pain
aggravated by physical activity
 Nausea and vomiting may occur.
 Possible history of incidental antecedent scrotal
trauma, but pain usually occurs during rest or
sleep
 Neonatal testicular torsion Can exhibit at
delivery as a nontender hard scrotal mass

20. HISTORY
 Torsion of the appendix testis
 Onset of pain and swelling is commonly acute but
can be progressive, usually occurring during rest.
 Pain can be severe, but nausea and vomiting are
less common than with testicular torsion.
 Acute epididymitis-orchitis
 History can reveal acute or more protracted onset
of pain.
 The patient may have fever or dysuria or pyuria
 Epididymal inflammation may arise after scrotal
trauma.

21. HISTORY
 Henoch-Schönlein purpura
 Onset may be insidious or acute, producing a
variable degree of erythema and edema.
 In more severe cases, the process may involve
the testis and epididymis, mimicking testicular
torsion.
 Focalfat necrosis
 Can exhibit with scrotal pain and swelling,
usually after trauma in an obese boy

22. HISTORY
 Trauma
 History (eg, injury from zipper entrapment of
scrotal skin) can be definitive.
 Mumps orchitis
 Rarely occurs in isolation; pain and swelling
usually occur within a week after parotitis.
 Scrotalskin disease
 History may be of limited utility.

23. HISTORY
 Scrotal swelling without pain
 Inguinalhernias and hydroceles
 Hernia
Swelling expands with increases in
intraabdominal pressure (eg, crying,
bowel movements, coughing).
The parent or child often reports the
swelling to be smallest in the morning
and largest late in the day.

24. HISTORY
 Hydrocele Whether the hydrocele is acute or
whether the scrotum has been chronically
enlarged is often unclear.
 The patient may have a history of trauma to the
scrotum that stimulates production of serous
fluid.
 Whenthe scrotum changes size during the day,
suspect a communicating hydrocele.

25. HISTORY
 Tumors
 Usually present as a hard, painless mass (or vague
heavy feeling) in the testicle detected by the
child, parent, or examining physician
 Spermatoceles and epididymal cysts
 Painless and round, they usually remain stable in
size but can sometimes enlarge.

26. PHYSICAL EXAM
 Acute scrotal swelling with pain
 Torsion of the testicle
 Scrotal erythema
 Swelling of the involved hemiscrotum
 Higher-than-normal position of the testis within the scrotum
 Palpation may show a horizontal rather than normal vertical
orientation of the testicle.
 Evaluation of the cremasteric reflex should begin on the
contralateral side; palpate the apparently unaffected testis to
confirm normal size and position.
 Unilateral loss of the cremasteric reflex on the side of the
swelling and pain highly correlates with the presence of
torsion.

27. PHYSICAL EXAM
 The testis should then be palpated.
 Despite the pain this maneuver may cause, it
helps differentiate torsion from epididymitis.
 Actual point of torsion of the spermatic cord can
sometimes be palpated.
 Associated hydrocele may be palpated and
confirmed by transillumination.

28. PHYSICAL EXAM
 torsion of the appendix testis May demonstrate
hemiscrotal erythema and swelling
 A blue-dot sign, if the necrotic appendage visible
through the scrotal skin, can help make the diagnosis.
 A normal cremasteric reflex is present bilaterally, and
the testis is normally positioned within the scrotum.
 Testicular discomfort, if present, is typically mild, but
point tenderness may be elicited from uppermost pole
of the testis near the head of the epididymis.

29. PHYSICAL EXAM
 Acute epididymitis-orchitis Scrotal erythema
and swelling are present, along with an intact
cremasteric reflex.
 Palpation during early phase of the
inflammatory process demonstrates tenderness
limited to the epididymis.
 In the later phase, tenderness and inflammation
include both epididymis and testis, and the
distinction between the 2 structures may be
difficult to appreciate.
 The Prehn sign (relief of pain with testicular
elevation) may be positive.

30. PHYSICAL EXAM
 Trauma
 Examination must include both hemiscrotums and
surrounding structures (penis, perineum), assessing
for swelling, ecchymosis, and bleeding.
 Tenderness may be limited to testis or
epididymis, depending on extent of trauma.
 Mumps orchitis
 Tender testis
 Scrotal skin disease
 Redness and edema limited to scrotum, with normal
testicle and spermatic cord

31. PHYSICAL EXAM
 Scrotal swelling without pain
 Inguinalhernias and hydroceles
 Feel for the testis first and keep it in mind
during the rest of the examination.
 Avoid confusing testis with contents of an
incarcerated hernia.

32. PHYSICAL EXAM
 Hernia
A bulge in the inguinal region with fluid that can be
gently reduced back into the abdomen is diagnostic
of an inguinal hernia.
In the cooperative child who can increase his
intraabdominal pressure, this procedure may be
repeatedly shown, particularly with the child
standing.
Presence of thickened spermatic cord or silk-
stocking sign (the feel of the layers of the processus
vaginalis being rubbed against each other) suggests
patency of the processus vaginalis or a hernia.

33. PHYSICAL EXAM
 Hydrocele When fluid is limited to the testis
and spermatic cord can be palpated above
the fluid, a hydrocele is present.
 Hydrocele of the spermatic cord feels
distinct from the testis and is round or ovoid,
possibly mimicking the presence of an
additional testis.
 Hydroceles (communicating, scrotal, or of
the cord) are rarely associated with
tenderness on palpation

34. PHYSICAL EXAM
 Tumors
 On palpation, mass is harder than the substance of
the testis, but this distinction may be difficult to
discern.
 Mass may bulge from surface of the testis.
 Spermatoceles and epididymal cysts
 Separate from the testis and can be transilluminated

36. Torsion of Sudden onset testicular Discolouration of scrotum;
the testis pain and swelling; exquisitely tender testis,
occasionally nausea, riding high
vomiting. Note: pain may
be in the iliac fossa
Torsion of More gradual onset of Focal tenderness at upper
(hydatid of testicular pain pole of testis; "blue dot" sign
Morgagni) – necrotic appendix seen
through scrotal skin
Epididymo Onset may be insidious; Red, tender, swollen
orchitis fever, vomiting, urinary hemiscrotum; tenderness
symptoms; rare in pre- most marked posteriolateral
pubertal boys, unless to testis. Pyuria may be
underlying genitourinary present.
anomaly, when
associated with UTI.

37. Incarcerat History of intermittent Firm, tender,
ed inguinoscrotal bulge, irreducible,
inguinal with associated inguinoscrotal
hernia irritability swelling
Idiopathic Swelling noted but Bland violaceous
scrotal child not distressed oedema of scrotum,
oedema extending into
perineum + penis;
testes not tender
Hydrocele Swollen hemiscrotum Soft, non-tender
in well, settled baby swelling adjacent to
testis;
transilluminates

38. Henoch Painful scrotal oedema, may be difficult to
Schonlein with purpuric rash over distinguish from testicular
purpura scrotum. May have torsion in absence of other
associated vasculitic features
rash of buttocks and
lower limbs, arthritis,
abdominal pain with GI
bleeding, and nephritis
Testicular or Scrotal trauma eg. Tender swollen testis.
epididymis straddle injury, bicycle Bruising, oedema,
rupture handlebars, sports haematoma, or
injury. Delayed onset of haematocele may be
scrotal pain and present.
swelling.

40. LABORATORY EVALUATION
 Urinalysis may help distinguish orchitis from
torsion of the spermatic cord or testicular
appendage when leukocytes or nitrites are
present.
 Acute scrotal swelling with pain
 Torsion of the testicle
Urinalysis is unremarkable.
Although the leukocytes count may be mildly
elevated, it is not discriminating.

41. LABORATORY EVALUATION
 Acute epididymitis-orchitis
Urinalysis may prove positive for
leukocytes and nitrite but is often
unremarkable among adolescents.
The leukocyte count is usually elevated

42. LABORATORY EVALUATION
 Scrotal swelling without pain
 Inguinalhernias and hydroceles
 Laboratory tests are useful only for
incarcerated inguinal hernias, with an
elevated leukocyte count and possible
acidosis.
 Tumors
 Preoperative tumor markers (α-
fetoprotein, β-human chorionic
gonadotropin) should be measured and
used for postoperative monitoring.

43. IMAGING
 Acute scrotal swelling with pain
 Torsionof the testicle
 Imaging by Doppler ultrasonography or
nuclear scintigraphy should be done if the
diagnosis of testicular torsion is in
question.
 Perform imaging only when it will not
delay surgical exploration if torsion exists,
adding to the risk of testicular loss.

44. IMAGING
 Torsion of the appendix testis
 If an inflammatory process resulting from
torsion of the appendage makes
differentiation from true spermatic cord
torsion impossible, imaging may be
helpful.
 Scrotal Doppler ultrasonography or
nuclear scintigraphy will show normal or
increased flow to ipsilateral testis.

45. IMAGING
 Acute epididymitis-orchitis
 Ultrasonography and nuclear scintigraphy
show normal symmetric blood flow or
increased blood flow to an enlarged
epididymis or testis.
 Voiding cystourethrography has been a
routine part of the evaluation, but its yield is
low with a normal ultrasound and a sterile
urine.

46. IMAGING
 Trauma
 Scrotal ultrasonography can document the
integrity of the testis and of the tunica
albuginea and the adequacy of blood flow.

47. IMAGING
 Scrotal swelling without pain
 Ultrasonography can determine cystic or
solid nature of a tense scrotal mass (eg,
hydrocele, tumor) or spermaticoInguinal
hernias and hydroceles
 Ultrasonography can delineate scrotal
contents, especially when a large or tense
hydrocele limits physical examination of
mass (eg, hydrocele of the cord,
paratesticular tumor).

48. IMAGING
 Tumors
 Scrotal ultrasonography is used to
delineate the mass.
 Varicoceles
 Testicular size, most accurately assessed
by ultrasonography, should be measured;
significant loss of testicular volume is an
indication for surgery.

49. TREATMENT
Acute scrotal swelling with pain
 Torsion of the testicle
 Surgical intervention is indicated not only
when testicular torsion is strongly
suspected, but also in equivocal cases
when torsion cannot be convincingly
excluded.
 The likelihood of salvaging the testis is
highest when surgery is done shortly after
onset of pain.

50. TREATMENT
 With surgery, first explore the affected testis, and,
when torsion is present, detorse the cord.
 Explore the contralateral testis (will have the same
defect in anatomy) and fix it in place to avert a
future torsion.
 If the testis can be saved, fix it in the scrotum.

51. TREATMENT
 Torsion of appendix testis Management is
nonsurgical.
 The patient should rest and use
nonsteroidal pain relievers and cold
compresses for several days to reduce
inflammation, swelling, and pain.
 Surgical intervention is indicated only when
acute testicular torsion cannot be excluded.
 In these cases, the infarcted appendage
is removed at surgical exploration.

52. TREATMENT
 Acute epididymitis-orchitis Treat with
antibiotics based on the results of the urine
culture and sensitivities.
 Anti inflammatory agents, scrotal elevation,
and rest should be prescribed.

53. TREATMENT
 Trauma
 Testicular or spermatic cord contusions:
Manage symptomatically.
 Testicular rupture requires surgical
exploration, evacuation of the hematoma,
debridement, and repair (when possible).
 Mumps orchitis
 Treatment is symptomatic.

54. TREATMENT
 Scrotal swelling without pain
 Inguinal hernias and hydroceles
 Repair on diagnosis to prevent incarceration ,
Perform surgery inguinally; isolate the sac from
the cord structures and ligate it at the level of the
internal ring.
 Inspect the contralateral ring using diagnostic
laparoscopy through the isolated ipsilateral sac.
If the internal ring is open, proceed with
contralateral surgical correction.
 If the hydrocele is painful, then surgery should
proceed sooner.

55. TREATMENT
 Tumors Perform radical orchidectomy through an
inguinal approach.
 If the mass is not suspicious for cancer, a possible
approach is to enucleate the mass and proceed
with orchidectomy only if the frozen section is
positive.
 Spermatoceles and epididymal cysts Management
typically is observation.
 Surgerymay be indicated when pain or significant
enlargement is present.

56. PROGNOSIS
 Acute scrotal swelling with pain
 Torsion of the testicle
 Spermatogenesis may be compromised after 4–6
hours of ischemia.
 Testicular salvage is time dependent, with universal
loss of the testis after 24 hours of torsion.
 Neonatal testicular torsion
 Neonatal testicular torsion can exhibit at delivery as a
nontender hard scrotal mass.
 Salvage in these cases is rare.
.

57. PROGNOSIS
 Mumps orchitis
 Infertility may occur when the condition results in
atrophy of both testicles.
 Scrotal swelling without pain
 hydroceles
 Most hydroceles resolve spontaneously by 1 year
and should be repaired if they persist beyond this
age.