Scrotal swellings are a common presenting complaint in the outpatient clinic. They are also therefore common in clinical examinations. It is important to be able to make a rapid diagnosis of testicular torsion and take appropriate action, i.e. surgery. It is also important to distinguish between those swellings that have underlying serious pathology (testicular tumour) and those that are simple and benign (epididymal cysts). Figure 57 Epididymal cyst. The patient may complain of several painful lumps on the scrotal skin. There may be a history of one or more of them becoming red, inflamed and tender with discharge. The patient will be often aware of what the lump is. He may be able to reduce it. The hernia may present with a painful, irreducible swelling and signs of intestinal obstruction. An idiopathic hydrocele usually presents as a painless scrotal swelling which may become quite large. They usually occur over the age of 50 years. Occasionally, there may be pain and discomfort if there is underlying testicular disease. A younger patient presenting with a hydrocele should raise the suspicion of an underlying malignancy. This presents as a painless scrotal swelling. Epididymal cysts may slowly enlarge over many years. They may be bilateral. The patient complains of pain and swelling, usually unilaterally. There are usually constitutional symptoms of malaise and fever. It may be accompanied by urinary tract infection with dysuria and frequency. This usually occurs around puberty. It is rare over 25 years of age. There is sudden onset of pain in the scrotum and groin, which may radiate into the lower abdomen. This may be accompanied by nausea and vomiting. There may be a history of violent exercise, e.g. straining in the gymnasium, lifting or even masturbation. Always ascertain the exact time of onset of symptoms. To be sure of testicular salvage, surgery should be carried out within 6–8 hours of onset of symptoms. Teratomas occur between 18 and 30 years, seminomas between 30 and 45 years. The common presentation is a feeling of heaviness in the scrotum accompanied by a painless swelling. Occasionally, symptoms are due to secondary deposits, e.g. abdominal pain from enlarged retroperitoneal lymph nodes. Occasionally, distant lymphadenopathy, e.g. cervical, may be a presenting symptom.
Scrotal Swellings
Causes
The swelling is being transilluminated. A 3 cm soft rounded swelling of the upper pole of epididymis can be seen. The fact that it transilluminates confirms the presence of an epididymal cyst containing clear fluid. A spermatocele, because of its opaque contents, does not transilluminate.
History
Sebaceous cyst
Indirect inguinal hernia
Hydrocele
Epididymal cyst
Epididymo-orchitis
Testicular torsion
Testicular tumour
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