DIFFERENTIAL DIAGNOSIS OF INGUINOSCROTAL SWELLING

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1. DIFFERENTIAL DIAGNOSIS OF INGUINOSCROTAL SWELLING

2. HERNIA Abnormal protrusion of the part or whole of the viscus through a normal or abnormal opening through the wall of the cavity that contains it

3. DIRECT HERNIA (Through Hesselbach’s Triangle) INDIRECT HERNIA (Through deep ring) Age Older Young Sex Never occur in female M:F = 20:1 History Reduced on lying down Reduced by manipulation Mostly bilateral Usually unilateral to start Inspection Hemispherical shape Pyriform shape Malgaigne's bulge (+) No Malgaigne's bulge Incomplete variety Complete/Incomplete Palpation Deep ring occlusion-swelling appear Swelling not appears Finger invagination - impulse felt at pulp of little finger Impulse at tip of finger Zieman's technique - impulse at superficial ring Impulse at deep ring Complication Uncommon Common

4. HYDROCELE Abnormal collection of serous fluid between the two layers of Tunica vaginalis HISTORY Swelling in the scrotum Not associated with pain (Pain is positive in case of associated orchitis) INSPECTION Skin over the scrotum is stretched Normal rugosity is lost No cough impulse

5. PALPATION No reducibility (Congenital hydrocele is reducible) Testis not separately palpable (Palpable in secondary hydrocele) Able to get above the swelling Fluctuation is positive Transillumination is positive

6. HEMATOCELE Collection of blood between the two layers of Tunica vaginalis HISTORY Sudden onset of pain and swelling after Trauma Tapping of hydrocele Neoplasms of testis EXAMINATION Same as that of hydrocele except that trans-illumination is negative and loss of testicular sensation (in case of neoplasms)

7. PYOCELE Collection of pus between the two layers of Tunica vaginalis HISTORY Painful swelling EXAMINATION Same as that of hydrocele except that trans-illumination is negative

8. VARICOCELE Dilation and tortuosity of the veins of the spermatic cord (Pampiniform plexus) HISTORY Swelling in scrotum mostly in left side Associated with pain INSPECTION Dilated veins over the testis Cough impulse is not seen on inspection but only on palpation we get a thrill like impulse

9. PALPATION Characteristic bag of worm like sensation is felt Thrill like impulse is felt

10. LYMPH VARIX It is a condition in which lymph vessels becomes dilated and tortuous caused by obstruction due to filariasis HISTORY Simultaneous development of pain and swelling Past history of periodic attacks of fever INSPECTION Swelling appears on standing and disappears on lying down Cough impulse is not seen on inspection but only on palpation we get a thrill like impulse

11. PALPATION Soft, cystic, doughy Thrill like impulse is felt

12. LIPOMA OF THE CORD Very rare condition Cord feels soft and lobulated Swelling is irreducible Cough impulse is negative

13. FUNICULITIS It is inflammation of the spermatic cord HISTORY Painful and tender swelling Periodic attacks of chills and rigors INSPECTION Skin becomes red, oedematous, shiny PALPATION To differentiate it from strangulated hernia, palpate just above the deep ring, - feeling of abdominal contents in case of strangulated hernia(as they enter the deep ring) - no such content in funiculitis

14. UNDESCENDED TESTIS It is a condition in which the testis is arrested at any point along its normal path of descent Bilateral undescended testis is called cryptorchidism INSPECTION Scrotum on the affected side will be empty PALAPTION Testis is recognised by its shape, feel, testicular sensation

15. ECTOPIC TESTIS It is a condition in which the testis is deviated from its normal path of descent (due to the weakness or rupture of scrotal tail of gubernaculum) EXAMINATION Same as that of undescended testis In leg raising test, ectopic testis in superficial inguinal pouch becomes more prominent but not in undescended testis located in inguinal canal

16. TORSION OF TESTIS It is an emergency condition of the testis where the testis rotate in its axis compromising the blood supply which may lead to gangrene (mimic like strangulated hernia) Common in undescended testis HISTORY Sudden onset of severe pain in groin and lower abdomen pain following an act of physical strain Vomiting due to pylorospasm

17. EXAMINATION Absence of testis in the scrotum Skin remains normal in early hours but after 6 hrs skin becomes red, hot, oedematous and tender The scrotum of the affected side is empty in case of undescended testis (but not in strangulated hernia) Prehn’s sign – elevation of scrotum increases the pain in torsion of testis (pain decreases in acute epididymo orchitis)

18. EPIDIDYMAL CYST It is a congenital condition caused by cystic degeneration of aberrant structure like - Paradidymis (most common) - Appendix of epididymis - Appendix of testis - Vas aberrans of Haller EXAMINATION Cystic in consistency Feels like bunch of tiny grapes (multiloculate) Situated behind the body of testis Transillumination – positive (CHINESE LANTERN APPEARANCE)

19. SPERMATOCELE It is an acquired retention of cyst derived from blockage of some portion of sperm conducting mechanism of epididymis EXAMINATION Cystic in consistency, unilocular Situated in the head of epididymis Less translucent (barley water like fluid which contains spermatozoa)

20. MULTIPLE SEBACEOUS CYST Also known as strawberry tumor EXAMINATION Small and multiple swellings in the scrotal skin Some of them may be discharging cheesy like material

21. TB EPIDIDYMO-ORCHITIS Inflammation confined to the epididymis is epididymitis and infection spreading to the testis is epididymo-orchitis EXAMINATION Firm, craggy tender nodules on epididymis In neglected cases cold abscess forms and discharging sinuses are present

22. ACUTE EPIDIDYMO-ORCHITIS Inflammation of testis and epididymis due to primary infection of urethra, prostate or seminal vesicles (older man – urinary infection, young – genital infection) EXAMINATION Epididymis and testis swell and become painful Scrotal wall at first red, oedematous, shiny and later becomes adherent to epididymis Prehn’s sign – elevation of scrotum decreases pain in acute epididymo orchitis