Testicular swelling

Testicular swelling

1. Testicular swelling Mohammed AlHinai

2. A 30 yr. old young man was referred to urology OPD for evaluation of right scrotal mass, which was noticed one week back. There was no h/o trauma, fever or urinary symptoms. Clinical examination showed enlarged right testis without any fluctuation or transillumination . Epididymis and cord were found to be normal Differential diagnosis

3. Approach to patient with scrotal swelling Ask about swelling as general : Onset and progression Site if Unilateral or bilateral Associated symptoms like pain, itch, bleeding, discharge, skin change. predisposing factors like trauma, insect bite, infection. Systemic symptoms like fever, weight loss, malaise. Other history including marital history, sexual activity and family history .

4. Examination of testis : During the examination, you need to answer some questions

5. answer to these four questions: 1- can you get above the swelling? 2- can you identify the testis and epididymis? 3- is the swelling translucent? 4- is the swelling tender?

6. Hydrocele Hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis which arise from an imbalance of secretion and reabsorption of fluid from the tunica vaginalis . Presentation : small , soft collections that still allow palpation of the scrotal contents to massive, tense collections of several liters that make examination impossible . Pain in case of large hydrocele. Hydrocele fluid in the scrotal sac transilluminates well. A 45 yrs old male patient with left sided scrotal swelling of one years duration. It is a progressively increasing painless swelling. On examination the right side of the scrotum shows a swelling of 9 * 7 cm size which is confined to the scrotum. The surface of the swelling is smooth and borders are well-defined. There is no local rise of temperature. The swelling is fluctuant and transilluminant . It is not reducible. There is no cough impulse. The right testis is not felt separately. Classify according to underlying etiology

7. Feature Primary hydrocele Secondary hydrocele Cause Idiopathic Trauma , infection , malignancy Rate of development Slow Rapid Size Large Small Appearance Tense Lax Testis Not palpable May be palpable Primary abnormality Defective absorption Excessive secretion Fluid Clear , amber color May be clear, purulent , blood stained Diagnosis Clinically by history and physical examination Scrotal US to confirm the diagnosis Management : Don’t require intervention if asymptomatic. If symptomatic, surgical procedure by excision of the hydrocele sac. Simple aspiration might be done but risk for recurrence. Scrotal US show fluid collection around testis

8. epididymal cyst An epididymal cyst is a fluid filled sac in the head of the epididymis. An epididymal cyst that is larger than 2 cm and filled with sperm is called a spermatocele . Presentation : Usually asymptomatic. Present as painless cyst behind the testis. Fluctuant and transilluminant mass. A 40 yrs old man was seen in the urology OPD for left scrotal mass. Patient had first noticed the swelling 6 months back while taking bath. There was no change in the size of swelling since then. Clinical examination showed fluctuant and transilluminant mass behind the left testis which was non tender. Left testis is palpable. Right testis and cord were also normal Well-circumscribed anechoic lesion in the epididymal head that does not demonstrate internal vascularity Diagnosed clinically but might need scrotal US to confirm. If asymptomatic, no intervention require. If symptomatic, excise the cyst. Avoid needle aspiration as risk of recurrence and infection.

9. Varicocele Varicocele is dilatation of the pampiniform plexus of spermatic veins caused by increased intravascular pressure which more in left vein as The left internal spermatic (gonadal) vein is one of the longest veins in the body, entering the left renal vein at a perpendicular angle. Presentation : Asymptomatic in early stage. Dull, aching, usually left-sided scrotal pain, typically noticeable when standing and relieved by recumbency . Atrophy of left testicle and decreased fertility as induction of apoptosis by increased scrotal temperature. 50 yrs old male present with scrotal swelling for 1 month. in examination, the swelling more obvious during valsala maneuver.

10. Diagnosed clinically but might need scrotal US to confirm if small size. Require semen analysis t o assess the fertility. If normal testicular size and semen parameters, no intervention require and monitoring with semen analysis every one to two yrs. If there is evidence of testicular atrophy or abnormal semen parameters, immediate intervention to prevent further damage by : Surgical ligation (prefer) by l igating the gonadal vein so that retrograde blood flow can no longer reach the plexus of veins in the scrotum . percutaneous venous emboli zation but there is risk of embolization coils migrating to the lungs and other organs and higher overall recurrence rates. Scrotal US show Dilatation of  pampiniform plexus veins with serpentine appearance percutaneous venous embolization