Differential Diagnosis of scrotal swelling Embryology Hydrocele Indirect inguinal hernia Strangulated inguinal hernia Direct inguinal hernia Femoral hernia

1. Approach to Scrotal Swelling
By:-
Jwan Ali Ahmed AlSofi

2. Contents:-
• Differential Diagnosis of scrotal swelling
• Embryology
• Hydrocele
• Indirect inguinal hernia
• Strangulated inguinal hernia
• Direct inguinal hernia
• Femoral hernia
2

3. 3

4. Differential Diagnosis of scrotal swelling in
neonates (newborns):-
1. Hernia,
2. Transient hydrocele,
▫ Hydroceles are clear and readily seen by transillumination,
3. in utero torsion of the testes
▫ Testicular torsion in the newborn may present as a painless, dark
swelling.
4. Dissected meconium from meconium ileus and
peritonitis.
4

5. Embryology:-
•During the seventh month in utero, the testis descends
from its origin on the posterior abdominal wall, down
the inguinal canal into the scrotum inside a
diverticulum of peritoneum, the processus
vaginalis, guided by a ligament, the gubernaculum.
•The structures that are found in the scrotum in a male
(testis, vas and blood vessels) or labium in a female
(attachment of the round ligament of the uterus) pass
through the abdominal wall and pick up layers
corresponding to those of the abdominal wall.
•In a male these make up the coverings of the spermatic
cord.
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6. Embryology:-
• The processus vaginalis
▫ Begins to obliterate shortly before birth
▫ Closure is normally completed during the first 6 months of life,
leaving only the tunica vaginalis surrounding the testis
• In both males and females there is a remnant of peritoneal
invagination, the processus vaginalis, which, if it remains patent
and in continuity with the abdomen, explains why abdominal
contents or fluid can become a hydrocele or hernia, respectively.
6

8. Failure of obliteration of the processus vaginalis
is associated with several clinical conditions in
infancy and childhood:-
1. Inguinal hernia
2. Hydrocele
3. Encysted hydrocele of the cord
4. Possibly acquired undescended testes.
8

9. The normally
obliterated
processus vaginalis
(PV) between the
internal inguinal ring
(IIR), external
inguinal ring (EIR)
and the tunica
vaginalis (TV).

10. A completely
patent hernia

11. Incomplete hernia

12. Hydrocele with
narrow but patent PV

13. Encysted hydrocele
with fluid collecting as
a cyst in the spermatic
cord.

14. Residual fibrous
remnant of PV, which
may cause ascending
testis

16. Hydrocele
16

17. Case history
A 12-month-old boy presents to his primary care
physician with a right scrotal mass.The mass is
smaller in the morning than in the evening and
increases significantly in size during crying. It
gets smaller again when he is lying down. He has
no GI or urinary symptoms. Physical exam
demonstrates normal findings on the left side of
the scrotum and a nontender soft swelling on the
right side.The mass is transilluminated when a
light is shone on the scrotum, suggesting it is
fluid-filled.The right testicle is palpable after
gentle pressure reduces the swelling.

18. Definition:-
•A hydrocele is an abnormal collection of serous fluid in
a part of the processus vaginalis, usually the tunica
vaginalis.
•Hydrocele fluid contains albumin and fibrinogen.
•If the contents of a hydrocele are allowed to drain into
a collecting vessel, the liquid does not clot; however,
the fluid coagulates if mixed with even a trace of blood
that has been in contact with damaged tissue.
•More common :-
▫ In Premature
▫ on the right side
18

21. Classification of Hydrocele:-
Hydrocele
Congenital Acquired
Primary or
idiopathic
Secondary to
epididymal or
testicular disease.
21

24. Aetiology:-
•A hydrocele can be produced in four different ways:
1. By excessive production of fluid within the sac, e.g. a
secondary hydrocele
2. By defective absorption of fluid; this appears to be the
explanation for most primary hydroceles, although the
reason why the fluid is not absorbed is obscure
3. By interference with lymphatic drainage of scrotal structures
4. By connection with the peritoneal cavity via a patent
processus vaginalis (congenital).
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25. 25
(a) Vaginal hydrocele (very common)
(b) ‘infantile’ hydrocele
(c) congenital hydrocele
(d) hydrocele of the cord.

26. Clinical Features:-
• Acute hydrocele is usually secondary to some affliction of the testis
or epididymis
• A hydrocele is a painless cyst containing peritoneal fluid.
• Hydroceles Sometimes appear blue.
• Hydroceles are typically translucent
• It is possible to ‘get above the swelling’ on examination of the scrotum
to palpate a normal spermatic cord. Except in unusual varieties that
extend up to the inguinal canal.
• The swelling usually encloses the testis and epididymis such that they
may become impossible to palpate separately.
▫ When the hydrocele is lax, the testis within it may usually be palpated with
ease.
▫ when the hydrocele is tense, its shadow may be demonstrated by
transillumination.
• There is no impulse on crying or straining.
• Hydrocele cannot be emptied by pressure because of a flap valve at
its junction with the processus.
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29. Congenital hydrocele:-
• In neonates and infants, virtually all hydroceles are
congenital.
• The processus vaginalis is patent and connects with the
peritoneal cavity.
• The communication is usually too small to allow herniation of
intra-abdominal contents.
• Pressure on the hydrocele will never empty it – as this causes an
inverted "ink bottle" effect at the internal ring
• The hydrocele may be intermittent – Diurnal variation in
the hydrocele’s size:-
▫ It is small or absent in the mornings
▫ At its biggest in the late afternoon, when it may cause a dragging ache.
▫ These changes are due to the narrow communication with the peritoneal
cavity along which the fluid returns during recumbency (lying down) into
the peritoneal cavity and reaccumulates by the effect of gravity during the
day
• Ascites should be considered if the swellings are bilateral.
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30. Secondary hydrocele:-
•Causes:-
1. Is most frequently associated with acute or chronic
epididymo-orchitis.
2. It is also seen with torsion of the testis
3. with some testicular tumours.
•A secondary hydrocele is
▫ usually lax
▫ of moderate size: the underlying testis is palpable.
•If a tumour is suspected, the hydrocele should
not be punctured for fear of needle-track
implantation of malignant cells.
•A secondary hydrocele subsides when the primary
lesion resolves.
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31. Primary vaginal hydrocele:-
• Is seen most commonly in middle and later life but can
also occur in older children.
• The condition is particularly common in hot countries.
• Because the swelling is usually painless it may reach a
prodigious size before the patient presents for treatment.
• The testis may be palpable within a lax hydrocele, but an
ultrasound scan is necessary to visualise the testis if the
hydrocele sac is tense.
• About 5% of inguinal hernias are associated with a vaginal
hydrocele on the same side.
• Be wary of an acute hydrocele in a young man
since there may be a testicular tumour.
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33. Encysted hydrocele of the cord:-
• Is a loculus of fluid located above and separate from the
tunica vaginalis.
• In some children, multiple loculi or cysts develop along
the processus.
• Is a smooth oval swelling near the spermatic cord,
• is liable to be mistaken for an inguinal
• The swelling moves downwards and becomes less
mobile if the testis is pulled gently downwards.
• It does not require an operation in infancy and
may be considered a variety of the natural process of
obliteration.
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34. Hydrocele of the canal of Nuck :-
• Is a similar condition in females.
• The cyst lies in relation to the round ligament and is
always at least partially within the inguinal canal.
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35. Complications of hydrocele:-
1. Rupture is rare.
2. Transformation into a haematocele occurs
after trauma or if there is spontaneous bleeding
into the sac.
3. The sac may calcify.
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36. Investigations:-
36

37. Treatment of Congenital hydrocoeles:-
• Congenital hydrocoeles are treated by herniotomy if they do not resolve
spontaneously within 2 years of age.
• Congenital hydrocele in < 2 years of age:-
▫ They are often large, lax and nearly always symptomless
▫ Have a strong tendency to close and absorb spontaneously.
▫ Most will have disappeared by the age of 1 year.
▫ An operation is only recommended if the hydrocele persists beyond 2 years
of age.
• In boys more than 2 years of age:-
▫ A hydrocele in this age group rarely disappears spontaneously.
▫ An operation is recommended.
▫ The operation is herniotomy:-
 The processus is transfixed and divided at the internal inguinal ring.
 The whole sac need not be removed but the fluid in it may be released.
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39. Treatment of Acquired hydrocoeles:-
•Small acquired hydrocoeles do not need treatment.
•If they are sizeable and bothersome for the patient, then
surgical treatment is indicated.
•Established acquired hydrocoeles often have thick
walls.
•There are three main surgical techniques for
hydrocoeles:-
1. Lord’s operation – Plication.
2. Jaboulay’s procedure – Eversion
3. Excision
4. Aspiration of the hydrocele fluid
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40. Lord’s operation – Plication:-
• Lord’s operation is suitable when the sac is reasonably
thin-walled.
• There is minimal dissection and the risk of haematoma is
reduced.
• A series of interrupted absorbable sutures is used to plicate
the redundant tunica vaginalis. When these are tied, the
tunica bunches at its attachment to the testis.
40

41. Jaboulay’s procedure – Eversion:-
• The hydrocele sac is opened and everted behind the testis
and anchored with sutures.
• With placement of the testis in a pouch prepared by
dissection in the fascial planes of the scrotum.
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42. Excision:-
• Unless great care is taken to stop bleeding after excision of
the wall, haemorrhage from the cut edge is liable to cause a
large scrotal haematoma.
• This approach is not recommended.
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43. Aspiration of the hydrocele fluid:-
• Cannula drainage of the hydrocele fluid is simple
• Drawbacks:-
1. the fluid always reaccumulates within a week or so.
2. Aspiration can result in bleeding into the hydrocele sac and
haematocele formation.
• It may be suitable for men who are unfit for scrotal surgery,
although hydrocele surgery can be undertaken under local
anaesthetic.
• Injection of sclerosants such as tetracycline is effective but
painful.
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44. 44

45. Haematocele:-
• The most common cause of a haematocele is vessel damage
during needle drainage of a hydrocele.
• Prompt refilling of the sac associated with pain, tenderness and
reduced transillumination will confirm the diagnosis.
• Acute haemorrhage into the tunica vaginalis sometimes results
from testicular trauma with or without testicular rupture.
• If the haematocele is not drained, the blood within it clots.
• It becomes painless and may be mistaken for a testicular
tumour.
• Indeed, a tumour may present as a haematocele.
• Ultrasound scanning usually helps with the differential
diagnosis.
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46. Clotted haematocele:-
• Clotted hydrocele may result from a slow spontaneous
ooze of blood into the tunica vaginalis.
• It is usually painless and may be mistaken for a testicular
tumour.
• Indeed, a tumour may present as a haematocele.
• Treatment is by orchidectomy unless the testis is
indubitably benign. As a rule, it is impossible to be certain
until the mass has been bisected.
• The testis is often compressed and relatively useless.
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47. A longstanding
haematocele.
The testis has
been flat-
tened by
prolonged
pressure.

48. Indirect Inguinal
herniae
48

49. Case History:-
•A 6-month-old boy presents with an
intermittent swelling in the left groin. Both
testes are in the scrotum.
Q 1.1What is the likely diagnosis?
Q 1.2 What is the treatment?
•1.1 Indirect inguinal hernia.
•1.2 Inguinal herniotomy – some surgeons
would do bilateral operation.

50. • Nearly all inguinal herniae in children are indirect.
• This is the most common condition requiring an operation
during childhood.
• There is a high familial incidence.
• About 10%–15% of indirect inguinal herniae occur in girls, in
whom they appear more evenly throughout childhood than in
boys.
• In boys, the greatest incidence is in the first year of life,
especially the first 3 months:-
▫ 60% are on the right side,
▫ 25% on the left
▫ 15% bilateral.
• The sac usually contains loops of small bowel, and sometimes
omentum.
• In girls, the ovary is often palpable in the sac and may be both
difficult and unwise to reduce.
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51. •Failure of obliteration of the processus is more often
right sided,
▫ perhaps because the right testis descends later than the left
and the processus on the right side is therefore more likely to
remain patent.
•Inguinal herniae are more common in premature
neonates,
▫ because the normally higher intra-abdominal pressure post-
partum compared with the fetus makes it more difficult for the
processus to close spontaneously.
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52. •Inguinoscrotal hernia
▫ A hernial sac may extend from the internal inguinal ring
to the tunica vaginalis.
•Incomplete sac
▫ More commonly,
▫ Occurs proximal to an obliterated segment, which
intervenes between the sac and the tunica vaginalis.
▫ This accounts for the vast majority of inguinal herniae in
children.
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53. Clinical features:-
• The child’s parent may report that there is an intermittent
swelling overlying the external inguinal ring.
• It is usually painless but on occasions may cause discomfort.
• An infant’s inguinal hernia is often seen at nappy changes as
the hernia is made more obvious with crying or
straining.
• It may reach the bottom of the scrotum, as in the case of a
complete sac.
• There is an impulse on crying or straining.
• Can’t “get above” the swelling.
• Swelling separate to testis
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55. When the history is suggestive but the
hernia is not seen during examination:-
•The index finger may be rolled transversely across
the spermatic cord at the point where it lies on the
pubic crest;
•When there is a hernial sac:-
1. the spermatic cord is thickened in comparison with the
side on which no swelling has been seen,
2. the rustle of contiguous layers of peritoneum represents
the empty hernial sac – sometimes referred to as a
silken sleeve.
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56. Differential Diagnosis:-
1. Hydrocele:-
▫ is cystic,
▫ brilliantly transilluminable
▫ irreducible (even though there is a connection, it is too narrow to squeeze
the water out quickly),
▫ no impulse on crying or straining,
▫ the examining hand can get above the swelling – that is, a hydrocele’s
proximal pole is distal to the external ring.
2. Femoral and direct inguinal herniae are rare but should
be kept in mind.
3. a retractile or undescended testis may mislead the
unwary
4. in young children, an inguinal lymph node may be situated
close to the external inguinal ring.
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57. Treatment:-
•An operation is necessary in all cases of an
inguinal hernia because of the danger of
strangulation, which occurs most commonly in the
first 6 months of life.
•Operation should be performed as soon as
practicable, unless there is an intercurrent
condition, which requires more immediate
attention, for example, a skin infection or
bronchitis.
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58. Strangulated
inguinal hernia
58

59. • Strangulation is the most important complication of indirect
inguinal herniae.
• It is more common in infancy under 6 months of age
• Is somewhat less common in older children.
• If small bowel becomes trapped in the hernial sac, the hernia is
irreducible and is termed incarcerated.
• Due to incarceration, blood supply of the trapped contents (and
testis) can become impaired, that is, strangulation.
• Untreated strangulation can be life-threatening.
• Therefore, any irreducible hernia should be considered
as being potentially strangulated and effort made to ensure
reduction as outlined below.
• In children, incarceration occurs at the external inguinal
ring, unlike adults in whom the obstruction is typically at the
internal ring.
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60. Clinical features:-
Stage of
Incarceration and
irreducibility:-
• The infant cries
and cannot be
pacified; when
the parent changes
the nappy, a
swelling in the
groin is noted –
often for the very
first time.
• There is a tense,
tender swelling at
the external
inguinal ring,
and no impulse
on crying.
Stage of complete
intestinal
obstruction :-
• this may occur 12
h after the
onset.
• There may be
generalised
colicky
abdominal pain,
vomiting,
abdominal
distension and
constipation
Stage of bowel
ischaemia:-
• With delayed
diagnosis,
• There may be
redness and
induration
overlying the lump,
or signs of
peritonitis,
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61. Secondary effects:-
•The testicular vessels may be severely
compressed by a tense, strangulated hernia.
▫ Testicular atrophy has been reported in 15% of
boys after an episode of irreducibility and
strangulation.
▫ For this reason, early reduction is important for both the
testis and the incarcerated bowel.
•Occasionally, in infant girls, the ovary may be
strangulated inside the hernial sac.
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62. Differential diagnosis:-
1. Encysted hydrocele of the cord,
▫ may appear suddenly –
▫ the swelling is not tender,
▫ the cyst moves readily with traction on the cord
▫ abdominal signs and symptoms are lacking.
2. Torsion of an undescended testis
▫ Absence of a testis in the scrotum on the affected side may point to
3. Torsion of a descended testis, which has been
elevated out of the scrotum.
4. Lymphadenitis or a local inguinal abscess may be
so confusing in young children as to warrant exploration
to clarify the diagnosis.
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63. Treatment:-
1. An incarcerated hernia may reduce spontaneously en
route to the hospital, but more often than not persists.
2. The strangulated hernia should be reduced by taxis.
▫ When it is successful, the patient should not return home until
herniotomy has been performed, usually after 24 h, to give time
for oedema of the sac and its investing tissue to subside.
3. When taxis fails, the child should be transferred
immediately for operation.
▫ The need for preoperative resuscitation and intravenous antibiotics
will be obvious from the clinical findings.
▫ The friable sac is difficult to handle and the surgery should always
be performed by a paediatric surgeon.
▫ In exceptional cases, the bowel is gangrenous and a segmental
excision with anastomosis may be necessary.
63

64. Taxis Manoeuvre:-
• The tips of the fingers of one hand are applied to the distal extent of the
hernia while the fingertips of the other hand are cupped at the external
ring.
• Gentle pressure is exerted initially by the upper hand to disimpact the
hernia from the external ring, and then, the contents of the hernia are
reduced by the lower hand along the line of the inguinal canal.
• Nothing seems to be accomplished for a minute or two, and then, the
bowel suddenly gurgles and returns to the abdomen.
• Taxis is a manipulative trick, not a matter of force, and if necessary may
be attempted several times.
• As long as the necessary monitoring is available, a distressed child may
be sedated with midazolam or opiate analgesia.
• Taxis is successful in over 90% of cases, with virtually no chance of
complication by en masse reduction.
64

65. Direct inguinal
hernia
65

66. •Direct inguinal herniae are rare in paediatrics,
forming less than 1% of inguinal herniae.
•They are occasionally seen in
1. premature infants who develop bronchopulmonary
dysplasia after prolonged ventilation,
2. in teenagers with cystic fibrosis.
•Repair of the posterior wall of the inguinal canal
medial to the epigastric vessels is required.
66

67. Femoral hernia
67

68. •Femoral herniae are equally rare.
•The diagnosis is made clinically when the swelling
is below the inguinal ligament and lateral to
the pubic tubercle.
•As in adults, femoral herniae are more common in
females, usually between 5 and 10 years of age.
•The hernia is usually small and irreducible, for
most of it is composed of a fibro-fatty investment
of the fundus.
•The hernia may be repaired easily from below the
inguinal ligament.
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69. Thanks
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