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PROBLEM ORIENTED CASE BASED LEARNING
Professor of Surgery
Melaka Manipal Medical college
Melaka Malaysia 75150
• Various causes(Differential diagnosis) of scrotal swellings
• Classical clinical vignette with probable diagnosis
• The diagnosis in detail- only one pathology in each episode
• Mind map of the diagnosis
• Tabular column of differential diagnosis depicting their
characteristic features to differentiate them from your
• References and feedback
Classical Clinical Vignette
• 30 years male patient presented with a swelling in the left side of
the scrotum for last 4years. The swelling started in the lower part
of the scrotum and subsequently the swelling is slowly increasing
in size and grown up to the root of the scrotum. The swelling
disappears on lying down position and reappears on standing and
• Patient complains of dull aching pain in the left side of the scrotum
for last 6 months, the pain is more towards the evening when the
swelling enlarges in size
• There is no pain abdomen, no urinary complaints
Classical Clinical Vignette
• O/E: A mass of dilated vein feeling like a bag of worms is palpable
on the left side of the scrotum along the left spermatic cord
extending from the upper pole of the testis up to the superficial
• No expansile impulse on cough is palpable, instead a thrill is
palpable. On lying down and on elevation of the scrotum the
• On asking the patient to stand up the dilated veins reappeared.
The left testicular volume is smaller than the right one. Abdominal
examination is normal
• Surgical Anatomy: Pampiniform plexus of veins (15 – 20) draining the
testis and epididymis makes the major bulk of the spermatic cord. As
they ascend, the number is reduced to 12 and on reaching the
superficial inguinal ring they unite to form 4 veins. At the level of deep
ring they are 2 in number and in retroperitoneum, it forms single
• Left testicular vein drains into left renal vein and right testicular vein
into inferior vena cava
• Dilatation and tortuosity of the pampiniform plexus of veins
• Seen commonly in men aged 15-30yrs and rarely after 40yrs.
• Occur in 15-20% of all males and 40% of all infertile males.
• Normal vein diameter of vessels of plexus- 0.5-1.5mm. Diameter
greater than 2mm- Varicocele.
• It is common on the left side5 reasons.
Left testicular vein is longer than right testicular vein
Left testicular vein enters at right angle to the left renal vein
Left testicular artery is arching over left testicular vein
A loaded sigmoid colon compressing left testicular vein
Left renal vein is compressed b/w the Aorta and SMA
• 1.Idiopathic/Primary – due to incompetency of valves. 98% occur on
the left side
Pelvic or abdominal mass.
Lt renal cell carcinoma with tumor thrombus in left renal vein.
Nutcracker syndrome- SMA compressing left renal vein. Other
conditions- Retroperitoneal fibrosis or adhesions
Varicocele- Clinical Features
• The patient may have aching or dragging pain particularly after
• It can be differentiated from an omentocele by the peculiar feel of the
bag of worms.
• Many varicoceles are asymptomatic and found incidentally
• It is more common on the left side for reasons stated above
• Infertility: Varicocele is often associated with infertility. The scrotal
temperature is usually higher in the presence of varicocele and this
may impair spermatogenesis
Varicocele- Clinical Features
• Bow sign- hold varicocele b/w thumb and fingers, patient is asked to
bow- reduced in size
• On lying down it gets reduced; On standing up it reappears
• Long standing cases- affected side testis is reduced in size and softer.
Testis size can be measured by Prader orchidometer
• No expansile cough impulse present, but thrill present while coughing
• Grade I: Small varicocele which is palpable only when patient performs
Valsalva maneuver (expiration against a closed glottis).
• Grade II: Moderate sized. Easily palpable varicocele without Valsalva’s
• Grade III: Large varicocele visible through the scrotal skin.
• Grade IV : Very much dilated and tortuous veins
• Venous color doppler of the scrotum and groin-
-standing/ valsalva’s manoeuvre
• USG abdomen to look for kidney tumours.
• Seminal analysis Oligospermia or azospermia
Varicocele- Indications for Surgery
• American Urological Society recommends that varicocele treatment
should be offered to the male partner of a couple attempting to conceive
when all of the following are present.
• A varicocele is palpable.
• The couple has documented infertility.
• The female has normal fertility or potentially correctable infertility
• The male partner has one or more abnormal semen parameters or sperm
function test results.
• The indications in adolescents- presence of significant testicular
asymmetry (>20%) demonstrated on serial examinations, testicular pain,
and abnormal semen analysis results.
• Asymptomatic varicocele—No treatment is required, only scrotal support
• Symptomatic varicocele—Excision of the pampiniform plexus in the
inguinal canal after ligating them. Testis still has venous drainage via the
• VARICOCELECTOMY- The most common approaches are
• Inguinal (groin)-easier and safer.
• Retroperitoneal (abdominal)
• Suprainguinal extraperitonial( Palomo’s operation)Open & Laparoscopic
• Scrotal approach- For Gr 4
• Non-surgical procedure.
• Steel coil or silicone balloon catheter is introduced into a vein below
the groin through a nick in the skin.
• Passed under X-ray guidance.
• Tiny metal coils or other embolizing agents introduced through the
• No stitches needed.
• Patient can go back in 24hrs.
• Lower rates of complications. Less effective, higher recurrence(5-11%),
danger that the coil could migrate to the heart and cause death
Scrotal Swellings Ex & Px Hx Sx Dx Tx
1. Hydrocele Primary-Idiopathic
No cough impulse
Get above swelling+
In doubt- USG of
USG of scrotum
3. Varicocele Idiopathic
Absence of valves in
Worm like in upper
Disappears on lying
down; Bag of worms
USG color doppler
Abnormal fixation and
lie of testis
UTI & trauma
Nausea & vomiting
Tender hemi scrotum;
USG color doppler
Germ cell- Seminoma
& Non seminoma
Hard in consistency
Testis felt separately
Clinical; No FNAC
USG OF scrotum
with or without
D/D for Scrotal Swellings (Compare &
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