This document provides information on acute and chronic scrotal disorders, including painful and painless scrotal masses. It discusses conditions like testicular torsion, epididymitis, hydrocele, inguinal hernia, testicular tumors, varicocele, and spermatocele. For each condition, it describes the typical presentation, diagnostic process, and treatment approach. The goal is to aid clinicians in differentially diagnosing the cause of scrotal masses and pain.

1. Urology Department
Under-graduate courses
Acute and Chronic scrotal
disorders

2. For our Lectures and Scientific resources
visit our web sites,
Uroainshams.blogspot.com
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3. Scrotal masses
Painful Scrotal Mass Painless Scrotal Mass
Testicular torsion Testicular tumor
Epididymitis Hydrocele
Inguinal hernia Inguinal hernia
Testicular tumor (rapidly growing) Spermatocele
Trauma (testicular rupture) Varicocele
Paratesticular tumors
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4. Scrotal mass
• The single most helpful piece of information is
whether the patient has pain.
• A history of recent significant trauma also will
narrow the diagnosis.
• Color-flow Doppler ultrasound is the best test to
aid in the diagnosis of scrotal pathology.
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5. Testicular torsion
• The classic presentation for testicular
torsion is a sudden onset of pain
that typically wakes the patient at
night and is associated with
abdominal discomfort and possibly
vomiting.
• The peak age is in adolescence.
• On examination, the testis is usually
very tender and often is riding high or
lying abnormally as a result of
shortening of the cord via the torsion.
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By Osama Heider, MBBcH Revised by M.A.Wadood , MD, MRCS

6. Testicular torsion- Management
Diagnosis (primarly clinical diagnosis) plus
• Scrotal dupplex shows affection or cut off of
arterial blood supply to affected testicle
Treatment
• Mechanical detorsion is now obsolete.
• Scrotal exploration as early as 6 hours to save
the testicle or orchidectomy of devitalized testis.
• Orchiopexy of other testis is done.
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By Osama Heider, MBBcH Revised by M.A.Wadood , MD, MRCS

7. Epididymitis and orchitis
Pathology
• Infection may involve epididymis alone (epididymitis), the
testis alone (orchitis) or both organs (epididymo-orchitis).
• The majority of cases of epididymitis have an infectious
etiology, from urethra, prostate or bladder.
Clinical features
• pain and swelling of the scrotum.
• urethral discharge.
• Symptoms of UTI .
• The epididymis and testis are swollen and impossible to
distinguish Between them.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

8. Epididymitis and orchitis
Investigations and diagnosis
The main differential diagnosis of epididymitis (and orchitis) is
torsion of the testis .
• Microscopic examination of the urine and/or urethral
discharge may differentiate epididymitis from torsion.
• Doppler ultrasonography evaluate blood flow to scrotum:
 epididymitis is associated with increased blood flow
whereas torsion results in decreased blood flow.
• if there is any doubt about the diagnosis the testicles
should be explored.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

9. Epididymitis and orchitis
Treatment
• symptomatic treatment: bed rest, scrotal
elevation and analgesics.
• Antibiotics should always be given for up to 6
weeks to prevent relapse.
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By Ahmad El Awam, MBBcH Revised by M.A.Wadood , MD, MRCS

10. Testicular tumors
• Testicular cancers usually are discovered as an
incidental finding of a painless lump or nodule in
the scrotum.
• Commonly at age of 20 to 40 years.
• The lump or nodule may be accompanied by a
heavy sensation or dull ache in the lower
abdomen.
• They do not transilluminate, yet an associated
hydrocele may occur.
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11. Testicular tumors
• Benign testicular tumors are rare (<1%) and
include teratoma of childhood, epidermoid cyst,
dermoid cyst, simple testicular cyst, and
adenomatoid tumor.
• Testicular ultrasound should be performed.
• Treatment and pathologic diagnosis is made by
radical inguinal orchiectomy.
• Consider all testicular masses malignant
until proven otherwise.
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12. Inguinal hernia
• An inguinal hernia often is first seen as a scrotal
mass secondary to loops of bowel within the
scrotum.
• Indirect inguinal hernias may be secondary to a
patent processus vaginalis or protrusion of a new
peritoneal process along the cord into the scrotum.
• Direct inguinal hernias result from weakness of the
transversalis fascia at Hesselbach's triangle, rarely
descending into the scrotum.
• Complications include: inflammation, irreduciblity
and strangulation.
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13. Hydrocele
• A hydrocele is a fluid collection within the tunica
vaginalis surrounding the testis.
• It presents as a painless swelling of the scrotum
that transilluminates.
• It often makes testicular palpation difficult and
can conceal an underlying testicular tumor.
• Surgery (hydrocelectomy) is indicated if
complicated.
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14. Congenital or Infantile Hydroceles
• Congenital or infant hydroceles are usually the result of
peritoneal fluid accumulation within the scrotum via a
patent processus vaginalis and occur in 6% of full-term
boys.
• Their size often changes from day to day or with
recumbency.
• Treatment should be delayed during the first year of life
because normal spontaneous closure of the processus
vaginalis may occur.
• After 1 year, surgical ligation of the processus vaginalis
should be undertaken.
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15. Adult acquired Hydroceles
• Acquired or adult hydroceles are usually idiopathic but
may be secondary to tumor, infection, or systemic
disease.
• Treatment is generally indicated to allow easy palpation
of the testis or because of symptomatic
discomfort or disfigurement.
• Definitive therapy is surgical drainage
and excision of tunica vaginalis.
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16. Varicocele
• abnormal dilatation of the veins of the pampiniform
plexus and internal spermatic vein of the spermatic cord.
• the most common cause of oligospermia.
• unilateral (on the left) in 80% of patients.
• bilateral in 18% of patients.
• Varicocele have been reported in about 15% of the fertile
male population.
• varicocele is seen in 40% of infertile males.
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17. Varicocele
• Unilateral right-sided varico-celes are rare
(noted in only 2% of cases) and should suggest
the possibility of compression or obstruction of
the inferior vena cava (e.g., tumor or thrombus).
• Physical examination makes the diagnosis.
• Dilated veins are best palpated with the patient
standing and aided by a Valsalva maneuver.
• Varicoceles have been described
as feeling like a bag of worms.
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18. Varicocele
• The significance of a varicocele is its association
with infertility.
• Indications for varicocelectomy include
oligospermia, decreased sperm motility, and a
painful symptomatic varicocele.
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19. Spermatocele
• A spermatocele is an epididymal retention cyst that
arises from the efferent ductules and holds a cloudy fluid
containing spermatozoa.
• It presents as a painless, cystic mass that lies above and
anterior to the testis.
• Ultrasound can confirm the diagnosis if doubt exists.
• Treatment consists of spermatocelectomy and
epididymectomy for extensive involvement.
• Therapy should be avoided in young male
patients concerned with fertility.
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20. Scrotal Edema
• Lymphedema of the scrotum can present as markedly
enlarged bilateral scrotal sacs.
Potential causes
• include obstruction secondary to inflammation (filariasis,
lymphogranuloma, tuberculosis, or syphilis), neoplasia,
surgical procedures, or radiation.
Diagnosis
• History
• Physical examination with transillumination of the
scrotum (use high-intensity light source if available)
• Color-flow Doppler ultrasound
• Urinalysis
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21. Thank You
By M.A.Wadood , MD, MRCS