Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani) This covers only : ANATOMY CAUSES TORSION OF TESTIS EPIDIDYMO-ORCHITIS HYDROCELE EPIDIDYMAL CYST VARICOCELE

2. CONTENTS
• ANATOMY
• CAUSES
• TORSION OF TESTIS
• EPIDIDYMO-ORCHITIS
• HYDROCELE
• EPIDIDYMAL CYST
• VARICOCELE

3. ANATOMY
OF SCROTUM AND TESTIS

4. ANATOMICAL POSITION:

5. STRUCTURE
OF THE
SCROTUM:

6. LAYERS OF THE SCROTUM:
“Some Dangerous Englishmen Called It The Testis”
S - Skin
D - Dartos M.and fascia
E - External Spermatic fascia
C - Cremasteric fascia
I - Internal Spermatic fascia
T - Tunica vaginalis
T - Tunica albuginea

7. Blood supply
of scrotum:

8. Innervation:

9. Lymphatic drainage of the scrotum:
Lymph from the
skin, fasciae
and tunica
vaginalis of
scrotum drains
into the
Superficial
inguinal
lymph nodes.

10. Coverings
of the
Testis:

11. Structure of
the Testis:

12. The
Epididymis:

13. Vascular Supply:
Arterial supply

14. Venous drainage

15. Innervation:
The testicular
plexus:
a network of
nerves
derived from the
renal and aortic
plexi.

16. Lymphatics:
The lymphatics ascend
along the testicular
vessels and drain into
the preaortic and para
aortic groups of lymph
nodes.

17. MICROANATOMY

18. Spermatic
cord
contents:

20. Causes of Scrotal Swellings
Acute Painful
• Torsion testis
• Torsion of testicular
appendages
• Acute epididymo-orchitis
Chronic Painless
•Hydrocele
•Epididymal cyst
•Spermatocele
•Varicocele
•Chronic epididymo-orchitis
•Testicular tumor

21. TORSION OF TESTIS

22. Case study - Torsion Testis
• A 14-year-old boy presents with acute onset of right scrotal
and RLQ pain for the past 4 hours. He additionally reports
nausea and one episode of vomiting. He denies any similar
past pain and reports no history of trauma.
• O/E: the skin overlying the right side of the scrotum appears
to be slightly erythematous and edematous. The right
testicle appears to be lying significantly higher in the
scrotum as compared to the left testicle.
• The entire right testicle is exquisitely tender to palpation,
whereas the left one is nontender
• He has an absent cremasteric reflex on the right.

23. Torsion Testis - Etiopathogenesis
• Testicle twist in a way that its blood supply becomes
compromised
• Twisting of testis along with spermatic
cordStrangulationNecrosis
• Uncommon (normal testis is anchored and cannot rotate)
• For torsion to occur, one of several abnormalities must be
present:
• Inversion of testis
• High insertion of tunica vaginalis- hang like a bell clapper
• Separation of epididymis from the body of the testis

24. Clapper = Testis

26. In Neonates In Adolescents
Torsion Testis - Types

27. • Most common between 10-25 years of age
• Sudden severe pain in hemiscrotum or both sides
• Nausea & vomiting
• Scrotal skin edematous and erythematous
• Testis exquisitively tender
• Cremastric reflex absent in affected side
Torsion Testis – Clinical features

28. Torsion Testis – Clinical features

29. Torsion Testis – Clinical features

30. Torsion Testis – Clinical features

31. Torsion Testis – Differential diagnosis

32. Torsion Testis- Doppler USG
Central testicular blood flow Normal Testis
No central testicular blood flow but
excessive peripheral blood flow

34. • Ipsilateral side through a scrotal incision, Exploration,
detorsion and fixation orchiopexy
• Contralateral side Exploration and fixation orchiopexy
(anatomical predisposition is likely to be B/L)
• An infarcted testis should be removed
• In doubtful cases and nonavailability of Doppler USG Better to
explore rather than unduly delay the treatment
• Testicular salvage rate is 100% if surgery is done within 6 hrs and it
is 20% if surgery is delayed > 24 hrs
Torsion Testis – Treatment

35. • Hydatid of testis & epididymis Remnant of obliterated
Mullerian ducts
• Sudden Swelling and redness of hemiscrotum
• Tender Testis
• ‘Bluedot sign’ +ve
• Cremastric reflex intact
Torsion of Testicular Appendages

36. Torsion of Testicular appendages
“Blue dot sign”

37. • Explore & Excise torsed appendages in early cases
• In delayed cases >48 hrs, conservative treatment
with antibiotics & anti inflammatory drugs
Torsion of Testicular Appendages -
Treatment

38. Testicular Torsion- Mindmap

39. EPIDIDYMO-ORCHITIS

40. A 24-year-old male presents to the emergency with
a painful, swollen right scrotum. The pain began 2
days ago and has become progressively worse. He is
sexually active with three partners and occasionally
uses condoms. His right scrotum is erythematous
and tender to palpation. On examination, there is a
positive Prehn’s sign. From the list below, what is the
most likely causative organism?
A. Neisseria gonorrhea
B. Escherichia coli
C. Pseudomonas aeruginosa
D. Chlamydia trachomatis
E. A paramyxovirus

41. • Inflammation of epididymis & testis due to infection or trauma
• Commonly associated with UTI or trauma
• Young  arises secondary to a sexually transmitted genital
infection (Chlamydia trachomatis, Neisseria gonorrhea)
• Older  secondary to urinary infection
• May be complication of catheterisation or instrumentation of
the urinary tract
• That’s why a dose of antibiotic is given after placing and after removal of
urinary catheter.
Acute epididymo-orchitis

42. • Scrotal pain, swelling, and erythema
• Fever
• Thickened & tender epididymis
• Can be treated conservatively with antibiotics
(Doxycycline/quinolones) and antiinflammatory
drugs

43. Acute Epididymo-orchitis
Doppler USG
USG Scrotum
• Thickened Epididymis
• Reactive Hydrocele
• Thick scrotal wall
Doppler USG
• Excessive blood flow to Epididymis
• Normal testicular parenchymal
blood flow

44. HYDROCELE

45. Case study – Vaginal Hydrocele
• A 35-year-old male patient presents with right sided scrotal
swelling of two years duration. It is a progressively
increasing painless swelling.
• O/E: the right side of the scrotum shows a swelling of 15 ×
10 cm size which is confined to the scrotum (can get above
the swelling). 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. On percussion it is dull.
• The spermatic cord is felt above the swelling and is tender.
• The contralateral testis and genitalia are normal. There is no
evidence of any mass or lymph nodes in the abdomen

46. Hydrocele is an abnormal collection of serous fluid in
a part of the processus vaginalis, usually the tunica
vaginalis.

47. Aetiology
A hydrocele can produced in 4 different ways:
1. Defective absorption  primary
2. Excessive production  secondary
3. Lymphatic obstruction  filarial
4. Connection with patent processus vaginalis 
congenital

48. Composition of Hydrocele Fluid
• Color—Straw or amber colored.
• Composition—Water, fibrinogen, inorganic salts,
albumin and cholesterol crystals
• Hydrocele fluid normally won’t clot if it is drained
into a container but will clot immediately even if it
comes into contact with a drop of blood

49. Primary Vs Secondary Hydrocele
Primary Hydrocele
• Defective absorption of
fluid
• Ex: Vaginal & infantile
hydroceles
• Attain moderate to big size
• Difficult to palpate testis
• Transillumination positive
• Consistency tensely
cystic
• Tx: Jaboulay’s & Lord’s
operations
Secondary Hydrocele
• Excessive production of fluid
• Ex: Filariasis, tumor, trauma
& epididymo-orchitis
• Attain small size
• Testis easily palpable
• Transillumination negative
• Consistency Lax cystic
• Tx: Treat underlying causes

50. Primary Hydrocele - Types
1. Congenital hydrocele
2. Funicular hydrocele
3. Infantile hydrocele
4. Encysted hydrocele of the cord
5. Vaginal hydrocele- commonest type
6. Bilocular hydrocele/-en-bisac
7. Hydrocele of the hernial sac

51. Primary Hydrocele - Clinical features
• Moderate to big size swelling
• Cough impulse negative
• Get above the swelling positive
• Not reducible
• Consistency tensely cystic
• Transillumination positive
• Testis not felt separately
• Transillumination negative in Hematocele, Pyocele,
Chylocele and thick sac

52. Primary Hydrocele - Clinical Pictures

53. Primary Hydrocele- Complications
• Infection
• Pyocele
• Hematocele
• Atrophy of testis
• Infertility
• Hernia of hydrocele sac (rare)
• Rupture & calcifications

54. Primary Hydrocele- Treatment
• Congenital hydrocele- Inguinal herniotomy
• Adult vaginal hydrocele
Small sizeLord’s plication / Jaboulay’s operation
Large sizeIncision and eversion of sac

55. Complications of surgery
• Reactionary haemorrhage Hematocele
• Infection
• Pyocele
• Sinus formation
• Recurrent hydrocele

56. Hydrocele - Mindmap

57. EPIDIDYMAL CYST

58. Case study – Epididymal Cyst
• A 45 years old male patient presented with a
swelling in right side of the scrotum for last 3 years
which is increasing very slowly in size. There is no
pain over the swelling.
• O/E: There is a soft cystic swelling in relation to the
head of the right epididymis. The swelling has a
lobulated surface and feels like a bunch of grapes.
• Testis can be felt separately from the swelling
• The swelling is brilliantly transilluminant and has
Chinese lantern pattern appearance

59. These are cysts in connection with the epididymis
divided into the following types:
1. Degeneration cysts occur due to cystic degeneration
of the epididymis Epididymal cyst
2. Retention cysts due to obstruction of the sperm
conducting mechanism Spermatocele (Ex: after
vasectomy)
Epididymal Cyst - Etiopathogenesis

60. • Most epididymal cysts occur in males over the age of 40
years
• An epididymal cyst usually contains clear fluid
• They are often multiple or multilocular and are frequently
bilateral and feels like bunch of grapes
• Brilliantly transilluminant “Chinese lantern pattern”
• Testis palpable separately
Epididymal Cyst- Clinical Features

61. Epididymal Cyst- Clinical Features

62. Spermatocele
• Unilocular retention cyst
• The fluid contains spermatozoa , and resembles
barleywater appearance
• Typically lies in the epididymal head above and
behind the upper pole of the testis

63. Epididymal Cyst - Treatment
• Single large cyst  Excision of cyst
• Recurrent or multilocular cyst Excision + partial
or total epididymectomy
• No role for aspiration because cysts are
multilocular
• Spermatocele if big aspiration or excision; If small
no intervention

64. Epididymal Cyst - Mindmap

65. VARICOCELE

66. Case study - Varicocele
• 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 walking
• 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

67. • 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 inguinal ring
• No expansile impulse on cough is palpable, instead a
thrill is palpable. On lying down and on elevation of the
scrotum the swelling disappears
• 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
Case study - Varicocele

68. Varicocele-Anatomy
• 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 testicular vein.
• Left testicular vein drains into left renal vein and right testicular vein into
inferior vena cava
• It is common on the left side5 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

69. Varicocele
• Varicose dilatation of
vein draining testis
• 20% , left sided
• Cause:
• Idiopathic
• Absent /incompetent
valve in proximal
testicular vein
• Obstruction
• Primary or secondary
• May lead to infertility

70. Varicocele- Etiology
1.Idiopathic/Primary – due to incompetency of valves. 98% occur on
the left side
2.Secondary – due to obstruction of flow
 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

71. Varicocele
(Bag of Worms Appearance)

72. Clinical features Investigations
• Asymptomatic
• Symptomatic
- Dragging
discomfort worse
on standing at end
of day
- Scrotum hangs
lower than normal
- Bag of worms
• Venous doppler of
scrotum and groin
• Ultrasound abdomen
• Semen analysis

73. • Asymptomatic varicocele—No treatment is
required, only scrotal support and reassurance
• Symptomatic varicocele—Excision of the
pampiniform plexus in the inguinal canal after
ligating them. (Testis still has venous drainage via the
cremasteric veins)
Varicocele- Treatment

74. Varicocele- Treatment

75. • Ligation of testicular vein
• Suprainguinal (Palomo’s)
• Inguinal (Ivanissevich)
• Subinguinal (Marc- Goldstein)*
• Scrotal

76. Varicocele - Coil Embolization
• 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 catheter.
• 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

77. Varicocele - Coil Embolization

78. • Haemorrhage and scrotal haematoma
• Infection Pyocele
• Injury to testicular artery
• Injury to ilioinguinal nerve and pain
• Recurrence—5-10%
Surgery- Complication

79. Varicocele - Mindmap

80. Scrotal Swellings Ex & Px Hx Sx Dx Tx
1. Hydrocele Primary-Idiopathic
Secondary- under
lying pathology
Painless big
swelling; not
reducible
No cough impulse
Get above swelling+
Transilluminant+
Clinical
In doubt- USG of
scrotum
Lord’s operation
Jaboulay’s
operation
2. Epididymal
cyst &
Spermatocele
Degeneration of
epididymis, occlusion
of pathway
Swelling in
scrotum
resembles 3rd
testis
Testis palpable
separately; Chinese
lantern appearance
Clinical
USG of scrotum
Conservative
Excision
3. Varicocele Idiopathic
Absence of valves in
testicular vein
Worm like in
upper scrotum;
infertility
Disappears on lying
down; Bag of worms
appearance
Clinical
USG color doppler
Varicocelectomy
Inguinal or
Retroperitoneal
4. Testicular
torsion &
Epididymo-
orchitis
Abnormal fixation
and lie of testis
UTI & trauma
Severe pain&
swelling scrotum
Nausea &
vomiting
Tender hemi
scrotum; cremasteric
reflex absent
Clinical
USG color doppler
Explore,detorse,
orchiopexy or
orchidectomy
Conservative
5. Testicular
carcinoma
UDT, Kieinfelter’s
Germ cell- Seminoma
& Non seminoma
Non germ cell tumor
Painless heavy
swelling
Not reducible
Hard in consistency
Testis felt separately
Clinical; No FNAC
USG OF scrotum
High orcidectomy
with or without
RPLND+ RT+CT
D/D for Scrotal Swellings
(Compare & Contrast) (Vertical Reading)

81. References
• Williams, Bulstrode, O’connell, Bailey and Love’s
Short Practice of Surgery, 26th edition, 2013
• Sriram Bhat M , SRB’s Manual of Surgery, 5th
edition, 2016
• https://www.slideshare.net/babysurgeon/scrotal-
swellings-1 (Dr Selvaraj Balasubramani)

82. •Thank you