Scrotal examination

 

Scrotum

Plan for examination of the scrotum
Scrotal neck Junction between corrugated & smooth skin

At root of penis

At the pubic tubercle

Skin
Tunica Normally not felt except there is fluid If Minimal fluid it is felt by benching

If large amount of fluid it is felt as swelling

Testis Testicular sensation

Size

Epididymis
Cord Thickness

Vas felt like tough structure

Inguinal region Inguinal lymph nodes (that drain scrotal skin)
Penis Shaft for Hypospadias

Epispadias

Circumcision
DRE Prostate

Seminal vesicles

Perineum
Abdomen Para-aortic lymph nodes

Maldescended testis

Neck Left  supraclavicular LNs ( Verchow’s sign)

 

Aim of examination in case of scrotal swelling is to answer 4 questions

Can you get above the swelling?

Can you identify the testis and the epididymis?

Is the swelling is translucent?

Is the swelling is tender?

and these are examples for how you can comment on your examination of scrotum.

Hydrocele

  1. “Enlarged right side of the scrotum”
  2. Look to back of the scrotum and penis
  3. “No signs of inflammation (scars, sinuses or dilated veins)”
  4. “No cough impulse and not reducible (بيرجع؟)”
  5. “I can get above the swelling so it is pure scrotal swelling”
  6. Feel the swelling (relation to testis and epidydimis)
  7. Transillumination

Varicocele

  1. Examine in supine position after standing
  2. Inspection normal
  3. Feel bag of worms
  4. May feel cough impulse or thrill
  5. Separate from testis
  6. Can get above it
  7. No transillumination

TAKING HISTORY FROM A PATIENT WITH scrotal CONDITION

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Differential diagnosis of different scrotal presentations

Main differential diagnosis
 

Testicular torsion

Epididymitis

Testicular cancer

Age range in years Most common 12 to 18
Less common 18 to 30
Most common 19 to 40
Less common <18 and >40
Peak incidence 25 to 35

74% in 20 to 49

Pain Sudden onset

50% report previous short episodes of pain resolving spontaneously

Onset over 24 to 48 hours Typically painless but diffuse pain or dragging sensation/ache in 30%

5 to 15% present with acute pain

Urinary symptoms 90% normal urinanalysis

4% frequency

Dysuria,

Frequency or urgency. Urethritis (smear/FVU) or pyuria

No association
Gastro-intestinal symptoms 33% nausea and vomiting

20 to 30% abdominal pain

Nausea and vomiting if acute orchitis develops May occur due to metastases
Pyrexia Usually absent May be low grade. >40°C in acute orchitis Usually absent
Inspection and palpation Oedema and erythema of affected side Oedema and erythema of affected side Testicle enlarged

15% with inflammation

Enlarged and exquisitely tender testis

high in scrotum

Epididymis distinguishable from tests unless very advanced or scrotum grossly enlarged Solid lump not separated from testis
Transverse lie and anterior epididymis on unaffected side
Cremastric reflex Absent Present Present
Ultrasonography < blood flow > blood flow Hypo-echoic mass within the testis
Causes of painful scrotum
  • Lesions in scrotal skin
    • Dermatitis
    • Irritation (urine/faeces in the incontinent)
    • Infected sebaceous cyst
    • Herpes simplex
    • Behcet’s disease (rare)
    • Fournier’s gangrene (rare)
  • Internal scrotal swellings
    • Strangulated hernia
    • Testicular torsion
    • Torsion of testicular appendage
    • Epididymo-orchitis
    • Haematocele
    • Varicocele
  • Referred pain
    • Ilio-inguinal nerve entrapment after hernia repair
    • Groin strain
    • Idiopathic cord neuralgia
    • Spinal nerve irritation (rare)
Differences between torsion of testis and acute epididymo-orchitis

Torsion of testis

Acute epididymo-orchitis

Age Usually adolescents and children Usually adults or elderly
History Sometimes mild trauma Usually UTI symptoms
Temperature Normal or slightly elevated Elevated
Elevation of scrotum Does not alleviate the pain Partial pain relief
Urgent urine analysis Free May show pus cells
Urgent Doppler or duplex Obstructed testicular vessels Patent testicular vessels
Empty scrotum
  • Maldescended testis
  • Ectopic testis
  • Retractile testis
  • Testicular agenesis
  • Atrophy of testis (after mumps orchitis)
  • Hermaphroditism (bilateral)

Maldescended testis in inguinal canal

Ectopic testis in inguinal region

Low mobility Highly mobile
Hard to feel Easily felt
Disappear with muscle contraction Bulges more with muscle contraction
In the cord Medial to the cord
Common scrotal swellings
  • Sebaceous cyst
  • Indirect inguinal hernia
  • Hydrocele
  • Epididymal cyst (spermatocele)
  • Epididymo-orchitis
  • Testicular torsion
  • Testicular tumor
  • Varicocele
  • Haematocele
  • Sperm granuloma
  • TB
  • Gumma
Classification of testicular tumors
  • Germ cell tumors
  • Seminoma
  • Teratomas
  • Combined seminoma and teratoma
  • Interstitial tumors
  • Leydig cell tumor
  • Sertoli cell tumor
  • Lymphoma

Approach for diagnosis of scrotal swelling

Swelling confined to the scrotum

Testis and epididymis not definable

Testis and epididymis definable

Opaque

Translucent

opaque

Not tender Tender Not tender Tender
  • Chronic heamatocele
  • Gumma
  • Tumor
  • Torsion
  • Sever epididymo-orchitis
  • Acute haematocele
  • Vaginal hydrocele
  • Cyst of epididymis
  • Tuberculous epididymis
  • Tumor
  • Acute epididymo-orchitis

Swelling not confined to the scrotum

  • Cough impulse
  • Reducible
  • Testis palpable
  • opaque
  • No cough impulse
  • Not reducible
  • Testis not palpable
  • Translucent
  • Hernia
  • Infantile hydrocele