• Clinical science

Scrotal abnormalities

Abstract

Scrotal abnormalities include various conditions such as varicoceles, hydroceles, and malpositioning of the testicles (e.g., cryptorchidism, retractile testes). The most common congenital anomaly is cryptorchidism, which involves the incomplete descent of the testicle into the scrotum. The testicle may be located within the abdominal cavity, inguinal canal, or at the external inguinal ring. Cryptorchidism is associated with an increased risk of infertility and/or testicular cancer; therefore, early diagnosis and initiation of medical or surgical treatment are essential. Retractile testes usually do not require surgical intervention. A varicocele is the abnormal dilation of the pampiniform vessels within the scrotum. Patients complain of a dull, aching, and swollen scrotum (typically on the left). A “bag of worms” sensation may be palpable at the apex of the scrotum. Surgery is required in complicated cases (i.e. concurrent testicular atrophy or infertility), while conservative treatment may be considered in older patients. A hydrocele is a fluid-filled sac derived from the tunica vaginalis or remnant of the processus vaginalis (infantile hydrocele) which results in a painless swelling of the scrotum that occurs at birth or later in life. Typical clinical findings and transillumination confirm the diagnosis. Hydroceles usually resolve spontaneously, but surgery may be indicated in prolonged congenital forms to prevent inguinal hernia.

Cryptorchidism

  • Definition: failure of one or both testicles to descend to their natural position in the scrotum
  • Epidemiology: most common congenital anomaly of the genitourinary tract
  • Etiology: unknown, possibly multifactorial
  • Risk factors
    • Prematurity
    • Low birth weight
  • Clinical features
    • Palpable (in 80% of cases): testicle cannot be manually manipulated into the scrotum
    • Non-palpable: may be intra-abdominal or absent
    • Possible variations
      • Inguinal testis: The testicle is located between the external and internal inguinal ring, preventing adequate mobilization (90% of cases).
      • Intra-abdominal testis: The testicle is located proximal to the internal inguinal ring.
      • Ascending testes: Testicular retraction into the scrotal pouch is possible; however, the testes immediately retract into the groin after manipulation.
  • Treatment: Surgery is recommended between 6–18 months of age.
    • Orchidopexy: exposure and fastening of the testicle to the scrotum
    • Non-palpable testes: potentially therapeutic open or laparoscopic orchidopexy
    • Orchiectomy (removal of the affected testicle) in cases of nonviable testicular remnants or late discovery of undescended testicle (> 2 years)
    • Close urological monitoring and early treatment are necessary in individuals with an increased risk of testicular cancer and infertility.
    • Conservative: Some centers administer hCG or GnRH as an adjuvant therapy along with surgery in order to improve fertility.
  • Complications

References:[1][2][3][4][5][6][7][8][9]

Ectopic testis

  • Definition: The testicle is located outside the normal path of descent.

Close urological monitoring is necessary, as the risk of testicular cancer and infertility is increased!
References:[6]

Retractile testis

  • Definition: temporary displacement of the testicle in the inguinal canal by the cremasteric reflex. The testis may be easily repositioned back into the scrotal pouch.
  • Treatment: No treatment is necessary.

References:[6]

Varicocele

  • Definition: abnormal enlargement and tortuosity of the pampiniform plexus in the scrotum due to proximal obstruction of the spermatic vein
  • Etiology
    • Idiopathic/primary
    • Symptomatic/secondary
  • Symptoms
    • May be a painless enlargement
    • Dull, aching pain of the hemiscrotum (typically left-sided)
    • Heaviness of the affected scrotum
    • Soft bands/strands are palpable in the upper pole of the affected scrotum (bag of worms” sensation)
    • Symptoms worsen when standing or when performing a Valsalva maneuver
    • Negative transillumination
    • In rare cases, paresthesia is possible because of the increase in size.
  • Diagnosis
    • Ultrasound: dilated (> 2 mm) hypoechoic pampiniform vessels
    • Doppler ultrasonography
    • In some cases, imaging studies of the retroperitoneum
  • Complications
  • Treatment
    • Invasive treatment
      • Indications
        • Adolescents with testicular atrophy or delayed growth of the affected testicle
        • Adult men with evidence of infertility (confirmed with an abnormal sperm analysis)
      • Procedures: laparoscopic varicocelectomy or percutaneous embolization
    • Conservative management (indicated in older patients): NSAIDs and scrotal support
    • Young men without testicular atrophy or evidence of infertility should receive follow-ups (regular assessment of testicle size and/or semen analyses every 1–2 years).

Always perform an ultrasound of both testicles, as bilateral manifestations may occur!

References:[10][2][11][5][12]

Hydrocele

  • Definition: Painless accumulation of fluid in a sac around one or both testicles which derives from the tunica vaginalis, a tissue covering the testes.
  • Etiology
    • Idiopathic (most common)
    • Secondary to underlying pathology (e.g., trauma, tumor, torsion)
      • Wuchereria bancrofti infection is the most common cause worldwide, but is basically nonexistent in the US (see lymphatic filariasis)
    • Communicating or noncommunicating
  • Clinical features
    • Fluctuant, painless swelling of affected scrotum
      • May be present since infancy or childhood.
      • May or may not be reducible.
    • Palpation above the swelling is possible: a normal spermatic cord and inguinal ring are present.
    • Positive transillumination
  • Diagnosis
    • Usually a clinical diagnosis
    • Ultrasound: hypoechoic fluid confirms the diagnosis.
  • Treatment
    • Usually resolves spontaneously within 6 months of birth
    • Indications for surgery
      • If spontaneous resolution does not occur in children by 1 year of age
      • Excessive discomfort and/or if scrotal skin integrity is compromised
      • An underlying pathology is suspected
      • Testicle not palpable
      • If infertility is a concern
    • Procedures

A hydrocele must be differentiated from an inguinal hernia!

References:[1][2][5][13][14][12][15]