• Clinical science

Scrotal abnormalities

Summary

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
  • 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
  • Complications

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

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
  • Epidemiology: 15/100 men
  • Etiology
    • Idiopathic/primary
      • The cause of primary varicocele is not fully understood.
      • The left testicle is most commonly affected (85% of cases)
    • Symptomatic/secondary
  • Symptoms
    • A painless enlargement may be present
    • 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”)
    • Symptoms worsen when standing or when performing the Valsalva maneuver.
    • Negative transillumination
    • In rare cases, paresthesia is possible
  • Diagnosis
    • Ultrasound: dilated (> 2 mm) hypoechoic pampiniform vessels
  • Complications
  • Treatment
    • Conservative management: scrotal support
    • Invasive treatment
      • Indications
        • Adolescents with testicular atrophy or delayed growth of the affected testicle
        • Painful varicocele
        • Infertile men (confirmed with an abnormal sperm analysis)
      • Procedures: laparoscopic varicocelectomy or percutaneous embolization
    • Young men without testicular atrophy, pain, 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 when varicocele is suspected, as the condition may manifest bilaterally.

A unilateral right-sided varicocele is uncommon and should raise suspicion of a mass in the retroperitoneal space (Ormond's disease, lymphoma, renal cell carcinoma) blocking the spermatic vein.

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)
    • Communicating or noncommunicating
      • Communicating hydrocele (usually discovered in infancy): failed closure of processus vaginalis during development
      • Noncommunicating hydroceles: no connection to the peritoneal cavity present
  • 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]