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 may 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.
- 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
- Low birth weight
- Clinical features
- 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
- Diagnosis 
- Differential diagnosis: testicular atrophy or agenesis
- Cryptorchidism typically resolves without treatment via spontaneous descent of testicles by 6 months of age.
- Persistent cases require surgery, which should be performed between 6 and 18 months of age.
- Close urological monitoring and early treatment are necessary in individuals with an increased risk of testicular cancer and infertility.
- Definition: The testicle is located outside the normal path of descent (e.g., superficial inguinal pouch, suprapubic region, perineum, femoral canal)
- Treatment: No treatment is necessary.
- Definition: abnormal enlargement and tortuosity of the pampiniform plexus in the scrotum due to proximal obstruction of the spermatic vein
- Most common cause of scrotal enlargement in men
- Found in 15% of healthy men
- The cause of primary varicocele is not fully understood.
- The left testicle is most commonly affected (85% of cases)
- The longer course of the left spermatic vein and its insertion at a 90° angle into the left renal vein predisposes to slower drainage and increased hydrostatic pressure.
- Left renal vein passes between the aorta and superior mesenteric artery → ↑ susceptibility of the renal vein to compression (nutcracker phenomenon) → ↑ intravascular pressure in the left spermatic vein → varicocele formation
- Caused by a mass in the retroperitoneal space (Ormond disease, lymphoma, renal cell carcinoma) obstructing venous drainage into inferior vena cava (right-sided varicocele) or left renal vein (left-sided varicocele) or a thrombotic event (e.g., pampiniform plexus obstruction in renal cell carcinoma)
- Persist in the supine position due to a physical obstruction to blood flow within the spermatic vein
- 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
- Negative transillumination
- In rare cases, paresthesia is possible.
|Grading of varicocele (Sarteschi classification) |
|Grade I|| |
- Conservative management: scrotal support
- Invasive treatment
- Definition: painless accumulation of fluid in a sac around one or both testicles which derives from the tunica vaginalis, a tissue covering the testes
- Idiopathic (most common)
- Congenital hydrocele
- Acquired hydrocele
- Clinical features
- Usually a clinical diagnosis
- Ultrasound: hypoechoic fluid confirms the diagnosis.
- Differential diagnosis
Treatment: Congenital hydrocele usually resolves spontaneously within 6 months of birth. 
- Indications for surgery