Scrotal Enlargement
Scrotal Enlargement: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
The presence or absence of testicular painis useful in the diagnostic approach to the problem of scrotal enlargement.
Principal Causes of Scrotal Enlargement
- Painfulscrotal enlargement
- Testicular
- Torsion of the testis
- Orchitis
- Trauma
- Nontesticular
- Torsion of appendages of the testisand epididymis
- Epididymitis
- Incarcerated inguinal hernia
- Nonpainful scrotal enlargement
- Testicular
- In uterotorsion
- Tumor
- Nontesticular
- Inguinal hernia
- Hydrocele
- Spermatocele
- Varicocele
- Henoch-Schönlein purpura
- Kawasaki disease
- Meconium peritonitis
- Tumors of the epididymis, spermaticcord, or scrotal wall
- Generalized edema
Clinical Features and Diagnosis
Painful Scrotal Enlargement
Testicular
Torsion of Testis
Twistingof spermatic cord causes diminished blood flow to testis and acutescrotal pain. Lower abdominal pain and vomiting also may occur.Tender, swollen testis is located higher in scrotum, and cremastericreflex is usually absent.History of intermittent bouts of scrotalpain may indicate previous intermittent torsion.In many cases, diagnosis can be madeclinically and should be confirmed by prompt surgical exploration.If diagnosis is uncertain, procedure of choice to determine testicularperfusion is U/S with color flow Doppler. Orchitis
May existas isolated viral infection (mumps virus is most common) or as extension ofepididymitis.Unusual before puberty.1 or both testes are swollen and painful.With mumps infection, orchitis usuallyoccurs a few days after onset of parotitis. Trauma
Trauma toscrotum may produce a spectrum of disease, including mild swelling,hematoma formation, or rupture of testis with blood in scrotum.U/S is procedure of choiceto assess structural integrity of scrotum. Nontesticular
Torsion of Appendages of Testis and Epididymis
Attachedto the testis and epididymis are vestiges of embryologic remnantsthat can twist around their base, producing infarction. This iscalled torsion of appendix testis or appendix epididymis.Usual age of occurrence is school agebefore adolescence. Pain is usually not as severe as with torsionof testis and develops over a few days. Tender bluish nodule signifyingtorsion of appendix testis is often seen at superior lateral aspectof testis. Torsion of appendix epididymis occurs at head of epididymis.This is often clinical diagnosis; however,scrotal U/S should be performed if diagnosis is uncertain. Epididymitis
Most commonin adolescents who are sexually active, whereas younger boys tendto have associated urinary tract infection.Scrotal pain and swelling as well asepididymal tenderness are usual findings. Early in illness, it maybe possible to distinguish epididymis from testis, but this maybe impossible with progression of inflammation and swelling.If diagnosis is uncertain, scrotalU/S with color flow Doppler can be performed. UA and urineculture also should be performed.After course of appropriate treatmentin older age group, if dysfunctional voiding exists, urinary urodynamictesting should be performed. In younger age group after course ofappropriate treatment, renal U/S and contrast voiding cystourethrographyshould be performed, because urinary tract anomalies (e.g., posteriorurethral valves or ectopic ureter emptying into seminal vesicle)may occur. Incarcerated Inguinal Hernia
Painful,tender mass is palpable in inguinal area with extension at timesinto scrotum.If hernia cannot be reduced, compromiseof bowel may occur, and surgery should be performed immediately.If hernia can be reduced, surgery is usually performed in a fewdays, after swelling has decreased. Nonpainful Scrotal Enlargement
Testicular
In Utero Torsion
Poor fixationof spermatic cord during fetal life predisposes to in utero torsionof testis during testicular descent.Firm testicular mass is discolored,and salvage of infarcted testis is unlikely.Although some controversy exists aboutmanagement, exploration and contralateral orchiopexy are performedelectively in our hospital once infant is stable. Tumor
Testiculartumors are rare in children and usually present as painless, firmto hard, testicular masses. Most common ones include yolk sac tumor,teratoma, and testis infiltration with leukemia or non-Hodgkin lymphoma.Scrotal U/S can confirm presenceof testicular tumor. Histologic diagnosis is definitive. Nontesticular
Inguinal Hernia
May extend into scrotum and produce enlargedscrotum. Increased intraabdominal pressure with crying or strainingmay produce recurrent episodes of painless inguinal and scrotalswelling. Although reduction is usually easy, hernia should be repairedto prevent incarceration.
Hydrocele
Fluid withintunica vaginalis surrounding testis is called a hydrocele. Becausepatent processus vaginalis permits communication with abdominalcavity, hydrocele may change in size because of changing amountof fluid in scrotum.Communicating hydrocele tends to persistand may lead to development of inguinal hernia if diameter of processusbecomes larger. Closed processus results in formation of noncommunicatinghydrocele. Its size does not fluctuate, and fluid often disappearsby 1 yr of age.Hydrocele of spermatic cord may presentas fluid-filled inguinal canal mass.Occasionally, hydrocele may occur inolder children secondary to trauma, inflammation, or testiculartumor.U/S is helpful if diagnosisis uncertain. Spermatocele
Is a sperm-containing cyst of rete testes,ductuli efferentes, or epididymis. It is nontender, usually <1cm in diameter, and located posterior and superior to testis inpostpubertal boys. Aspiration yields milky fluid composed of spermcells. Surgery may be required if cyst is painful.
Varicocele
Group ofdilated, elongated spermatic cord veins, which may be seen in boys10–15 yrs of age. Most varicoceles occur on left side.Scrotum is enlarged and sometimes painful.Mass is often described as bag of worms. Veins are palpable on standingbut collapse and disappear in supine position. Valsalva maneuveror coughing also may cause varicocele to become more apparent.Presence of testicular atrophy on affectedside is indication for surgery because of possible occurrence ofinfertility. Henoch-Schönlein Purpura
Purpuric rash in this disorder typicallyoccurs on buttocks and lower legs. Occasionally, rash may involvescrotum and cause some swelling. See Chap.28, Hematuria.
Kawasaki Disease
Scrotal swelling also may occur with Kawasakidisease, which is discussed in Chap.21, Fever.
Meconium Peritonitis
Intestinalperforation is cause of antenatal meconium peritonitis. Meconiumpasses along patent processus vaginalis into scrotum, and bilateralneonatal hydroceles may be palpable as firm nodular masses on 1or both sides of scrotum.Abdominal radiography that includesscrotum demonstrates calcifications in scrotum as well as underdiaphragm. U/S also may confirm diagnosis. Tumors of Epididymis, Spermatic Cord, or Scrotal Wall
Benign tumorsinclude lipoma, fibroma, leiomyoma, and lymphangioma. Paratesticularrhabdomyosarcoma is of most concern.U/S can help locate and defineextent of tumor.Histologic diagnosis is definitive. Generalized Edema
Scrotal edema may occur as part of generalizededema, which is discussed in Chap.17, Edema. Testis and spermatic cord are normal.
Diagnostic Approach
Cause ofscrotal enlargement often can be determined clinically based onhistory and physical exam. Age of child, type of presentation (acuteor chronic, unilateral or bilateral), and presence of scrotal ortesticular pain or testicular enlargement are distinguishing featuresuseful in diagnosis.Torsion of testis, torsion of appendixtestis, and epididymitis often can be distinguished clinically earlyin clinical course. With progression of disease process, this maynot be possible. If diagnosis is uncertain, U/S with colorflow Doppler should be performed. Surgical exploration is indicatedwhenever there is high suspicion of torsion of testis.Transillumination can help distinguishsolid or cystic lesions, but incarcerated inguinal hernia also cantransilluminate.U/S can determine whethermass is testicular or nontesticular and can distinguish solid from cysticlesions.Nontesticular cystic lesions are usuallybenign and can be managed according to specific diagnosis. Testicularmass is assumed to be malignant tumor until proven otherwise. References
- Kadish HA, Bolte RG. A retrospectivereview of pediatric patients with epididymitis, testicular torsion,and torsion of the testicular appendages. Pediatrics 1998;102:73–76.
- Kass EJ, Lundak B. The acute scrotum. Pediatr ClinNorth Am 1997;44:1251–1266.
- Klein BL, Ochsenschlager DW. Scrotal masses in childrenand adolescents: a review for the emergency physician. Pediatr EmergCare 1993;9:351–361.
- Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluationof the acute scrotum in the emergency department. J Pediatr Surg1995;30:277–282.
- MacDonald NE. Epididymitis, orchitis, and prostatitis.In: Long SS, et al., eds. Principles and practice of pediatric infectiousdiseases. New York: Churchill Livingstone, 1997:402–405.
- Perron CE. Pain—scrotal. In: Fleisher GR,Ludwig S, eds. Textbook of pediatric emergency medicine, 4th ed.Philadelphia: Lippincott Williams & Wilkins, 2000:473–481.
- Rowe MI, et al. Essentials of pediatric surgery. St.Louis: Mosby-Year Book, 1995.
- Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
- Siegel MJ. The acute scrotum. Radiol Clin North Am1997;35:959–976.
- Skoog SJ. Benign and malignant scrotal masses. PediatrClin North Am 1997;44:1229–1250.
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Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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