Scrotal Swelling

A scrotal mass may or may not be detected by the patient or the patient's parent. Many are discovered by the clinician during routine physical examinations. Most scrotal masses seen in infants are hydroceles and inguinal hernias; both are more common in premature infants. Hernia is the most common cause in teenagers.

Differential Diagnosis

• Hydrocele
  –Fluid surrounding the testicle
  –Typically seen in infancy
  –Results from remnant of testicular descent from the abdomen through the inguinal canal into the scrotum
  –May be communicating or noncommunicating; communicating hydroceles have retained patency of the tract of descent, and noncommunicating hydroceles do not
  –Communicating hydroceles may be reducible and are likely to fluctuate in size depending on the amount of fluid within the scrotal sac; crying or any increase in intra-abdominal pressure results in an increase in size
  –Usually is noncommunicating; i.e., not reducible, and does not change in size with crying
  –Testes may be difficult to palpate because surrounded by the hydrocele

• Hernia
  –Protrusion of a loop of bowel into the scrotum
  –Direct hernias represent a channel directly through the musculature of the pelvic floor; indirect hernias have proceeded through the inguinal canal
  –Usually painless unless incarcerated
  –Usually reducible and changes in size with changes in intra-abdominal pressure
  –Testes usually palpable below the hernia

• Varicocele
  –A collection of dilated veins in the scrotum
  –Usually painless, but patients may complain of heaviness
• Edema
  –Generalized edema often is accompanied by scrotal edema
• Tumor
  –Presents as painless nodule on testes
  –May be accompanied by sexual precocity or gynecomastia secondary to hormone production by the tumor
• Leukemia
  –Patients may present with unilateral scrotal swelling (common site for relapse)

Workup and Diagnosis

• History
  –Onset, duration of symptoms
  –Unilateral or bilateral
  –Associated systemic symptoms
• Physical exam
  –General state of health, including growth parameters and weight loss
  –Unilateral or bilateral lesions
  –Reducibility of scrotal mass or enlargement
  –Palpation of testes: Tenseness, nodules
  –Hydroceles can sometimes be transilluminated
  –Patent defects can usually be palpated when there is a hernia, particularly if the patient performs a Valsalva maneuver (“turn your head and cough”)
  –Varicocele is usually left sided and feels like “a bag of worms”
  • Labs
    –CBC and differential, LDH, ESR if malignancy is suspected
  • Radiology
    –Ultrasound may be helpful confirming hernia, hydrocele, or varicocele
    –PET scans are used to detect malignant metastasis or relapse
  • Studies
    –A testicular nodule usually must be biopsied to rule out malignancy

  Treatment

  • Hydrocele
    –Usually resolves spontaneously by 1 year of age
    –Surgery is indicated at 6–12 months if stable, sooner if hydrocele is tense or progressively enlarging
  • Hernia
    –Inguinal hernias must be repaired surgically to avoid incarceration
    –Contralateral side is frequently explored surgically and closed if necessary
  • Varicocele: Can be associated with infertility and may need to be surgically repaired
  • Edema: Treatment of the cause of generalized edema
  • Tumor and leukemia: Management by pediatric oncologist
  • Men and teenage boys should be taught testicular self-examination to assist with early detection of testicular cancer

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: HEADACHE (Differential Diagnosis in Primary Care)

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