Approach to the Problem
Common causes of scrotal swelling vary by age. Inguinal hernia is a common cause of scrotal swelling at any age. Spermatocele, varicocele, and primary testicular tumors are seen predominantly during adolescence. An acute scrotum may be caused by epididymitis, testicular torsion, or torsion of the testicular appendage (appendix testis torsion). At any age, generalized edema or edema in reaction to local trauma or inflammation may cause scrotal swelling that can be quite significant. To prevent ischemic damage and the need for the removal of the testicle, rapid diagnosis and intervention are essential when testicular torsion is suspected.
Key Points in the History
• A swelling present since birth suggests a hydrocele or hydrocele of the spermatic cord, while the acute onset of scrotal swelling is more suggestive of a reactive hydrocele, testicular torsion, or epididymitis.
• Fluctuation in the swelling size with physical activity or Valsalva maneuvers may be seen with a communicating hydrocele or inguinal hernia.
• A history of sexual activity, urethral discharge, or both may be present in patients with epididymitis.
• Pain, especially acute, raises the concern for testicular torsion.
• A history of nausea, vomiting, or abdominal distension in a patient with a suspected inguinal hernia suggests incarceration.
• Recurrent epididymitis may be seen in patients with dysfunctional voiding.
Key Points in the Physical Examination
• The scrotum of an adolescent male should be examined in the standing position. Varicoceles may be missed when the patient is recumbent.
• Use of a Valsalva maneuver may aid in the detection of hernias, communicating hydroceles and varicoceles.
• Scrotal swelling with fullness at the inguinal ring is consistent with an inguinal hernia or hydrocele of the spermatic cord.
• A smooth mass that transilluminates when a light source is applied directly to the scrotum suggests a hydrocele.
• In testicular torsion, the affected testis may appear to sit higher than the contralateral testes.
• Redness limited to the upper pole of the testis is consistent with torsion of the appendix testis.
• The testicular surface should be smooth; an irregular surface should raise suspicion for a testicular tumor.
• The presence of tenderness, firmness, or discoloration suggests incarceration or strangulation of an inguinal hernia.
• The reduction of an apparent hydrocele is consistent with a communicating hydrocele or an inguinal hernia.
• Edema affecting both sides of the scrotum may occur in patients with generalized edema—for example, in patients with hypoalbuminemia—and in patients with local trauma, including blunt trauma to the perineal area or severe perineal dermatitis.
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PHOTOGRAPHS OF SELECTED DIAGNOSES |
Figure 58-1 Schematic of a hydrocele, varicocele, and spermatocele. (Image from Rubin E, Farber JL. Pathology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.)
Figure 58-2 Varicocele with “bag of worms” appearance above the testicle. (Courtesy of T. Ernesto Figueroa, MD, FAAP, FACS.)
Figure 58-3 Infant with a hydrocele. (Courtesy of T. Ernesto Figueroa, MD, FAAP, FACS.)
Figure 58-4 Inguinal hernia. Note the fullness near the inguinal ring. (Courtesy of Philip Siu, MD.)
Figure 58-5 Adolescent with testicular torsion. (Courtesy of T. Ernesto Figueroa, MD, FAAP, FACS.)
Figure 58-6 Torsion of the appendix testis with reactive hydrocele. (Courtesy of T. Ernesto Figueroa, MD, FAAP, FACS.)
Figure 58-7 Testicular tumor. (Courtesy of T. Ernesto Figueroa, MD, FAAP, FACS.)
Figure 58-8 Scrotal swelling in a 7-year-old boy with nephrotic syndrome. (Used with permission from Fleisher GR, Ludwig S, Baskin MN. Atlas of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:304.)
DIFFERENTIAL DIAGNOSIS
Other Diagnoses to Consider
• Henoch–Schönlein purpura
• Leukemic infiltration
• Intraperitoneal hemorrhage
• Inguinal lymphadenopathy
• Generalized edema
When to Consider Further Evaluation or Treatment
• Acute scrotal swelling that suggests the possibility of testicular torsion requires emergent evaluation by a urologist or general surgeon.
• Newborns with a noncommunicating hydrocele can be observed for resolution.
• During the examination of a suspected hydrocele, fluctuation of the volume of fluid suggests a communicating hydrocele or hernia. Communicating hydroceles and hernias should be referred for surgical evaluation and treatment.
• If a hernia is incarcerated or strangulated, the patient should be referred for emergent surgical evaluation.
• Treatment of varicoceles in adolescents is controversial. Patients should be referred to a urologist or pediatric surgeon to discuss treatment options.
• A suspected tumor of the testis requires further evaluation and referral to a urologist. Ultrasound will localize the tumor and may be helpful in differentiating benign tumors from malignant tumors. Tumor markers (e.g., hCG and AFP) may also be helpful.
SUGGESTED READINGS
Fleisher GR, Ludwig S, Baskin MN. Atlas of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:304.
Leslie JA, Cain MP. Pediatric urologic emergencies and urgencies. Pediatr Clin North Am. 2006;53:513–527.
Merrian LS, Herrel L, Kirsch AJ. Inguinal and genital anomalies. Pediatr Clin North Am. 2012;59:769–781.
Serefoglu EC, Saitz TR, La Nasa JA, et al. Adolescent varicocele management controversies. Andrology. 2013;1:109–115.
Sheldon CA. The pediatric genitourinary examination. Pediatr Clin North Am. 2001;48:1339–1380.
Wan J, Bloom DA. Genitourinary problems in adolescent males. Adolesc Med. 2003;14:717–731.