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A scrotal swelling

1.   How would you clinically determine the cause of this scrotal swelling?
2.   What is your differential diagnosis?
3.   How would you treat either of these conditions?

This large scrotal swelling was an inguinoscrotal hernia.  The swelling was not confined to the scrotum and with difficulty it could be reduced.  The swelling was separate from the testis and it did not transilluminate. Its size prevented the adequate demonstration of a cough impulse,  If it had been a hydrocele it would have been irreducible, would not have had a cough impulse and the testis would have been impalpable. The examiner would have been able to get above it and it would have transilluminated brightly.

Other causes of scrotal swellings include testicular tumours, acute epididymo-orchitis, epididymal cysts and rarely haematoceles and gummas.  All of these swellings are confined to the scrotum.  Testicular tumours usually present as painless lumps arising from and rarely replacing the testis.  Epididymo-orchitis usually causes a painful erythematous swelling of the hemi-scrotum.  Both the testis and epididymis are swollen and exquisitely tender.  An epididymal cyst causes a painless epididymal lump palpable separate from the testis.  Gummas and haematoceles, like tumours, present as painless scrotal swellings, but unlike tumours, the testis and epididymis can not be easily defined.

In those patients who are considered fit for operation, large indirect hernias usually require surgery.  Surgery is offered both to relieve symptoms and prevent the risk of strangulation, the mortality of which has not improve over the past 30 years. Whether all elderly men with easily reducible direct hernias require surgery is a controversial issue.  Many different types of hernia repair have been described over the last 100 years.  The Bassini repair involved apposition of the conjoint tendon, under tension, down to the inguinal ligament.  Such a repair has been associated with recurrence rates as high as 10%.  Today, the techniques that have been shown to be associated with the lowest recurrence rates have been the Lichtenstein mess repair and the Shouldice repair.  The Shouldice repair is more technically demanding, involving a four layer reconstruction of the transversalis fascia, but in good hand recurrence rates as low as 0.1% have been reported.  All mesh repairs are based on tension-free reinforcement of the posterior wall of the inguinal canal.  This is the commonest technique used in the United Kingdom today.

Hydrocele are usually seen in elderly men.  Asymptomatic small hydrocele require no treatment.  They can be aspirated but this method of treatment is associated with both a high recurrence rate and also with the risk of infection.  Various operative techniques have been described.  In all of these procedures the scrotum is incised and the hydrocele drained.  The sac of the hydrocele can be excised.  Alternatively, the sac can be plicated (Lord's or Riddle's procedure).  In a Jaboulay procedure the sac is everted and sutured behind the testis.

Recent papers

Working Party of the Royal College of Surgeons.  Clinical guidelines on the management of groin hernias in adults.  RCS London 1993.

Kingsnorth A N.  Modern hernia management.  In: eds. Taylor I Johnson C D Recent Advances in surgery 18. Churchill Livingston 1995.  159 - 178.

Kingsnorth A N. Inguinal hernia repair.  Current Practice in Surgery 1993; 5: 202 - 206.

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