Scrotal Swelling

Overview

Scrotal swelling is a common urological complaint that can occur at any age, from newborns to elderly men. The scrotum is a thin-walled sac that houses the testicles, epididymis, and the initial portion of the spermatic cord. Due to its dependent position and loose skin, the scrotum is particularly susceptible to fluid accumulation and swelling. The condition can develop suddenly or gradually, may be painless or painful, and can affect one side (unilateral) or both sides (bilateral) of the scrotum.

The severity and implications of scrotal swelling vary greatly depending on the underlying cause. While some causes are benign and self-limiting, others require urgent medical intervention to prevent complications such as testicular loss or systemic infection. The scrotum's anatomy, with its multiple layers and structures, means that swelling can originate from the skin, the layers surrounding the testicle, the testicle itself, or from adjacent structures such as the inguinal canal.

Understanding scrotal swelling is important because early recognition and appropriate treatment can prevent serious complications. The condition affects quality of life, causing discomfort, embarrassment, and anxiety. In some cases, scrotal swelling may be the first sign of a systemic condition such as heart failure or kidney disease. Proper evaluation by a healthcare provider is essential to determine the cause and appropriate management strategy.

Symptoms

Scrotal swelling can present with various accompanying symptoms that help identify the underlying cause. The nature, onset, and associated features of the swelling provide important diagnostic clues.

Condition-Specific Presentations

• Hydrocele: Painless swelling that transilluminates, may increase throughout the day
• Varicocele: Dull ache, worse with standing, improves when lying down
• Epididymitis: Gradual onset pain, tenderness, urinary symptoms
• Testicular torsion: Sudden severe pain, nausea, high-riding testicle
• Inguinal hernia: Swelling that extends into groin, increases with coughing
• Testicular cancer: Painless firm mass, heaviness sensation

Causes

Scrotal swelling can result from numerous conditions affecting different anatomical structures within or adjacent to the scrotum. Understanding these causes is crucial for appropriate diagnosis and treatment.

Fluid Accumulation

• Hydrocele: Collection of fluid between layers of the tunica vaginalis
  • Communicating: Connected to peritoneal cavity
  • Non-communicating: Isolated fluid collection
  • Can be congenital or acquired
• Lymphedema: Accumulation of lymphatic fluid due to obstruction
• Edema: General fluid retention from heart failure, liver disease, or kidney disease
• Hematocele: Blood collection, usually from trauma

Vascular Causes

• Varicocele: Dilated veins of the pampiniform plexus
  • More common on left side (90%)
  • Often described as "bag of worms"
  • May affect fertility
• Testicular torsion: Twisting of spermatic cord cutting off blood supply
• Thrombosis: Blood clot in scrotal vessels

Infectious Causes

• Epididymitis: Inflammation of the epididymis
  • Bacterial: E. coli, STIs (gonorrhea, chlamydia)
  • Viral: Mumps, other viruses
  • Most common cause of scrotal pain in adults
• Orchitis: Inflammation of the testicle, often with epididymitis
• Fournier's gangrene: Severe necrotizing infection (emergency)
• Cellulitis: Skin and soft tissue infection
• Abscess: Localized collection of pus

Structural Abnormalities

• Inguinal hernia: Intestinal contents protruding into scrotum
• Spermatocele: Cyst of the epididymis containing sperm
• Epididymal cyst: Benign fluid-filled cyst
• Testicular appendix torsion: Twisting of vestigial remnant

Neoplastic Causes

• Testicular cancer: Germ cell tumors, stromal tumors
• Paratesticular tumors: Rare tumors of surrounding structures
• Lymphoma: Can involve testicles
• Metastatic disease: Rare but possible

Traumatic Causes

• Testicular rupture: From severe blunt trauma
• Hematoma: Blood collection from injury
• Post-surgical swelling: After vasectomy, hernia repair

Systemic Causes

• Heart failure: Right-sided failure causing dependent edema
• Liver cirrhosis: Portal hypertension and hypoalbuminemia
• Nephrotic syndrome: Protein loss leading to edema
• Filariasis: Parasitic infection (in endemic areas)

Risk Factors

Various factors can increase the likelihood of developing scrotal swelling. Understanding these risks helps in prevention and early detection of underlying conditions.

Diagnosis

Accurate diagnosis of scrotal swelling requires a systematic approach combining history, physical examination, and appropriate investigations. The urgency of evaluation depends on the presentation.

Medical History

• Onset and duration: Sudden vs. gradual development
• Pain characteristics: Severity, quality, radiation
• Associated symptoms: Fever, urinary symptoms, nausea
• Precipitating factors: Trauma, heavy lifting, sexual activity
• Past medical history: Previous episodes, surgeries, STIs
• Sexual history: Recent partners, protection use
• Systemic symptoms: Weight loss, night sweats

Physical Examination

Laboratory Tests

• Urinalysis: Infection, pyuria, hematuria
• Urine culture: Identify bacterial pathogens
• STI testing: Gonorrhea, chlamydia PCR
• Complete blood count: Infection markers
• Tumor markers: AFP, beta-hCG, LDH for testicular cancer
• Blood cultures: If systemic infection suspected

Imaging Studies

Special Tests

• Surgical exploration: When torsion cannot be ruled out
• Fine needle aspiration: For fluid analysis in hydroceles
• Biopsy: Rarely needed, mainly for suspected malignancy

Treatment Options

Treatment of scrotal swelling depends entirely on the underlying cause. Options range from conservative management to emergency surgery. Early diagnosis and appropriate treatment are crucial for optimal outcomes.

Emergency Treatments

Medical Management

Surgical Treatments

Treatment of Underlying Conditions

• Heart failure: Diuretics, cardiac medications
• Liver disease: Manage ascites, treat underlying cause
• Kidney disease: Dialysis if needed, fluid management
• Lymphatic obstruction: Compression, lymphatic drainage

Cancer Treatment

• Radical orchiectomy: Through inguinal approach
• Chemotherapy: Based on tumor type and stage
• Radiation therapy: For specific tumor types
• Retroperitoneal lymph node dissection: If indicated
• Surveillance: For early-stage disease

Follow-up Care

• Monitor for treatment response
• Ensure infection resolution with repeat cultures
• Fertility assessment if varicocele or infection
• Cancer surveillance protocols
• Management of chronic conditions

Prevention

While not all causes of scrotal swelling can be prevented, many risk factors can be modified to reduce the likelihood of developing this condition.

Infection Prevention

• Safe sexual practices: Condom use, limiting partners
• STI screening: Regular testing for sexually active individuals
• Proper hygiene: Regular washing, keeping area dry
• Prompt treatment: Of urinary tract infections
• Mumps vaccination: Prevents viral orchitis

Trauma Prevention

• Protective equipment: Athletic cup for contact sports
• Proper lifting technique: Avoid straining
• Seat adjustment: Proper bicycle seat positioning
• Workplace safety: In high-risk occupations

General Health Measures

• Regular self-examination: Monthly testicular self-exams
• Maintain healthy weight: Reduces hernia risk
• Manage chronic conditions: Heart, liver, kidney disease
• Avoid prolonged sitting: Take regular breaks
• Stay hydrated: Prevents kidney stones, UTIs

Early Detection

• Know normal anatomy and appearance
• Report changes promptly to healthcare provider
• Don't delay seeking care for scrotal pain
• Regular check-ups for those at high risk

When to See a Doctor

Scrotal swelling always warrants medical evaluation, but the urgency depends on accompanying symptoms. Some conditions require immediate emergency care to prevent permanent damage.

Related Conditions

References

1. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009;79(7):583-587.
2. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
3. Dagur G, Gandhi J, Suh Y, et al. Classifying hydroceles of the pelvis and groin: An overview of etiology, secondary complications, evaluation, and management. Curr Urol. 2017;10(1):1-14.
4. Leslie SW, Sajjad H, Siref LE. Varicocele. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
5. Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam Physician. 2014;89(9):723-727.