Scrotal abnormalities

Scrotal abnormalities include various conditions such as varicoceles, hydroceles, and malpositioning of the testicles (e.g., cryptorchidism, retractile testes). The most common congenital anomaly is cryptorchidism, which involves the incomplete descent of the testicle into the scrotum. The testicle may be located within the abdominal cavity, inguinal canal, or at the external inguinal ring. Cryptorchidism is associated with an increased risk of infertility and/or testicular cancer; therefore, early diagnosis and initiation of medical or surgical treatment are essential. Retractile testes usually do not require surgical intervention. A varicocele is the abnormal dilation of the pampiniform vessels within the scrotum. Patients may complain of a dull, aching, and swollen scrotum (typically on the left). A “bag of worms” sensation may be palpable at the apex of the scrotum. Surgery is required in complicated cases (i.e. concurrent testicular atrophy or infertility), while conservative treatment may be considered in older patients. A hydrocele is a fluid-filled sac derived from the tunica vaginalis or remnant of the processus vaginalis (infantile hydrocele) which results in a painless swelling of the scrotum that occurs at birth or later in life. Typical clinical findings and transillumination confirm the diagnosis. Hydroceles usually resolve spontaneously, but surgery may be indicated in prolonged congenital forms to prevent inguinal hernia.

• Definition: failure of one or both testicles to descend to their natural position in the scrotum
• Epidemiology: most common congenital anomaly of the genitourinary tract ^[1]
• Etiology: unknown, possibly multifactorial
• Risk factors
  • Prematurity
  • Low birth weight
• Clinical features
  • Palpable (80% of cases): testicle cannot be manually manipulated into the scrotum ^[2]
  • Non-palpable: may be intra-abdominal or absent
• Variants
  • Inguinal testis: The testicle is located between the external and internal inguinal ring, preventing adequate mobilization (90% of cases).
  • Intra-abdominal testis: The testicle is located proximal to the internal inguinal ring.
  • Ascending testes
    • Testicular retraction into the scrotal pouch is possible.
    • However, the testes immediately retract into the groin after manipulation.
• Diagnosis ^[3]
  • Primarily a clinical diagnosis
  • Laboratory tests
    • Testosterone
      • Bilateral cryptorchidism: ↓ testosterone levels
      • Unilateral cryptorchidism: normal levels (normal Leydig cell function)
    • ↓ Inhibin B
    • ↑ FSH, ↑ LH
• Differential diagnosis: testicular atrophy or agenesis
• Treatment ^[4]
  • Cryptorchidism typically resolves without treatment via spontaneous descent of testicles
  • Persistent cases require surgery, which should be performed as soon as possible after 6 months of age.
    • Orchiopexy
      • Open/laparoscopic orchiopexy is used when testes are not palpable in the scrotum.
      • Exposure and fastening of the testicle to the scrotum
      • Orchiectomy: in cases of nonviable testicular remnants or late discovery of undescended testicle (> 2 years)
  • Close urological monitoring and early treatment are necessary in individuals with an increased risk of testicular cancer and infertility.
• Complications
  • Testicular cancer (germ cell tumors): The risk of testicular cancer is not eliminated by surgery.
  • Infertility: higher temperature of the abdominal cavity is suboptimal for spermatogenesis → oligospermia → infertility
  • Testicular torsion
  • Inguinal hernia

• Definition: The testicle is located outside the normal path of descent (e.g., superficial inguinal pouch, suprapubic region, perineum, femoral canal)

Close urological monitoring is necessary, as the risk of testicular cancer and infertility is increased.

• Definition
  • Temporary displacement of the testicle in the inguinal canal by the cremasteric reflex
  • The testis may be easily repositioned back into the scrotal pouch.
• Treatment: No treatment is necessary.

• Definition: abnormal enlargement and tortuosity of the pampiniform plexus in the scrotum due to proximal obstruction of the spermatic vein
• Epidemiology ^[5]
  • Most common cause of scrotal enlargement in men
  • Found in 15% of healthy men
• Etiology
  • Idiopathic/primary
    • The cause of primary varicocele is not fully understood.
    • The left testicle is most commonly affected (85% of cases)
      • The longer course of the left spermatic vein and its insertion at a 90° angle into the left renal vein predisposes to slower drainage and increased hydrostatic pressure.
      • Left renal vein passes between the aorta and superior mesenteric artery → ↑ susceptibility of the renal vein to compression (nutcracker phenomenon) → ↑ intravascular pressure in the left spermatic vein → varicocele formation
  • Symptomatic/secondary
    • Caused by a mass in the retroperitoneal space (Ormond disease, lymphoma, renal cell carcinoma) obstructing venous drainage into inferior vena cava (right-sided varicocele) or left renal vein (left-sided varicocele) or a thrombotic event (e.g., pampiniform plexus obstruction in renal cell carcinoma)
    • Persist in the supine position due to a physical obstruction to blood flow within the spermatic vein
• Clinical features
  • A painless enlargement may be present
  • Dull, aching pain of the hemiscrotum (typically left-sided)
  • Heaviness of the affected scrotum
  • Soft bands/strands are palpable in the upper pole of the affected scrotum (“bag of worms”)
  • Symptoms worsen when standing or when performing the Valsalva maneuver.
  • Negative transillumination
  • In rare cases, paresthesia is possible.
• Diagnosis
  • Ultrasound: dilated (> 2 mm) hypoechoic pampiniform vessels
  • In some cases, imaging studies of the retroperitoneum
  • Doppler ultrasonography: to determine the grade of varicocele based on the extent of vein dilation and reflux during Valsalva maneuver

• Treatment
  • Conservative management: scrotal support
  • Invasive treatment
    • Indications
      • Testicular atrophy or delayed growth of the affected testicle in children and adolescents
      • Pain
      • Infertility (confirmed with an abnormal sperm analysis) ^[7]
    • Procedures
      • Laparoscopic varicocelectomy: affected dilated testicular veins (pampiniform plexus) are occluded by ligation
      • Percutaneous embolization
• Complications
  • Testicular atrophy and infertility
    • Sperm is produced in the testicles at 2°C below the average body temperature.
    • In a varicocele, blood stasis within the scrotum increases local temperature, resulting in a suboptimal environment for spermatogenesis.

Always perform an ultrasound of both testicles when varicocele is suspected, as the condition may occur bilaterally.

A unilateral right-sided varicocele is uncommon and should raise suspicion of a mass in the retroperitoneal space (Ormond disease, lymphoma, renal cell carcinoma) blocking the spermatic vein.

• Definition: painless accumulation of fluid in a sac around one or both testicles which derives from the tunica vaginalis, a tissue covering the testes
• Etiology
  • Idiopathic (most common)
  • Congenital hydrocele
    • Communicating hydrocele
      • Occurs due to the failed closure of the processus vaginalis during development
      • Usually discovered in infancy
    • Noncommunicating hydrocele: no connection to the peritoneal cavity present
  • Acquired hydrocele
    • Secondary to underlying pathology (e.g., trauma, tumor, torsion, infection)
    • Wuchereria bancrofti infection is the most common cause worldwide, but virtually nonexistent in the US (see “Lymphatic filariasis”).
• Clinical features
  • Fluctuant, painless swelling of affected scrotum
    • May be present since infancy or childhood
    • May or may not be reducible
  • Positive transillumination
  • Palpation above the swelling is possible: a normal spermatic cord and inguinal ring are present.
• Diagnosis ^[8]
  • Usually a clinical diagnosis
  • Ultrasound: hypoechoic fluid confirms the diagnosis.
• Differential diagnosis
  • Testicular tumor (negative transillumination test)
  • Inguinal hernia
• Treatment: Congenital hydrocele usually resolves spontaneously within 6 months of birth. ^[9]
  • Indications for surgery
    • If spontaneous resolution does not occur by 1 year of age
    • Excessive discomfort and/or if scrotal skin integrity is compromised
    • Underlying pathology suspected
    • Testicle not palpable
    • If infertility is a concern ^[10]
  • Procedures
    • Hydrocelectomy
      • Performed to correct a hydrocele and prevent its recurrence
      • Indicated for the reduction of large or thick-walled hydroceles
      • Involves incision and complete/partial resection of the hydrocele sac (tunica vaginalis)
    • Percutaneous aspiration of the hydrocele fluid combined with instillation of a sclerosing promoter into the sac

A hydrocele must be differentiated from an inguinal hernia.