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.
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