Anomalies of the Scrotal Contents - A Comprehensive Review

Introduction

The scrotum contains the primary reproductive organ of males, and any abnormalities might cause painful or painless swellings, inflammation, or hardening. The abnormalities can be genetic or acquired.

What Are the Risk Factors of Scrotal Content Anomalies?

• Previous history of testicular cancer.

• Undescended testicle as a child.

• A close relative with testicular cancer.

• Unprotected sex.

• Multiple sex partners.

What Are the Types of Scrotal Content Anomalies?

• Testicular cancer.

• Spermatocele.

• Epididymitis.

• Orchitis.

• Hydrocele.

• Hematocele.

• Varicocele.

• Inguinal hernia.

• Testicular torsion.

• Cryptorchidism.

• Ectopic testes.

• Retractile testes.

• Scrotal wall cellulitis.

• Scrotal abscess.

• Fournier’s gangrene.

What Is Testicular Cancer?

Testicular cancer is the most common malignancy in males aged between 15 to 45 years and represents one of the curable malignancies if identified early and treated with a multimodal approach.

Signs and Symptoms of Testicular Cancer

• Systemic Manifestations: Anorexia, malaise, and weight loss.

• Pulmonary Manifestations: Cough or shortness of breath.

• Lymphatic Manifestations: Cervical or supraclavicular lymphadenopathy.

• Retroperitoneal Manifestations: Bulky retroperitoneal disease can present as back pain or may lead to compression of the gonadal veins.

• Vascular obstruction or thrombosis leads to lower extremity edema.

• Nausea, vomiting, or gastrointestinal hemorrhage.

• Central or peripheral nervous system symptoms from the cerebral, spinal cord, or peripheral nerve root involvement.

Treatment of Testicular Cancer

The treatment protocol is dependent on the staging of the cancer:

• Stage 0: Orchiectomy and radiotherapy.

• Stage I: Orchiectomy, single-agent Carboplatin chemotherapy, Bleomycin, Etoposide, or Cisplatin (BEP) chemotherapy or Etoposide and Cisplatin (EP) chemotherapy, or retroperitoneal lymph node detection(RPLND).

• Stage II: Orchiectomy, radiotherapy, or three cycles of BEP, four cycles of EP, or retroperitoneal lymph node detection(RPLND).

• Stage III: BEP, EP, or Cisplatin-based chemotherapy regimens, VeIP (Vinblastine, Ifosfamide, Cisplatin) regimen.

What Is Spermatocele?

Spermatocele is a pathologic cyst that develops in the epididymis. The cyst is non-cancerous, painless, and contains a milky or clear fluid, sometimes sperm as well. These cysts do not reduce fertility and require intervention. The cyst might develop from a blockage in one of the multiple tubes within the epididymis.

Symptoms of Spermatocele

Initially, spermatoceles are not symptomatic and might remain stable. If the cysts grow in size, the patient might present with:

• Pain or discomfort.

• Heaviness in the testicle.

• Fullness behind and above the testicle.

How to Treat Spermatocele?

Although the spermatocele does not remit, they mostly do not need any treatment. They cause pain and discomfort only when the cyst enlarges. Pain is managed using Acetaminophen or Ibuprofen. A surgical procedure called spermatocelectomy is where a surgeon makes an incision in the scrotum and separates the spermatocele from the epididymis. Other treatment protocols involve aspiration and sclerotherapy.

What Is Orchitis?

Orchitis is an inflammation of one or both of the testicles arising from a bacterial, viral, or non-specific etiology. In some reported cases, orchitis occurred as a consequence of sexually transmitted infections and mumps virus. Sometimes orchitis is associated with epididymitis, together known as epididymo-orchitis. The condition may cause pain and lead to infertility, testicular atrophy, or scrotal abscess.

Symptoms of Orchitis

• Swelling

• Pain ranging from mild to severe.

• Fever.

• Nausea and vomiting.

• Malaise.

• Tachycardia.

• Headaches.

• Muscle pain.

• Fatigue.

How to Treat Orchitis?

The symptoms of orchitis ease within a few days without treatment. Underlying bacterial or viral infection may require up to two weeks of antibiotic therapy. STI (sexually transmitted infections) etiology would warrant treatment for sexual partners as well. Alternatively, applying an ice pack, heat pad, rest, and jockstrap can be helpful. NSAIDs (nonsteroidal anti-inflammatory drugs) can reduce pain and swelling.

What Is Hydrocele?

Hydrocele is the swelling of the scrotum resulting from the fluid collection in the sheath surrounding the testicles. The condition is more common in newborns than in adults and usually disappears by the first birthday without treatment. The condition is seen in adult males due to inflammation or trauma to the scrotum. Adult men pertaining to the condition experience some discomfort and heaviness of the scrotum with diurnal variation in the size of the swelling. The condition does not affect fertility.

Treatment of Hydrocele

There is no pharmacotherapeutic regimen against hydrocele, and it usually does not require any surgical intervention. The swelling generally remits on its own within six to 12 months. Surgery is required if the swelling does not subside after one year, and the surgeon repairs the swelling to prevent further complications.

What Is Hemoscrotum?

Hemoscrotum refers to the collection of blood in the tunica vaginalis around the testes. The condition develops from infections, trauma like saddle injury, or as post-surgical complications. The condition is also seen in patients with hemophilia and catheterization of the femoral artery.

Symptoms of Hemoscrotum

• Unusual lump.

• Sudden pain.

• Dull aching pain.

• Heaviness in the scrotum.

• Radiating pain.

• Tender, swollen, or hardened testicle and epididymis.

• Swelling.

• Redness of the scrotum.

• Nausea or vomiting.

• Pus.

• Pus or blood in the urine.

• Fever.

How to Treat Hemoscrotum?

Most hemoscrotums require minor or major interventions depending on their severity. The repair of the defect is challenging, especially in the case of circumferential hemoscrotum. Foot elevation and bed rest might be sufficient in minor cases. Surgeries might be indicated to establish drainage of the accumulated blood. If the underlying tumor causes such bleeding, then the entire testicle needs to be removed to prevent cancer metastasis. Pharmacotherapy might be necessary to manage post-surgical swelling.

What Is Varicocele?

Varicocele is a harmless enlargement of the veins on the scrotum, usually on the left side, when circulating blood pools in the scrotal veins instead of disseminating out of the scrotum. Varicocele occurs during puberty and progresses over time and causes some levels of pain and discomfort but usually remains asymptomatic. The condition may lead to poor development of a testicle, low sperm production, and even infertility.

Symptoms of Varicocele

• Pain.

• A mass in the scrotum.

• Differently sized testicles.

• Infertility.

Treatment of Varicocele

There are no medications to treat or prevent varicoceles, but Acetaminophen or Ibuprofen might be prescribed against pain. Non-surgical intervention may involve embolization to temporarily block the veins. Surgery is performed under local anesthesia. The interventions involve microscopic varicocelectomy and laparoscopic varicocelectomy. Post-surgical complications involve persistent or recurring varicocele, hydrocele, or injury to the testicular artery.

What Is Inguinal Hernia?

An inguinal hernia occurs due to the protrusion of abdominal components into the scrotum through a weak point in the abdominal muscles. A hernia occurs due to intense pressure within the abdomen, a preexisting weak spot in the abdominal muscles, straining during defecation or urination, strenuous activity, pregnancy, or chronic coughing or sneezing.

Symptoms of Inguinal Hernia

• A bulge on either side of the pubic bone becomes more prominent while standing, coughing, or straining.

• A burning or aching sensation.

• Pain or discomfort in the groin while behind, coughing, and lifting.

• The heaviness of the groin.

• Weakness or pressure in the groin.

• Pain and swelling around the testicles.

• Nausea.

• Vomiting.

• Fever.

• Acute intensifying pain.

• Red, purple, or dark bulging.

• Inability to defecate.

• Absence of flatulence (passing gas).

Treatment of Inguinal Hernia

Surgical intervention is the only treatment for inguinal hernia. Open hernia repair or minimally invasive hernia repair (laparoscopic surgery) methods are used to treat the condition where the surgeon repositions the protruded intestine into the abdomen and repairs the weak abdominal muscle.

What Is Testicular Torsion?

Testicular torsion is a condition when the testicle rotates and chokes the spermatic cord, which supplies blood to the scrotum. This sudden reduction in blood flow results in severe pain and swelling. The condition is common in teenagers between 12 and 18 years but can prevent at any age, even at birth.

Symptoms of Testicular Torsion

• Sudden, severe pain in the scrotum.

• Swelling.

• Abdominal pain.

• Nausea and vomiting.

• Repositioned testicle.

• Polyuria.

• Fever.

Treatment of Testicular Torsion

Surgery is indicated to treat most testicular torsions. In some cases, the physician might successfully perform manual detorsion; otherwise, the spermatic cord is freed through surgery. Some extreme cases might need testicle removal.

What Is Cryptorchidism?

Cryptorchidism is the failure of testicular descent into the scrotum prior to birth. Often just one testicle is involved, and rarely (10 % of cases) involves both testicles. Cryptorchidism is caused due to disruption of hormones, physical changes, and nerve activity influenced by a cascade of genetic, maternal health, and environmental factors.

Risk Factors of Cryptorchidism

• Low birth weight.

• Premature birth.

• Familial history.

• Down syndrome or an abdominal wall defect.

• Alcohol consumption during pregnancy.

• Cigarette smoking.

• Pesticides exposure.

Treatment of Cryptorchidism

Usually, the condition is self-limiting, and the testicles descend within the first year itself; otherwise, surgical intervention may be necessary. Laparoscopic or open surgery might be required to reposition the testicle into the scrotum.

What Is Ectopic Testis?

The ectopic testis is a condition when one or both of the testes are found in an unusual location in the abdomen. It is different from cryptorchidism in the fact that in cryptorchidism, the undescended testes are stuck within the path of their natural descent, while in ectopic testis, the position of the undescended testes is non-specific.

The testes may be found in the lower part of the abdomen, front of the thigh, femoral canal, the skin of the penis, or behind the scrotum and are usually well developed. The testes may be independent of the epididymis, present in the scrotal sac, and also accompanied by an indirect inguinal hernia.

Treatment of Ectopic Testis

The only treatment of ectopic testis is through surgical intervention. Orchidopexy is the surgery in which the surgeons, under general anesthesia, reposition the testes into the scrotum.

What Is Retractile Testicle?

A testicle is called retractile if it alternates its position between the groin and scrotum. While residing in the groin, the testicle can be manually guided back into the scrotum. The condition arises due to the overactivity of the cremaster muscle in which a testicle rests. The muscle may be activated by inner thigh rub, fear, laughter, and a cold environment.

Symptoms of Retractile Testicle

The testicle may be repositioned manually into the scrotum and will not immediately retreat to the groin. Sometimes the testicles retract into the groin for a long time and then re-appear back in the scrotum on their own.

Treatment of Retractile Testicle

The condition is usually self-limiting, and the problem disappears before or during puberty when the testicle moves into its correct position and stays there permanently. Sometimes the testicle fails to move back into the scrotum permanently; the condition is ascending testicle or acquired undescended testicle.

What Is Scrotal Wall Cellulitis?

Scrotal wall cellulitis is a presentation of infection of the scrotal wall due to bacterial or viral infection. The condition is rare and is found mostly in diabetic and immunocompromised patients. The cellulitis leads to rapid accumulation of fluid between the Colle’s and Buck’s fascia and may compromise blood flow to genital contents.

Symptoms of Scrotal Wall Cellulitis

• Swelling.

• Redness.

• Pain.

• Reactive hyperemia.

• Malaise.

• Fever.

• Elevated white blood cell count.

Treatment of Scrotal Wall Cellulitis

The condition is treated with antibiotic therapy with regular monitoring of the progression or improvement.

What Is Scrotal Abscess?

A scrotal abscess is the collection of pus within the scrotum. It may arise as complications of untreated bacterial infection of the bladder or urethra, STI, infected hair follicles, appendicitis, neurogenic bladder, and urethral stricture, or even progress from scrotal wall cellulitis.

Symptoms of Scrotal Abscess

• Penile discharge.

• Pain.

• Polyuria.

• Heaviness in the scrotum.

• Swollen or hard testicles and scrotum.

• Fever

Treatment of Scrotal Abscess

The scrotal abscess may be treated with a proper broad-spectrum antibiotic regimen and by draining the abscess surgically. Delayed diagnosis may lead to dead tissues which have to be surgically excised.

What Is Fournier’s Gangrene?

Fournier’s gangrene is an uncommon, fatal bacterial infection affecting the scrotum, penis, or perineum. The condition is similar to necrotizing fasciitis (flesh-eating disease) that destroys soft tissues, including arteries, muscles, and nerves. The condition may affect and destroy soft tissues of the thighs, stomach, and chest.

Symptoms of Fournier’s Gangrene

• Changes in mental activity.

• Tenderness.

• Redness.

• Dehydration.

• Fever and chills.

• Inflammation.

• Lethargy.

• Nausea and vomiting.

• Pain.

• Putrid smell.

• Sepsis.

Treatment of Fournier’s Gangrene

Surgery has been effective in treating Fournier’s gangrene, where the necrotized tissue is debrided, followed by reconstructive surgeries. The patient may also undergo hyperbaric oxygen therapy. The complete penis and scrotum are only rarely medically removed.

How to Diagnose Anomalies of the Scrotal Contents?

Most of the conditions are self-reported to the physician. The physician extrapolates a diagnosis initially by a clinical examination which is then followed up with ultrasound, CT (computed tomography), or MRI (magnetic resonance imaging) studies. Some conditions like hydrocele and hemoscrotum might require transillumination examination.

Conclusion

Many of the scrotal content abnormalities are self-limiting and get resolved without any specialist’s involvement, while some of them require early intervention. A few conditions, like Fournier’s gangrene, scrotal abscess, and testicular torsion, require immediate medical attention, as any delay can lead to surgical removal of the penis and scrotum. Usually, the conditions, on timely treatment, have a good prognosis, and patients usually live a normal life.