Expansion
Can you get above it, is it separate from the testis, does it transilluminate
Expansion
Three questions, in order
- Can you get above it? If no, it is an inguinoscrotal hernia
- Is it separate from the testis? If separate, think epididymal cyst, varicocele or epididymitis. If the testis is not separately palpable, think hydrocele or tumour
- Does it transilluminate? Yes suggests fluid, so a hydrocele or epididymal cyst. No suggests solid, so a tumour or haematocele
| Swelling | Features |
|---|---|
| Hydrocele | Surrounds the testis, transilluminates, testis impalpable within |
| Epididymal cyst | Separate, above and behind the testis, transilluminates |
| Varicocele | Bag of worms, disappears lying down, left commoner, larger on standing |
| Testicular tumour | Hard, craggy, painless, does not transilluminate, no cough impulse |
| Inguinal hernia | Cannot get above it, cough impulse, reducible, bowel sounds |
The acute scrotum
- Torsion: sudden severe pain, nausea, high riding transverse testis, absent cremasteric reflex, negative Prehn’s sign (pain not relieved by elevation), typically under 25 years. Surgical emergency, explore within 6 hours; imaging must not delay it
- Epididymo-orchitis: gradual onset, fever, dysuria, positive Prehn’s sign, older patients or sexually transmitted infection
- Torted hydatid of Morgagni: the blue dot sign, in prepubertal boys
A new unilateral varicocele, especially on the right or one that does not empty on lying down, warrants imaging for a retroperitoneal mass obstructing the testicular vein.