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III./4.4.: Differential diagnosis
Hydrocele can be differentiated from the other space-occupying processes within the scrotum as follows:
III./4.4.1.: Scrotal hernia
In this case patients often report that the size of their swollen scrotum changes; it grows upon making an effort or while standing. During physical examination bowels can be palpated bulging through the hernial orifice upon increased abdominal pressure. Ultrasound examination shows moving loops of bowel instead of clear fluid. Therapy: herniotomy should be performed from an inguinal incision.
III./4.4.2.: Scrotal hematoma (organizing)
The history often reveals a trauma; the swelling developed after that, the skin of the scrotum may transiently show a livid discoloration. Ultrasound examination shows a thick wall of hematoma and often an inhomogeneous content in it. Unlike the tumors, however, no circulation is detected in it with Doppler examination. If it is not absorbed spontaneously, its treatment consists of a surgical removal.
III./4.4.3.: Testicular tumor
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The history often includes a disorder of testicular descending (the risk of developing a testicular tumor increases 22fold due to this!). During physical examination usually nodes can be palpated on the surface of the testis, which are as hard as cartilage, painless, and have uneven surface; however a tumor which has grown to very large (when the whole testis is tumorously involved and enlarged) can sometimes be differentiated from a tense hydrocele with difficulty.
In patients with hormone-producing tumors gynecomastia may be observed; in certain histological types elevated levels of tumor markers (alpha fetoprotein – AFP and beta human choriogonadotropin – BHCG) can be measured in the blood. Ultrasound examination clearly identifies the foreign tissue that destructs the testis. Testicular tumors may be associated with hydrocele, therefore the testis should always be sought within the accumulated fluid, and the homogeneous structure of its tissue should be checked. In patients with a tumor the first step of therapy includes the removal of the testis together with as long spermatic cord as possible, from and inguinoscrotal incision.
III./4.4.4.: Other intrascrotal tumors, e.g.: lipoma, etc.
During physical examination a mobile mass can be palpated which is independent of the testis and is located separately from it. Ultrasound describes a solid mass (i.e. containing no fluid and showing a circulation) beside the intact testis and located independently of it. Therapy: complete surgical extirpation while preserving the testis.
III./4.4.5.: Epididymitis
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In the history the patients often report on a previous lower urinary tract infection or occasionally on an inflammation of their prostate, as it develops via an ascending, canalicular spread. Rarely the epididymitis may be a partial phenomenon of tuberculosis; the primary disease is in the lung, the way of spread is hematogenous and the disease does not respond to antibiotic therapy. During physical examination a normal testis can be palpated, and only the swollen epididymis is painful; however in more severe cases the whole half of the scrotum is filled and painful and often even the testis cannot be identified.
In an acute case the leading symptoms include pain and fever, the results of laboratory tests characteristically show differential count shifted to the left, high WBC count, accelerated ESR, elevated CRP and procalcitonin values; the urinary sediment often shows pyuria, and the microbiological culture of the urine is positive. In patients with a chronic disease the above are less marked. The ultrasound examination describes, in addition to a normal testis, a widened, inhomogeneous epididymis, in which also abscesses can be seen in severe cases. If the disease has spread also to the testis (orchidoepididymitis), rarefactions are seen also in its mass. In the first step its therapy is conservative: supporting, compress, medication with combined broad spectrum antibiotic and anti-inflammatory agents. If abscess develops within the epididymis, surgical exploration and removal of the epididymis (epididymectomia), or even the entire testis may become necessary.
III./4.4.6.: Orchitis
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It occurs rarely, usually as a partial phenomenon of mumps. During physical examination, in addition to the swollen parotid gland, also the concomitant swelling of the testis is observed. Ultrasound examination shows an intact epididymis, a widened testicular mass with increased circulation in Doppler, and no abscess within it. Its therapy is conservative including supporting, compress, administration of anti-inflammatory agents. If it is bilateral, it may lead to infertility.
III./4.4.7.: Varicocele
It is more common in tall, lean, young males and, due to anatomic causes, on the left side. Characteristically it causes a pain of pulling or pressing nature during exertion or prolonged standing, but it often remains asymptomatic. During physical examination a venous plexus is palpated above the testis, the dilatation of which increases upon abdominal pressing. In advanced cases it may fill the whole half of the scrotum; the ipsilateral testis is often smaller, atrophic. Contrary to hydrocele, no ballottement is feasible; it increases upon abdominal pressing, though the hernial orifice is closed.
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Ultrasound shows cross sections of the veins which dilate during increased abdominal pressure, and circulation is seen in them with Doppler. If varicocele occurs suddenly in a later age, it should be clarified that is not caused possibly by a tumorous thrombus of a renal neoplasm with no other symptoms, which has grown into the renal vein or into the inferior hollow vein. Therapy is required in case of complaints or infertility, usually ligation and/or intersection of the dilated vessels is performed with or without their removal from a scrotal, inguinal or abdominal entry.
III./4.4.8.: Testicular torsion
Typically it occurs in the neonatal age and between 12 and 20 years of age; it is characterized by a sudden sharp pain occurring at rest. During physical examination the testis is located higher than the contralateral one; it is swollen and very tender. In a process that persists for a longer time also a concomitant hydrocele and fever may develop. During ultrasound examination no circulation is detected in the testis with Doppler. Its therapy consists of surgical exploration: if the patient was operated on within 6 hours, and the testis has not necrotized, detorquation and fixation may be performed; otherwise a removal of the necrotized testis is the task.
III./4.4.9.: Scrotal edema
It may develop as a part of a generalized edema related to cardiac failure or as a part of a local edema after extended pelvic tumors, or the irradiation or radical surgery of those. It is characterized by an accumulation of fluid in the loose subcutaneous connective tissue of the scrotum. A large, soft swelling of the scrotum develops which retains the impression of a finger and causes no complaint to the patient; occasionally even the penis cannot be visualized; the hernial orifice is free. Ultrasound shows no definite fluid accumulation within the scrotum, only normal testis and epididymis with good circulation. Its therapy includes, in addition to the treatment of the underlying disease, supporting, compress, administration of diuretic agents and wearing close, elastic underclothes.
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