What is the cause of scrotum enlargement and how to treat it?

Overview of scrotum enlargement: Scrotum enlargement refers to the pathological changes of scrotum skin and its contents (tunica vaginalis, epididymis and spermatic cord), or the contents of abdominal cavity (ascites organs) fall into scrotum, which leads to the increase of scrotum volume. Scrotal wall or scrotal contents, such as testis tunica vaginalis, epididymis and spermatic cord, can cause pathological swelling or inflammatory exudation of scrotum due to acute and chronic inflammation, parasite invasion and organic tumor. If the peritoneal sheath process is not closed or not completely closed after birth, the contents of abdominal cavity can numb scrotum. Clinically, the location and nature of scrotum enlargement can be determined by physical examination such as medical history inquiry and local palpation light transmission test, so as to make a correct diagnosis. Causes of scrotum enlargement: According to the classification of etiology, scrotum enlargement can be divided into three categories: (1) scrotum wall lesions such as cyst wall edema, scrotum wall hematoma, scrotum wall elephantiasis after filariasis, erysipelas skin gangrene, cellulitis, urinary extravasation, scrotum wall benign tumor (seboma, hemangioma x scrotum wall malignant tumor. (2) Scrotal content lesion 1. Hydrocele of tunica vaginalis, hydrocele of tunica vaginalis, hydrocele of tunica vaginalis. Choroidal chyme 2. Epididymis acute and chronic epididymitis, epididymal tuberculosis, epididymal blood stasis and sterilized semen cyst. 3. Testicular inflammation, testicular tuberculosis and testicular syphilis. Testicular tumor 4. Sperm hydrocele, varicocele, torsion cyst of spermatic cord, nodus of spermatic cord worm, nodus of spermatic cord blood swelling and pain after sterilization, and granuloma of sperm after sterilization. (3) Abdominal cavity contents enter scrotum, such as ascites or indirect inguinal hernia contents (small intestine, bladder, omentum, etc.). ) into the scrotum. The mechanical scrotum is the continuation of the abdominal wall, and its structural level is consistent with that of the anterior wall. Each layer of tissue is extremely loose and elastic, and the gap can accommodate more liquid, so in the case of inflammation and edema, the scrotum can be significantly enlarged. There are two layers of tunica vaginalis between scrotal wall and contents. The tunica vaginalis attached to the scrotum wall is called the tunica vaginalis attached to testis and epididymis, and there is a small amount of serosity between the two tunica vaginalis. When the tunica vaginalis changes and secretes a large amount of fluid or bleeding, due to its great elasticity, it can accommodate a large amount of fluid in the tunica vaginalis cavity, and the scrotum is extremely enlarged. The tunica vaginalis originated from the peritoneal sheath process in embryonic period. When the testis descends to the scrotum, the part where the sheath process communicates with the peritoneal cavity closes, forming a sheath ligament. If the peritoneal sheath process is not closed or completely closed, it still communicates with the abdominal cavity after birth. Ascites can flow into the scrotum contents, such as small intestine, bladder, omentum, etc., and can also be herniated into the scrotum under the action of intra-abdominal pressure, making the scrotum swollen. The scrotum is divided into two sacs by the scrotal mediastinum formed by the scrotal flesh membrane. If scrotal contents (testis, epididymis, etc. ) does not invade the scrotal wall, and the lesion can be limited to one side, showing unilateral swelling of the scrotum. However, when the scrotum has pathological changes or systemic edema, it often makes the whole scrotum swollen. Diagnosis of scrotum enlargement: It is very important to inquire about the history of scrotum enlargement in detail, including the course of scrotum enlargement, local symptoms and symptoms of the whole body or other systems. 1. The length of the infection process often leads to the sudden onset of scrotal swelling; The course of hydrocele progresses slowly, often delaying for several years; Testicular tumors generally have a short course of disease; Elephant swelling has a long history of contact with epidemic water, which is gradually developing; Most vulvar cysts caused by inguinal defect change with the change of intra-abdominal pressure, from large to small. 2. Most of the local symptoms of infectious vulvar cyst are accompanied by redness, swelling, heat and pain. Testicular or adnexal tumors often fall pain; In the late stage of elephantiasis, eczema or ulcer often occurs due to secondary infection. 3. Systemic or other systemic symptoms scrotum enlargement with systemic fever is acute infection such as mumps complicated with acute orchitis; Epididymal tuberculosis may be accompanied by symptoms of urinary tuberculosis such as frequent urination, urgency and dysuria. Physical examination 1. Local palpation is the most important and simple method to diagnose scrotal enlargement. Scrotum and its contents belong to external reproductive organs. Examiners must be familiar with the gross anatomy of scrotal contents in order to clearly diagnose whether the lesion occurs in scrotum or scrotal skin. Whether from scrotal contents or groin area; Is testicular swelling or epididymal swelling; Is it cystic enlargement or substantial enlargement? During the examination, the patient should stand first, and then touch his hands at the same time after the decubitus examination, which is beneficial to the left and right comparison. 2. Cough shock For tumors from the abdominal sulcus, traces of inguinal region and hydrocele can be differentiated by cough shock examination. 3. The light transmission test is of great value in distinguishing whether scrotal swelling is cystic or substantial. 4. Scrotal puncture can be used to identify the nature of scrotal effusion, but it can also be used to aspirate tissues for pathological examination to find substantial swelling. 5. Other examinations include prostate examination, abdominal examination and related general examination. Laboratory examination, urine routine examination and erythrocyte sedimentation rate examination have certain auxiliary diagnostic significance for acute and chronic infection; Microfilariasis found under blood smear microscope has diagnostic value for scrotal elephantiasis. The determination of human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFG) in blood or urine is of great significance for the diagnosis of chorionic epithelial carcinoma or testicular embryonic carcinoma. Four. Imaging diagnosis mainly includes ultrasound examination, Doppler ultrasound examination, radionuclide Gade angiography, infrared scrotal temperature recording and so on. The diagnosis method and differential points of scrotum enlargement are summarized in Figure 7-7-L. The differential diagnosis of scrotum enlargement is 1. Scrotal wall lesions 1. Scrotal edema is caused by scrotal allergy (neuroedema caused by insect bite), inflammation, contusion, vena cava reflux under tumor compression or systemic diseases (such as heart failure nephrotic syndrome, high ascites, cachexia, etc.). ), the scrotal wall tissue accumulated too much water, which showed that the scrotal swelling was obvious, the wrinkles disappeared, the pressure was bright and shiny, and there was obvious depression without tenderness. If accompanied by inflammation, there may be tenderness and congestion. 2. Scrotal elephantiasis is the clinical manifestation of urogenital filariasis. Parasitic bloodshot worms block lymphatic vessels in scrotum and its vicinity, prevent lymphatic reflux and overflow, stimulate a large number of fibrous tissue proliferation in scrotum and subcutaneous tissue, and cause edema. It is characterized by rough scrotum skin, extremely thick cortex and subcutaneous tissue, which is not easy to sag, and the penis skin is often involved, which makes the penis invaginate. The other is that scrotal skin is wet due to lymphatic deposition. In severe cases, continuous dripping of lymph can lead to secondary infection. Acute lymphangitis such as ulcer and eczema is often accompanied by fever and local redness and pain. This disease is common in filariasis endemic areas, and microfilaria can be found by checking the surrounding blood films at night. 3. Erysipelas is an inflammatory lesion of scrotal skin lymphatic network, which makes the skin hyperemia, edema and tenderness, and the boundary of the diseased skin is clear, often accompanied by fever, chills and other systemic symptoms. 4. Scrotal cellulitis or gangrene is an acute infection of scrotal cellulite. The scrotal skin is suddenly congested, swollen and painful, and the scrotal skin becomes hard and dark. Gangrene sometimes sounds distorted and has a special smell. Bacteriological examination of wound exudates is often accompanied by symptoms of poisoning such as chills, high fever, nausea and vomiting, and most of them are mixed infections of hemolytic streptococcus, Pseudomonas aeruginosa, Staphylococcus aureus and anaerobic streptococcus. 5. Urine extravasation has a history of urethral bladder injury or urethral relaxation. Urine can leak into the scrotum honeycomb tissue, which is characterized by obvious swelling of scrotum, pale skin, disappearance of wrinkles, brightness and luster, and obvious depression. It must be treated urgently, otherwise it may cause secondary infection. 6. Scrotal skin cancer can be primary skin cancer or metastatic cancer. Local skin thickens and hardens, shrinks and sinks, with radial wrinkles around it, which may be accompanied by ulcers. Biopsy can be done to confirm the diagnosis. Scrotal inclusion body lesions (1) tunica vaginalis lesions 1. Hydrocele of tunica vaginalis can be caused by inflammatory tuberculosis, tumor, trauma or filariasis infection. Common hydrocele has a slow course of disease, swollen scrotum is cystic, elastic wave moves, and light transmission test is positive. The type of hydrocele can be judged by the shape and position of scrotal swelling and whether it can disappear when lying down. Testicular effusion is pear-shaped, smooth, elastic and cystic; Communicative hydrocele, swollen scrotum can gradually become smaller or even disappear when lying flat; The hydrocele of spermatic cord is located at a high position above scrotum. Huge hydrocele will affect walking and painless delivery. Because mucus is wrapped in scrotum, you can't touch testis and epididymis. If secondary tunica vaginalis mucus is suspected, you can puncture and aspirate the effusion, and carefully examine the testis and epididymis. 2. Hematocrit in the tunica vaginalis can appear in the tunica vaginalis cavity due to trauma or tumor erosion, and the light transmission test is negative, and the puncture can absorb hemorrhagic liquid. 3. The hydrocele in the tunica vaginalis can cause obvious local tenderness due to inflammatory exudation, and the light transmission test is negative, often accompanied by fever. 4. The chylothorax in the tunica vaginalis is caused by filariasis and may be accompanied by other symptoms of filariasis. Scrotal cystic swelling, no tenderness, negative light transmission test, chylous fluid can be sucked out by puncture. (2) Epididymis 1. Epididymitis is the most common infectious disease of scrotum, which is more common in young people. Pathogens infect epididymis from urethral vas deferens, and there are also blood-borne infections, which can be divided into specificity and non-specificity according to the nature of infection. The former is infected by pathogens such as Neisseria gonorrhoeae and Chlamydia. The latter is mostly secondary to prostatitis, seminal vesiculitis, urethral stricture, prostatic hyperplasia or long-term indwelling catheter in urethra. Pathogens are mainly bacteria of urinary tract infection, including acute epididymitis and chronic adnexitis. Acute epididymitis is characterized by acute onset, sudden enlargement of halo, tenderness obviously accompanied by chills, fever, headache, nausea and vomiting, often involving spermatic cord, which makes it thicker; If the testis is invaded, it is called epididymitis, which should be differentiated from testicular torsion and testicular tumor. Chronic epididymitis is mostly the sequela of acute epididymitis or chronic infection at the onset. Mostly in the tail of epididymis, there are nodules with slightly hard texture and mild tenderness, which are aggravated when tired, and generally have no systemic symptoms. Epididymal nodules should be differentiated from epididymal tuberculosis, epididymal tumor sperm cyst and sperm granuloma. The lesion swells at the tail of the satellite to form a hard nodule, or 2. Most epididymal tuberculosis is secondary to renal or prostatic seminal vesicle tuberculosis, showing a chronic course. The early formation of cold abscess or adhesion to scrotal skin can sometimes form tubules and heal from time to time. A few cases can have an acute course similar to acute epididymitis, and almost half of the patients have symptoms of renal tuberculosis such as frequent urination and hematuria at the same time. 3. Sperm cyst is a cyst caused by semen retention. It may be round and smooth at or near the epididymal head. Elasticity without tenderness can suck out milky white liquid during puncture, and sperm can be seen under microscope. 4. A small number of epididymal stagnation causes slight swelling of scrotum, which can touch bilateral halo swelling and softness without obvious tenderness. The cause of the disease is not clear, which may be caused by epididymal inflammation or sperm granuloma due to the dysfunction of epididymal blood supply or its absorption function after operation. (3) Testicular lesion 1. Testitis is mostly secondary to acute atopic orchitis, which is often manifested as epididymal orchitis in clinic. Acute onset, testicular pain, swelling and obvious tenderness. In severe cases, it can spread to the scrotal wall, causing scrotal skin congestion, edema and adhesion, accompanied by systemic chills, high fever and other symptoms. Mumps is the most common orchitis caused by specific infection. Generally, 70% cases are unilateral, and the right side is more common 4 ~ 6 days after onset. 2. Testicular tumors mostly occur in young adults aged 20-40. There is a painless small lump on the testis, which grows rapidly. The swollen testis still maintains its original shape, hard and heavy, and the epididymis and spermatic cord are normal. If the testicular tumor with negative light transmission test is secondary to hydrocele, the scrotum is obviously enlarged. A few cases have acute testicular swelling, and the pain and fever are similar to acute rhinitis. The occult rate is very easy to cause tumors, which are manifested as abdominal masses and scrotum without testicles. In order to determine the nature of the tumor, pathological examination is needed. (4) Lesions of spermatic cord 1. Torsion of spermatic cord, also known as testicular torsion, refers to the torsion of testis along the axis of spermatic cord in the tunica vaginalis. The sheath process is closed at a high position, and those with incomplete testicular descent are prone to sudden torsion. The severe pain of a spermatic cord can radiate to the navel, and testicular swelling is quickly accompanied by nausea and vomiting. Testicular prolapse is a typical symptom of this disease. In order to avoid misdiagnosis and strive for the time and opportunity of surgical reduction, in recent years, it is helpful to diagnose varicocele in time by comparing the blood perfusion of two testicles with an obstacle or Doppler ultrasound. 2. Varicocele is more common in young adults, and left and bilateral varicocele accounts for about 15%. Patients with varicocele generally have no obvious symptoms or feel slight swelling or local swelling of scrotum. Many patients go to see a doctor because of infertility. Severe varicocele can lead to infertility. When the patient takes a standing position, he can see that the left scrotum is looser than the right scrotum, and the varicose veins in the scrotum are like a group of mollusks. If the signs are not obvious, the patient can be instructed to disappear when lying flat. Otherwise, we can consider whether there is a mass pressing the vein and affecting the blood return. In recent years, the diagnostic method of vascular imaging is helpful to find patients with varicocele with inconspicuous signs. Pathological indirect inguinal hernia with contents of abdominal cavity entering scrotum: after birth, the peritoneal sheath process is not completely closed or closed, which makes the abdominal cavity communicate with scrotum, which can make the contents of abdominal cavity hernia enter scrotum and form congenital indirect hernia; If there are anatomical defects in inguinal region, it is easy to form acquired indirect hernia. Oblique inguinal hernia is the main cause of huge scrotum enlargement. The characteristic of this disease is that the swollen scrotum is connected with the inguinal area, and the lump is often standing. When walking, coughing or working, it is pear-shaped and hemispherical. Touching the lump with your hand may cause the patient to cough, which may cause swelling shock. If the patient lies on his back or pushes the mass into the abdominal cavity by hand, the mass will be absorbed back into the abdominal cavity and disappear. If the trace cannot be recovered when lying down, it is difficult to regain delusion and distinguish it from other scrotal enlargement. Incarcerated dementia often occurs when the intra-abdominal pressure suddenly rises, such as strenuous labor or defecation, and the hernia mass suddenly increases, causing obvious pain. If the content of incarceration is intestinal loop, not only the local pain is severe, but also the symptoms of mechanical intestinal obstruction such as abdominal cramps, nausea and vomiting, constipation and abdominal distension will appear. If not treated in time, it will eventually form a narrow hernia.