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Identify the common causes of acute and chronic scrotal swellings. Use Bailey and Love Short Practice of Surgery 28th Edition, Sabiston Textbook of Surgery 21st Edition, and Shwartz's Principles of Surgery 11th Edition, and for each part state what reference the information was extracted out of.

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Causes of Acute and Chronic Scrotal Swellings

PART 1: ACUTE SCROTAL SWELLINGS

From Bailey and Love's Short Practice of Surgery, 28th Edition

(Source: Chapter 86 - THE SCROTUM, block 13; and Chapter 17 - ACUTE SCROTAL DISORDERS, block 3)
Bailey & Love organizes the acute scrotum under the heading "ACUTE SCROTAL DISORDERS" and identifies the following causes:
1. Testicular Torsion (Intravaginal / "Bell-Clapper" Torsion) The most time-critical cause. The testis twists within the tunica vaginalis due to abnormal posterior anchoring. Torsion compromises blood flow, causing acute scrotal or abdominal/groin pain, nausea and vomiting. Tenderness, absent cremasteric reflex and a high-riding testis are found on examination. The incidence is 3.8 per 100,000 males under 18 years annually, and it accounts for 10-15% of acute scrotal disease in children. Three predisposing anatomical variants are described:
  • High investment of the tunica vaginalis ("bell-clapper deformity") - most common in adolescents and typically bilateral
  • Inversion of the testis (lying transversely or upside down)
  • Separation of the epididymis from the body of the testis, permitting torsion about the connecting pedicle
Extravaginal torsion is seen almost exclusively in neonates (70% prenatal, 30% postnatal), due to increased testicular mobility before scrotal wall fixation.
2. Torsion of the Appendix Testis / Appendix Epididymis The appendix testis (hydatid of Morgagni, a Müllerian duct remnant) and appendix epididymis (a Wolffian remnant) are small pedunculated structures at the upper pole that can twist and infarct. Most common between 7-14 years of age. Produces mild to severe acute scrotal pain, usually without vomiting. A characteristic "blue-dot sign" - a dark, infarcted appendage - may be visible through the scrotal skin.
3. Epididymo-orchitis Bacterial or viral inflammation of the epididymis and/or testis. In young sexually active men, Chlamydia trachomatis is now the most common cause, with gonococcal infection occasionally seen. In older men with bladder outflow obstruction, epididymitis results from urinary infection - proposed mechanism is reflux of infected urine up the vasa due to high prostatic urethral pressure. Blood-borne infection is less common. It can also follow urethral instrumentation or be associated with an indwelling catheter and prostate infection. Infection usually starts in the tail of the epididymis and spreads proximally. Complications include abscess formation, testicular infarction, atrophy and infertility.
4. Idiopathic Scrotal Oedema Occurs in children between 4 and 12 years. The scrotum is very swollen but there is little pain or tenderness. The swelling is usually bilateral and may extend to the perineum, groin and penis. It is thought to be an allergic/hypersensitivity phenomenon; eosinophilia is occasionally present. It resolves within a day but may recur.
5. Strangulated Inguinal Hernia A small tense strangulated inguinal hernia can occasionally compress the cord and the pampiniform plexus, mimicking testicular torsion.
6. Secondary Hydrocele (Acute) Secondary hydroceles can present acutely from local injury (including torsion), infection, neoplasm, or radiotherapy.
7. Scrotal Trauma Blunt or penetrating injury to the scrotum and its contents.
8. Fournier's Gangrene A polymicrobial necrotising fasciitis of the perineum, external genitalia and perianal region. It can arise following minor perineal injuries or procedures (bruise, scratch, urethral dilatation, injection of haemorrhoids). There is a mixed aerobic and anaerobic infection causing obliterative arteritis of arterioles, leading to rapid gangrene. Predisposing factors include diabetes mellitus and alcoholism. Hallmark is intense pain and tenderness of the genitalia.
9. Orchitis (Mumps) Mumps orchitis develops in 20-30% of postpubertal patients with mumps virus infection, usually as parotid swelling wanes. Cord is not particularly thickened and the condition is often bilateral.

From Sabiston Textbook of Surgery, 21st Edition

(Source: Chapter 121, block 30, "Testicular Torsion" section)
Sabiston explicitly identifies the acute scrotum as a clinical presentation and lists:
1. Testicular Torsion Described as "the most urgent cause of the acute scrotum." Occurs when the spermatic cord twists, creating arterial occlusion and loss of vascular supply. The normal attachment of the inferior testis to the scrotum via the gubernaculum is disrupted. Without reversal, irreversible damage begins as early as 4 hours and is complete by 8-12 hours. Classic presentation: sudden onset of intense unilateral scrotal pain, unrelated to trauma, with nausea and vomiting. The most consistent examination finding is loss of the cremasteric reflex.
2. Epididymitis Included in the differential diagnosis of the acute scrotum.
3. Incarcerated/Strangulated Hernia Included in the differential diagnosis of the acute scrotum.
4. Torsion of the Appendix Testis Included in the differential diagnosis of the acute scrotum.
5. Trauma Included in the differential diagnosis of the acute scrotum.

From Schwartz's Principles of Surgery, 11th Edition

(Source: Chapter 40, "Scrotum and Testes" section, block 19)
Schwartz's chapter on urology covers scrotal anatomy and then addresses scrotal disorders primarily by pathological category:
1. Testicular Torsion - covered under genitourinary trauma and general urology, with mention that the venous pampiniform plexus can be affected.
2. Epididymo-orchitis / Infection - discussed under the broad urology infection section. Schwartz notes that the spermatic cord contains the testicular artery (from the aorta), deferential artery (from the internal iliac), and cremasteric artery (from the external iliac), providing collateral flow - relevant to ischaemic vs. inflammatory presentations.
3. Varicocele - described as a dilation of the pampiniform venous plexus that "can serve as an etiology of chronic testicular pain."
4. Trauma - Schwartz dedicates a section to genitourinary trauma, noting that the scrotum and testicles can be injured by blunt and penetrating mechanisms. Approximately 10% of victims of abdominal trauma will have a urologic injury.

PART 2: CHRONIC SCROTAL SWELLINGS

From Bailey and Love's Short Practice of Surgery, 28th Edition

(Source: Chapter 86 - THE SCROTUM, block 13)
Bailey & Love provides a structured approach to chronic scrotal swellings, organizing them anatomically. The clinical examination approach described emphasizes:
  1. Can you get above the swelling (to distinguish from an inguinoscrotal hernia)?
  2. Is the testis/epididymis palpable separately from the swelling?
  3. Does the swelling transilluminate?
1. Hydrocele Defined as an abnormal collection of serous fluid in the tunica vaginalis (or along the spermatic cord). Affects approximately 1% of adult men. Classified into:
  • Communicating (congenital) hydrocele: patent processus vaginalis allows peritoneal fluid to flow into the scrotum; associated with indirect inguinal hernias
  • Non-communicating (vaginal/primary) hydrocele: processus vaginalis is closed; fluid accumulates due to excessive production and/or defective absorption by the tunica vaginalis (disruption of lymphatic drainage). These primary hydroceles are the most common type globally.
  • Infantile hydrocele: distal end of processus closes but mid-portion remains patent; proximal end may communicate with tunica vaginalis
  • Hydrocele of the cord: isolated fluid collection along the spermatic cord
Secondary hydroceles occur in men >40 years and result from: local injury (including torsion), infection, neoplasm, or radiotherapy. Bailey & Love emphasises that if a tumour is suspected, the hydrocele should not be punctured due to the risk of malignant needle-track implantation.
2. Epididymal Cyst and Spermatocele Epididymal cysts are common and contain clear fluid; they are distinct from the testis on palpation. A spermatocele contains milky fluid with spermatozoa and arises from the epididymis or the efferent ducts. Both present as smooth, non-tender swellings separate from the testis and transilluminate.
3. Varicocele A varicocele is a dilation of the pampiniform plexus of veins. Around 90% are left-sided due to the left testicular vein draining into the high-pressure left renal vein (whereas the right drains into the low-pressure inferior vena cava). Varicoceles occur in 15-20% of all males and in approximately 40% of infertile males. Three aetiological mechanisms are described:
  • Absence or failure of the anti-reflux valve at the junction of the testicular vein with the left renal vein / IVC
  • "Nutcracker" effect: compression of the left testicular vein between the superior mesenteric artery and aorta
  • Angulation at the left testicular vein / left renal vein junction
Other causes of varicocele include renal tumour or nephrectomy obstructing the testicular vein (characteristically does not decompress supine), deep vein thrombosis, renal arteriovenous malformations and thrombosis of the pampiniform plexus. An isolated right-sided varicocele is extremely rare and should prompt retroperitoneal imaging to exclude a mass.
4. Inguinoscrotal Hernia Cannot get above the swelling; it is reducible and has a cough impulse. It does not transilluminate.
5. Tuberculosis of the Epididymis Secondary to haematogenous spread from a primary focus (usually renal or pulmonary tuberculosis). Presents as a chronic induration of the epididymis, which may be "beaded" or have a "craggy" feel. The vas deferens may be thickened (a "rosary bead" feel). May produce a cold abscess or scrotal sinus.
6. Testicular Tumours (Neoplasms) Present as a painless, hard, irregular swelling of the testis itself (the testis cannot be felt separately from the mass). The most common histological type is germ cell tumours (GCTs), accounting for 90-95% of cases. Types include:
  • Seminoma - peak incidence in the fourth decade
  • Non-seminomatous germ cell tumours (NSGCT): embryonal carcinoma, yolk sac tumour, teratoma, choriocarcinoma - more common in the third decade
  • Sex cord-stromal tumours (<5%): Leydig cell tumour (most common in this group, 1-3% of adult testicular tumours), Sertoli cell tumour
  • Spermatocytic seminoma - seen in men >50 years, rarely metastasises
Epidemiological risk factors include cryptorchidism, male factor infertility (including Klinefelter syndrome), family history of testicular tumours among first-degree relatives, and presence of a contralateral tumour or germ cell neoplasia in situ (GCNIS).
7. Syphilitic Orchitis Now uncommon. Can cause bilateral orchitis (feature of congenital syphilis), interstitial fibrosis causing painless destruction, or a gumma of the testis presenting as a unilateral, slowly growing, painless swelling - may be difficult to distinguish from neoplasm without surgical exploration.
8. Haematocele A collection of blood within the tunica vaginalis, usually following trauma. Does not transilluminate.

From Sabiston Textbook of Surgery, 21st Edition

(Source: Chapter 121, block 30)
Sabiston covers chronic scrotal swellings in the context of male reproductive surgery and urological evaluation:
1. Varicocele Described as "an abnormal dilation of the pampiniform venous plexus of the internal spermatic venous system." Identified as a significant cause of male infertility and mentioned as confirmable by scrotal ultrasound (measures testicular volume and symmetry, excludes neoplasm, identifies epididymal anatomy).
2. Testicular Cancer (Neoplasm) Sabiston describes it as "the most common tumor in males between the ages of 20 and 40 years." Most primary testicular cancers are of germ cell origin (95%), with the remainder being predominantly stromal (Leydig cell) or sex cord (Sertoli cell) tumours. The incidence is 5/100,000 males in the United States. Any solid intratesticular mass is treated as a malignant germ cell tumour unless strong evidence suggests otherwise.
Risk factors listed: Scandinavian descent, cryptorchidism, orchitis, family history of testicular cancer, and intratubular germ cell neoplasia.
Division of GCTs:
  • Pure seminoma (~50%): classic (85%), anaplastic, or spermatocytic
  • Mixed NSGCT (~50%): embryonal carcinoma, yolk sac/endodermal sinus tumour, choriocarcinoma, teratoma, mixed germ cell tumour
The most common presenting complaint is a painless testicular mass. Metastatic disease may present with back pain, palpable abdominal mass, shortness of breath, or haemoptysis. Scrotal ultrasonography is the diagnostic study of choice.
3. Hydrocele Confirmed on scrotal ultrasound evaluation.
4. Epididymal Abnormalities (Epididymal Cysts / Spermatocele) Identified on ultrasound in the context of male infertility work-up.

From Schwartz's Principles of Surgery, 11th Edition

(Source: Chapter 40, "Scrotum and Testes" section, block 19)
Schwartz addresses chronic scrotal swellings within its urology chapter as follows:
1. Varicocele Described as a dilation of the venous pampiniform plexus, which "can serve as an etiology of chronic testicular pain or infertility." The anatomical basis is the multiple venous drainage sources: testicular artery (from aorta), deferential artery (from internal iliac), and cremasteric artery (from external iliac).
2. Testicular Malignancy Covered in the UROLOGIC MALIGNANCIES section. Schwartz's focus in this area is on the surgical approach (radical inguinal orchiectomy), staging (CT of abdomen/pelvis, chest imaging), and use of tumour markers (AFP, beta-HCG, LDH).
3. Hydrocele The tunica vaginalis is described as the space between the visceral and parietal layers in which hydroceles form, with the anatomy clearly laid out (external spermatic fascia from external oblique; cremasteric fascia from internal oblique; internal spermatic fascia from transversus abdominis).
4. Inguinoscrotal Hernia Schwartz notes that the scrotal layers (external spermatic fascia, cremasteric fascia, internal spermatic fascia) each derive from layers of the anterior abdominal wall, providing the anatomical basis for hernias descending into the scrotum.

Summary Table

CauseCategoryB&L 28th Ed.Sabiston 21st Ed.Schwartz 11th Ed.
Testicular torsionAcute✓ (Ch. 86, block 13)✓ (Ch. 121, block 30)✓ (Ch. 40, block 19)
Torsion of appendix testis / epididymisAcute✓✓-
Epididymo-orchitisAcute✓ (Ch. 86, block 13)✓✓
Idiopathic scrotal oedemaAcute✓ (Ch. 17, block 3)--
Strangulated inguinal herniaAcute✓✓-
Fournier's gangreneAcute✓ (Ch. 86, block 13)--
Mumps orchitisAcute✓--
Scrotal trauma / haematoceleAcute✓✓✓
Hydrocele (primary)Chronic✓ (Ch. 86, block 13)✓✓
Secondary hydroceleChronic✓✓-
Epididymal cyst / SpermatoceleChronic✓✓-
VaricoceleChronic✓ (Ch. 86, block 13)✓✓
Testicular tumour / cancerChronic✓ (Ch. 86, block 13)✓ (Ch. 121, block 30)✓
Inguinoscrotal herniaChronic✓-✓
Tuberculous epididymo-orchitisChronic✓--
Syphilitic orchitis / GummaChronic✓--
Reference Notes:
  • All Bailey & Love content is from Bailey and Love's Short Practice of Surgery, 28th Edition (ISBN 9780367548117), Chapters 17 and 86
  • All Sabiston content is from Sabiston Textbook of Surgery, 21st Edition (ISBN 9780443124341), Chapter 121
  • All Schwartz content is from Schwartz's Principles of Surgery, 11th Edition (ISBN 9781259835346), Chapter 40
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