Read Common Problems Of the Adult Scrotum text version

Kaiser Oakland Urology

Common Scrotal Problems

Part I : Normal Scrotal Anatomy Part II: Hydroceles Part III: Spermatoceles Part IV: Orchalgia ( Testicular Pain Syndrome)

Part 1

Basic Anatomy

The Scrotum

2 scrotal sac compartments Contain right and left testicles



The Testicle

The testicle has 2 main functions

Produce sperm Produce the main male hormone testosterone

Normal Anatomy

Each testicle has its own blood vessels and nerves Like our right and left hands, they are independent of each other!

Arteries, Veins and Nerves

Testicle Testicle

Normal Anatomy

Each testicle is surrounded by a small amount of fluid produced by the compartment lining called the tunica vaginalis. This fluid lets the testicle move without friction within its scrotal compartment



Compartment filled with fluid produced by the tunica vaginalis

Normal Anatomy

The Tunica Vaginalis

Lining that produces the fluid around the testicle

Normally, there is a balance between fluid produced and reabsorbed by the tunica vaginalis

Fluid reabsorbed


Fluid produced

Tunica Vaginalis

The Epididymis

The epididymis is closely attached the testicle Here the sperm mature on their way from the testicle to the vas deferens

The Epididymis

A "c" shaped and wormlike structure lies behind the testicle The "head" and "tail" are often rounded Normally a little tender or sensitive to the touch

Vas Deferens


Testicle Side Views!



Vas Deferens

Carries sperm from epididymis to prostate ( near bladder)

Spermatic Cord

Tubular structure Travels through groin ("inguinal") area into scrotum Contains:

Testicular artery and many veins Small muscle fibers that attach to abdominal muscles Nerves to testicle, vas and epididymis Vas deferens

Spermatic Cord Components

The testicular artery and veins originate high in the upper abdominal area, near the kidneys

Spermatic Cord

The vas deferens, testicular artery and vein and nerves come together just inside the abdominal wall to become the spermatic cord

Part II



Excessive fluid around the testicle Fluid production by tunica vaginalis exceeds reabsorption Caused by damaged tunica vaginalis from:

infection Injury/ trauma Surgery Unknown cause ­ Most common!

Testicl e More Fluid!


Harmless problem! Large hydrocoeles may cause discomfort from their massive size and weight Small and moderate size hydroceles do not cause symptoms

This impressive size is VERY RARE !


Diagnosis: Exam

Hydroceles transilluminate!


Light passes through the fluid. Light will NOT pass through a solid mass (tumor) or thicken inflammatory tissue

Hydrocele Treatment Options

Aspiration with a needle ­

Generally not recommended

Results in fluid reaccumulation (failure!) Possible pain, bleeding or infection Can make surgery later more difficult

Hydrocele Treatment Options

Surgery is the most effective option:

Outpatient procedure ­ usually about 1 hr Local , general or spinal anesthesia Recovery

physical restrictions, swelling and pain should be expected for several weeks


infection, pain, bleeding/hematoma reoccurrence of hydrocele

Hydrocele Treatment Options

Small and moderate sized hydroceles are usually best left alone! Postoperative pain, swelling ,physical restrictions and potential risks make surgery less desirable for hydroceles that do not cause symptoms! For many, the treatment can be worse than the problem!

Part III



Benign cyst of epididymis Harmless! Cause is unknown Usually cause NO symptoms



VERY COMMON! Bubblelike Usually above the testicle Contains clear fluid containing sperm May increase size in time Most the size of a grape or walnut Sometimes multiple



Exam usually very easy to identify

Mobile, smooth and round Usually above and separate from testicle Transilluminates

Spermatocele Treatment

Surgery: Excision of cyst

Reserved for symptomatic or very large cysts! Recovery:

swelling and pain often restrict physical activities for several weeks

Risks: infection, bleeding, pain/inflammation, more spermatoceles can form in the future! Infertility can be caused by scarring of epididymis

Men considering fathering children should NOT have surgery!

Spermatocele Treatment

Small and moderate sized spermatoceles are usually best left alone! Postoperative pain, swelling ,physical restrictions and potential risks make surgery less desirable for spermatoceles that do not cause symptoms!

Part IV:


Testicular Pain Syndrome


Pain Syndrome Pain often involves: Groin Testicle Scrotum Inner thigh

Cause of Orchalgia

Often Unknown

Diagnosis of Orchalgia

Exclude other causes of testicular pain by:

History Examination Appropriate tests based on exam and history


Many men with Orchalgia are told that they may have "epididymitis". Men with epdidymitis have abnormal urine tests and/or an swollen and enlarged epdidymis


Normal Testicle and Testicle Epididymis


Other Causes of Testicular Pain

Kidney stone in the ureter Prostatitis ­ prostate inflammation Infection male pelvic pain syndrome Epdidymitis urinary tract infection Testicular torsion Tumors rare Usually obvious by exam Complications of vasectomy Granuloma or vasitis Epididymal engorgement Chronic Pelvic Pain Syndromes

Hydroceles and Spermatoceles?

Hydroceles and spermatoceles rarely cause significant pain! Surgery for spermatoceles and hydroceles:

Often does NOT reduce orchalgia pain The cause is usually nerve related! May increase pain May cause prolonged recovery and discomfort Risks complications ­ infection, bleeding, infertility, etc.

Cause of Orchalgia

Research Says: Most cases caused by irritation of nerves to groin, testicle and scrotum

Ilioinguinal nerve Sensation for the groin and scrotum Genitofemoral nerve Sensation for the inner thigh and testicle

Orchalgia = Nerves Problem

These nerve arise in the upper lumbar area of the spinal cord They travel through large muscles of the back and inside the abdominal wall

Ilioinguinal and Genitofemoral nerves

Nerves arise from 1st and 2nd Lumbar Spine

Ilioinguinal and Genitofemoral nerves

The nerves then travel through an opening in the abdominal wall near the groin ( "inguinal canal"). The nerves become part of the nerves of the spermatic cord and nerves of the scrotum.

Nerves to the Groin, Testicle and Scrotum

Groin area

Spermatic cord

Nerve Irritation

Possible causes: Irritation/pressure of L12 nerve roots near spine Irritation/pressure by muscle above the spermatic cord Irritation/pressure by muscle or scar tissue within the groin

Hernia Previous hernia surgery scar tissue or mesh

Irritation by process in the scrotum

Previous vasectomy scar tissue

Need an example? Sciatica

A similar, but more common problem among adults Sciatica is caused by irritation to lower lumbar and sacral nerves Pressure on the nerve roots near the spine by a bulging spinal disc is often the cause of pain in the buttucks, thigh and leg


Tends to last fewseveral months

Occasionally long lasting May come and go

More common among

Younger men Hispanic men Muscular men?

Common Symptoms Suggesting Nerverelated Orchalgia

Positional pain

Vague, poorly localized pain

Pain caused by specific physical activities Pain and/or hypersensitivity involving:

The inner thigh ­highly suggestive of orchalgia! Both testicles The groin, scrotum and testicle

Is Orchalgia Serious?


Although frustrating and occasionally very painful, orchalgia does not affect overall health in any way. Orchalgia does not lead to any other nerve, testicular, sexual or medical problems!

Treatment of Orchalgia

Treated like Sciatica!

Avoid activities and positions that irritate pain Take daily "NSAIDs" ­ at least 3 weeks

Naprosyn Ibuprofen Relafen

Nerve pain medications ­ if NSAIDs fail

Elavil and Neurontin ­ may helpful Problems: sideeffects like dry mouth and sedation

Long Term NSAIDs

Must have good kidney function! Avoid if you:

Are taking blood thinners like:

Aspirin Plavix Coumadin

Have stomach problems like:

Gastrointestinal bleeding Gastritis or ulcers

Take with food and lots of water Talk to your doctor!

Treatment of Orchalgia What about surgery?

Surgery to cut or free up nerve tissue is sometimes successful Surgery Problems

Often fails to reduce pain May cause pain to worsen Often results in numbness of the groin or scrotum Risks of infertility, infection, bleeding and injury to testicle or vas deferens

What about removing the testicle?

Surgery to remove the testicle often fails to stop pain since the testicle is NOT the cause. Since the pain is often caused by a nerve above the testicle, the pain may continue even after the testicle is removed. This is called "Phantom Pain"!


Common Problems Of the Adult Scrotum

48 pages

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