CASE # 3 Amaro.Amolenda.Anacta

Case #3 A 35-year old male comes to your clinic with the following problem of 10 years duration. Except for the mass, he is relatively asymptomatic.

Differential Diagnosis HYDROCELE Collection of serous fluid that results from a defect or irritation in the tunica vaginalis of the scrotum Adult hydroceles are usually late-onset (secondary). Late-onset hydroceles may present acutely from local injury, infections, and radiotherapy; they may present chronically from gradual fluid accumulation. Morbidity may result from chronic infection after surgical repair. Hydrocele can adversely affect fertility. Clinical Manifestation: Most hydroceles are asymptomatic or subclinical* The patient may report a sensation of heaviness, fullness, or dragging. The usual presentation is a painless enlarged scrotum Hydrocele usually is not painful; pain may be an indication of an accompanying acute epididymal infection.

Differential Diagnosis TESTICULAR TORSION Testicular torsion occurs when a testicle rotates on the spermatic cord, which provides blood flow to the testicle* Testicular torsion is most common in males under 25, but it can occur at any age, including in newborns and infants. Clinical Manifestation: Sudden or severe pain in one testicle Swelling of the scrotum (a loose bag of skin under your penis that contains your testicles) Nausea and vomiting Abdominal pain Fever This rotation cuts off the flow of blood and causes sudden, often severe pain and swelling

Differential Diagnosis ORCHITIS Orchitis is an acute inflammatory reaction of the testis secondary to infection. Most cases are associated with a viral mumps infection; however, other viruses and bacteria can cause orchitis. Clinical Manifestation: Testicular swelling on one or both sides Pain ranging from mild to severe Tenderness in one or both testicles Nausea Fever Discharge from penis Blood in semen

Differential Diagnosis INGUINAL HERNIA Inguinal hernias occur when soft tissue, usually part of the intestine protrudes through a weak point or tear in the lower abdominal wall. * Some inguinal hernias have no apparent cause. But many occur as a result of: (1) Increased pressure within the abdomen, (2) A pre-existing weak spot in the abdominal wall, (3) A combination of the two* The resulting bulge can be painful — especially when you cough, bend over or lift a heavy object. Whether or not you have a pre-existing weakness, extra pressure in your abdomen can cause a hernia. This pressure may result from: Straining during bowel movements or urination, Heavy lifting, Fluid in the abdomen (ascites), Pregnancy, Excess weight, Even chronic coughing or sneezing can cause abdominal muscles to tear.

Differential Diagnosis Clinical Manifestation A bulge in the area on either side of your pubic bone Pain or discomfort in your groin, especially when bending over, coughing or lifting A heavy or dragging sensation in your groin Occasionally, in men, pain and swelling in the scrotum around the testicles when the protruding intestine descends into the scrotum

Initial Assessment Late-Onset Hydrocele Probably secondary to Scrotal injury Infection Radiation therapy

DIAGNOSIs

Physical Examination Enlarged, non tender scrotum Testicles cannot be palpated If there’s an associated inguinal hernia, pressure on the abdomen or scrotum will enlarge or shrink the fluid-filled sac Transillumination shine a flashlight at the swollen area of the scrotum the light will show the outline of the testicle, indicating a clear fluid surrounding it UTS may If the area of swelling becomes larger or smaller as the doctor examines the scrotum, the patient may have an inguinal hernia or a communicating hydrocele. If an infection (e.g., epididymitis) is suspected, blood or urine tests may be performed. not help differentiate hydrocele from herniaIn addition, testicular atrophy suggesting chronic torsion and a reactive hydrocele can be seen on sonograms. Failure to clearly delineate testicular anatomy with palpation indicates the need for further diagnostic imaging such as ultrasonography. Duplex ultrasonography As with ultrasonography, duplex studies are not warranted in simple hydroceles. However, duplex studies may provide substantial information regarding testicular blood flow when a hydrocele may be associated with chronic torsion. Additionally, epididymitis associated with a reactive hydrocele can be distinguished based on findings from duplex scanning, as evidenced by increased epididymal flow. Finally, duplex studies may help identify Valsalva-augmented regurgitant flow in patients with varicoceles.

Ultrasound often used to confirm the diagnosis of hydrocele as it provides excellent detail of the testicular parenchyma rule out a tumor, torsion, spermatocele or other conditions if a testicular tumor is a diagnostic consideration, ultrasonography is an excellent screening study

Ultrasound of Hydrocele

Plain abdominal radiography Plain radiography may be useful for distinguishing an acute hydrocele from an incarcerated hernia Gas overlying the groin may indicate an incarcerated hernia.