Scrotal Swelling and Scrotal Masses of Childhood

This section reviews diagnostic entities and management specific to prepubertal boys. In particular, painless scrotal masses and swelling are reviewed. The most common causes of painless cystic scrotal masses in prepubertal boys are inguinal hernias, hydroceles, varicoceles, and spermatoceles. Less frequently encountered entities include various painless solid scrotal masses, such as acute idiopathic scrotal edema, testicular tumors, and soft-tissue tumors of the spermatic cord.

PAINLESS CYSTIC SCROTAL MASSES Inguinal Hernias and Hydroceles Inguinal hernias and hydroceles, caused by incomplete or abnormal obliteration of the processus vaginalis, are the most common cause of inguinal and scrotal masses in childhood. The incidence of pediatric inguinal hernias is 10 to 20 per 1000 live births and is much higher in premature and low-birth-weight infants. Inguinal hernias are more common on the right side (60 percent) than on the left (30 percent), and 10 percent are bilateral. They are more common in boys (male-to-female ratio, 4:1). In addition to prematurity and low birth weight, many other conditions are associated with increased incidence of inguinal hernias and hydroceles, including (1) all forms of ascites and increased quantities of peritoneal fluid, (2) a positive family history, (3) hypospadias and epispadias, (4) cryptorchidism, (5) cystic fibrosis, (6) various connective tissue diseases, and (7) the mucopolysaccharidoses.

Hydroceles exist when fluid surrounds the testes, with or without direct communication with the abdominal cavity through the processus vaginalis. Their natural course is distinctly different from that of inguinal hernias. Isolated hydroceles manifest a substantially lower risk of incarceration than inguinal hernias. Most noncommunicating hydroceles are painless, are apparent in the immediate neonatal period, and disappear spontaneously by 1 year of age.

Clinically, a child with an inguinal hernia has a bulge or swelling in the scrotum or groin that is most apparent when the child is crying. At times the parent remarks on symptoms of fussiness, vomiting, or other feeding problems. Examination of the child reveals a smooth mass arising from the external ring, perhaps accompanied by swelling in the ipsilateral hemiscrotum. Unincarcerated hernias are easily reducible. Palpation of the spermatic cord reveals a thickening or the "silk-sleeve" sign.

Examination of a child with suspected hydrocele reveals a scrotal fullness that transilluminates. However, the presence of transillumination of the scrotal mass fails to exclude reliably the possibility of coexisting hernia or another pathologic condition. Palpation of the testis confirms descent and is necessary in order to exclude accompanying testicular tumor. If palpation fails to adequately demonstrate a normal-sized and -shaped testis, sonography is indicated to rule out the possibility of an accompanying intratesticular tumor.

A noncompressible, painless cystic mass in a newborn that is unassociated with abnormalities of the testis suggests a diagnosis of noncommunicating hydrocele. Observation of such a child is appropriate, since the majority of cases resolve spontaneously within the first year of life.

Compressibility of the mass suggests a hydrocele communicating with the abdominal cavity through the processus vaginalis. In such a situation and in cases of suspected inguinal hernia, surgical consultation is indicated for the purpose of scheduling surgical repair. Meanwhile, the family is educated about the signs and symptoms of incarceration of an inguinal hernia, including (1) increase in the size of the hernia mass or persistence of a mass, (2) systemic toxicity, (3) abdominal distention, or (4) vomiting, especially bilious vomiting. In cases where a clear clinical diagnosis is not possible, surgical consultation and elective exploration are warranted.

A clinical challenge exists when a child with a hydrocele presents with a coexisting condition that leads to scrotal pain and/or increased scrotal swelling. Inguinal hernia incarceration, testicular torsion, epididymitis, intrascrotal tumors, and acute intraabdominal pathologic conditions may occur in a child with a hydrocele. Careful and gentle examination is usually sufficient to diagnose an incarcerated inguinal hernia or coexistent testicular pathologic condition.

The safest and one of the more effective maneuvers for reducing incarcerated inguinal hernias involves relaxation of the abdominal wall, using sedation if necessary, and subsequent placement of the child in the Trendelenburg position. This results in successful reduction of the incarceration more than 70 percent of the time. Failure of this technique represents an indication for immediate surgical consultation and exploration.

Varicoceles A varicocele is a dilated and elongated network of veins of the pampiniform plexus and apparently is a consequence of spermatic venous valvular incompetence. Found predominantly on the left side (85 to 90 percent), varicoceles are rare in children under 10 years of age, but the incidence increases through early puberty to include 15 percent of adolescents.

Physical examination is best performed in the upright position and reveals a mass posterior, lateral, and superior to the testis extending up the spermatic cord. The mass as been described as feeling like a bag of worms. While usually painless, some boys report a dull ache in their scrotum associated with the varicocele.

The clinical significance of varicocele rests primarily with the association between this condition and adult male infertility. While infrequently an immediate concern of the adolescent, there is ample evidence that the risks of testicular hypotrophy, declining semen parameters, and infertility progress the longer the varicocele remains untreated. Therefore, the identification of a varicocele represents an indication for urologic referral in conjunction with the boy's primary care physician. Urologists recommend surgical repair of varicoceles that are (1) bilateral, (2) painful, or (3) associated with a significant disparity in testicular size of greater than 2 cm 3 Rarely, a varicocele may develop as a consequence of an acute increase in inferior vena caval pressure, in turn the consequence of an intra-abdominal tumor or vena caval thrombosis.

Spermatoceles and Epididymal Cysts Sperm-containing cysts of the rete testis or efferent ducts (spermatoceles), or of the epididymis (epididymal cysts) are the next most common cause of painless scrotal masses in children after hernias, hydroceles, and varicoceles. Located superior and posterior to the testes, they usually transilluminate well. Ultrasound studies confirm the location of the mass, demonstrating a nearly echo-free zone without disorganization of the surrounding parenchyma. Spermatoceles and epididymal cysts are unassociated with infertility and are usually painless. Management consists of confirming the diagnosis with sonographic study if necessary and subsequent parental and patient education. Surgical excision is reserved for enlarging spermatoceles, particularly those associated with discomfort unresponsive to nonsteroidal anti-inflammatory medications.

PAINLESS SOLID SCROTAL MASSES Idiopathic Scrotal Edema Idiopathic scrotal edema results in painless scrotal erythema and induration in boys from age 2 to 11 years. Two-thirds of cases are unilateral. The etiology remains obscure. No specific allergen has been identified.

The child has no complaint of pain but may note minimal pruritis and may exhibit a waddling gait. Erythema and swelling may extend to portions of the phallus, abdomen, and groin. Examination reveals a thickened and edematous scrotal skin and underlying tunics, but the boy has little or no tenderness to palpation of the affected areas. There is no fever. The testes, epididymis, and tunica vaginalis are normal, although the degree of swelling of the scrotal skin may preclude adequate examination by palpation. In sonographic studies done in such extreme cases, the underlying scrotal structures and vascular flow appear normal. The urinalysis results and peripheral white blood cell count are normal.

The scrotal edema and erythema resolve in 1 to 4 days, although recurrence rates approach 21 percent. Management involves reassurance of the child and parents. No benefit has been observed from use of steroids, antihistamines, and antibiotics.

Solid Painless Extratesticular Masses Of greatest concern upon identifying a painless solid paratesticular mass in childhood is the diagnosis of paratesticular rhabdomyosarcoma, the most common paratesticular malignancy in childhood. Rhabdomyosarcoma is one of the most common malignant solid tumors of childhood, along with the lymphomas, Wilms tumor, and neuroblastoma. The paratesticular site is the primary location in 10 percent of children with rhabdomyosarcoma. Rhabdomyosarcoma has two peak incidences: one between 2 and 6 years of age, and the other between 14 and 18 years of age.

The clinical presentation is that of a painless, unilateral, solid scrotal mass that initially is distinct from the testis, characteristics that are confirmed by sonographic evaluation. Immediate referral to a pediatric hematologist-oncologist, who will coordinate a multidisciplinary surgical-diagnostic staging and management approach, is mandatory.

There exist a variety of other painless malignant and benign solid tumors of the extratesticular scrotum, but the diagnosis and subsequent management of all of them rest with histologic methods following surgical exploration through an inguinal incision.

Solid Painless Intratesticular Masses Testicular tumors account for less than 1 percent of solid tumors in infants and children. The peak incidence of testicular tumors occurs at 2 years of age. Their significance lies, not in their frequency, but in the relatively frequent development of a secondary hydrocele in 7 to 25 percent of affected patients. This association leads to misdiagnoses and delays initiation of definitive treatment of the underlying tumor. As stated previously, the association of testicular tumors and secondary hydrocele mandates sonographic visualization of the testis if the size or position of the hydrocele precludes an adequate palpation examination of the testis.

Demonstration of a painless intratesticular mass mandates immediate referral to a pediatric hematologist-oncologist, who will coordinate obtaining a surgical diagnosis and determine treatment based on histologic analysis and staging of the tumor.

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