Scrotal masses are common in young males, and determining the exact anatomical site of the scrotal mass is of utmost clinical importance. Any mass that arises from the testis should be investigated to exclude testicular cancer. Masses that arise from the epididymis and scrotal lesions, such as fluid (hydrocele) or hernias, are also clinically important but are not malignant.
The ultrasound scan revealed fluid surrounding the testis, which is diagnostic of a hydrocele. Simple cysts arising from and around the epididymis (epididymal cysts) can be easily defined.
A diagnosis of lymphoma was suspected.
Lymphoma is a malignant disease of lymph nodes. Most lymphomas are divided into two specific types, namely Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. If caught early the prognosis following radical chemotherapy is excellent.
The patient underwent a biopsy, which was performed from the posterior approach. He was placed in the prone position in the computed tomography (CT) scanner. A fine needle with a special cutting device was used to obtain a lymph node sample. A left-sided approach was used because the inferior vena cava is on the right side and the nodes were in the para-aortic regions (i.e., the biopsy needle would have to pass between the inferior vena cava and the aorta from a posterior approach, which is difficult). The skin was anesthetized using local anesthetic at the lateral border of the quadratus lumborum muscle. The needle was angled at approximately 45° within the quadratus lumborum muscle and entered the retroperitoneum to lie beside the left-sided para-aortic lymph nodes. Because this procedure is performed using CT guidance, the operator can advance the needle slowly, taking care not to “hit” other retroperitoneal structures.
A good biopsy was obtained and the diagnosis was Hodgkin’s lymphoma. The patient underwent chemotherapy and 2 years later is in full remission and leads an active life.
A 35-year-old man had a soft mass approximately 3 cm in diameter in the right scrotum. The diagnosis was a right indirect inguinal hernia.
What were the examination findings?
The mass was not tender and the physician was not able to “get above it.” The testes were felt separate from the mass, and a transillumination test (in which a bright light is placed behind the scrotum and the scrotal sac is viewed from the front) was negative. (A positive test occurs when the light penetrates through the scrotum.)
When the patient stood up, a positive cough “impulse” was felt within the mass.
After careful and delicate maneuvering, the mass could be massaged into the inguinal canal, so emptying from the scrotum. When the massaging hand was removed, the mass recurred in the scrotum.
An indirect inguinal hernia enters the inguinal canal through the deep inguinal ring. It passes through the inguinal canal to exit through the superficial inguinal ring in the aponeurosis of the external oblique muscle. The hernia sac lies superior and medial to the pubic tubercle and enters into the scrotum within the spermatic cord.
A direct inguinal hernia passes directly through the posterior wall of the inguinal canal. It does not pass down the inguinal canal. If large enough, it may pass through the superficial inguinal ring and into the scrotum.
A 25-year-old man developed severe pain in the left lower quadrant of his abdomen. The pain was diffuse and relatively constant but did ease for short periods of time. On direct questioning the patient indicated that the pain was in the inguinal region and radiated posteriorly into his left infrascapular region (loin). A urine dipstick was positive for blood (hematuria).
A diagnosis of a ureteric stone (calculus) was made.
The patient’s initial infrascapular pain, which later radiated to the left groin, relates to passage of the ureteric stone along the ureter.