SU30.3-5 | Epididymo-Orchitis, Varicocele and Hydrocele — Summary & Reflection

KEY TAKEAWAYS

Three common benign scrotal swellings present alongside one emergency that must always be excluded first. Epididymo-orchitis is an ascending infection (STI organisms — Chlamydia/gonococcus — in young men; coliforms in older men/UTI) causing a gradual, febrile, tender swelling with a positive Prehn's sign and a preserved cremasteric reflex; it is treated with organism-directed antibiotics, analgesia, scrotal support and partner treatment — but if testicular torsion (sudden severe pain, high-riding tender testis, absent cremasteric reflex, salvage best within ~6 hours) cannot be excluded, the patient goes to urgent exploration, and ultrasound must never delay theatre. Varicocele is a dilated pampiniform plexus, almost always left-sided (left testicular vein enters the left renal vein at a right angle), a 'bag of worms' that is worse standing and a treatable cause of subfertility; a new/right-sided/non-decompressing varicocele warrants imaging for a renal/retroperitoneal mass, and intervention (varicocelectomy/embolisation) is reserved for pain, atrophy or subfertility. Hydrocele is fluid within the tunica vaginalis — transilluminant, you can get above it — managed by observation or surgery (Jaboulay/Lord's), with the rule that a secondary hydrocele needs its cause treated and an underlying tumour excluded (never aspirate-and-reassure).

REFLECT

Imagine the next acutely painful scrotum that arrives on your shift. Are you confident that your very first act would be to ask whether this could be testicular torsion — checking the onset, the position of the testis, the cremasteric reflex and Prehn's sign — and that you would send a teenager with sudden severe pain to theatre rather than reaching for antibiotics or a scan? When you next meet a soft, painless scrotal swelling, will you remember the simple bedside discipline of getting above it, transilluminating it, and feeling the testis separately — and will you scan the testis before reassuring, in case the hydrocele is hiding a tumour? And faced with a 'bag of worms', will you examine the patient standing, check it decompresses on lying down, and treat a new right-sided one as a clue to a renal mass? Reflect on how a handful of bedside signs, applied in the right order, keep you from the two classic traps: missing a torsion and missing a tumour.