Scrotal Swellings: Synopsis of Differential Diagnosis (Part III)

Scrotal swellings enshrine clinical conditions affecting dermis and /or sub-cutaneous tissue, and those of scrotal contents. A clear cut insight into their symptoms and signs are imperative to comprehend before arriving at their precise diagnosis. A concerted endeavor in this direction has been made to appraise the audience with their nomenclature origin, clinical variants, presentation and clear cut diagnostic criteria. Accordingly angioedema, lichen simplex chronicus, orchitis, epididymitis related epididymo-orchitis, varicocele, testicular torsion, and hydrocele formed the subject matter. The role of Ultrasonography, Ultrasonic colour doppler imaging and magnetic resonance imaging in evaluating scrotal swellings has succinctly been emphasized to enrich the core curriculum of the viewers. *Corresponding author: Virendra N. Sehgal, MD, Dermato-Venerology (Skin/VD) Center, Sehgal Nursing Home, A/6 Panchwati, Delhi-110 033, India, Tel: 9810182241; E-mail: drsehgal@ndf.vsnl.net.in / sehgalvn@yahoo.co.in Citation: Sehgal, V.N., et al. Scrotal Swellings Synopsis of Differential Diagnosis (Part III). (2016) Invest Dermatol Venereol Res 2(3): 17. Scrotal Swellings: Synopsis of Differential Diagnosis (Part III) Virendra N Sehgal1*, Ruchi Sehgal1, Deepa Sehgal1, Shyam S Pandey2, Syed S Amin3, Sambit N Bhattacharya4, Rakesh Oberai5 Received date: May 6, 2016 Accepted date: August 7, 2016 Published date: October 15, 2016 DOI: 10.15436/2381-0858.16.905 Invest Dermatol Venereol Res | Volume 2: Issue 3 Sehgal, V.N., et al. and exit/ slipping of small bowel into the scrotum, the inguinal hernia are its other presentations. It is, therefore, worthwhile to take stock of these conditions by their salient clinical presentation, diagnosis criteria including investigation like Ultrasonography[19], Ultrasonic colour Doppler imaging[20] and magnetic resonance imaging (MRI)[21,22] to form the perspective clinical diagnosis. Accordingly, their cardinal briefs are defined in the adjoining tables (table 1 to 4) for at a glance evaluation. Scrotal swellings of dermis and sub-cutaneous tissue Angioedema (Figure. 1a), lichen simplex chronicus (Figure. 2a & b): Nomenclature, clinical variants, salient presentation and diagnostic criteria are outlined in Table 1.


Introduction
and exit/ slipping of small bowel into the scrotum, the inguinal hernia are its other presentations. It is, therefore, worthwhile to take stock of these conditions by their salient clinical presentation, diagnosis criteria including investigation like Ultrasonography [19] , Ultrasonic colour Doppler imaging [20] and magnetic resonance imaging (MRI) [21,22] to form the perspective clinical diagnosis. Accordingly, their cardinal briefs are defined in the adjoining tables (table 1 to 4) for at a glance evaluation.
In addition to the clinical picture supplement of haemogram, serum, electrolytes, liver and kidney functions are mandatory Clinical as well as laboratory test, inhibitor of complement enzyme, C1 esterase (C1INH) for HAE [23] Rapid swelling, edema of the dermis, subcutaneous tissue, mucosa and sub mucosal tissues.
Thickening of the skin, variable scaling arising secondary to repetitive scratching / rubbing.
The re-crossed keratinocytes that forms keratinocytes-derived amyloid in the dermis.
Scrotal swellings of the contents of the scrotum Orchitis, Epididymitis and Epididymo-orchitis ( Figure 3) The origin of nomenclature, clinical variants, presentation and diagnostic criteria are succinctly defined in the adjoining (table 2) www.ommegaonline.org
Inferno [29] Brown novel) colour Doppler ultrasound, a sign of orchitis. Inflammation of the testicles caused either by bacteria or virus, affecting one or both Epididymitis [11,12,28,30] Discomfort or pain [31] Acute, Chronic Chills, low-grade fever, Pain/discomfort in the pelvic area, painful, red, warn and swollen scrotum, pain and tenderness in the testicles, enlarged groin lymph nodes, painful, frequent urination or bowel movements, painful intercourse and ejaculation.
Gram Stain of Urethral is charge with Intracellular Neisseria, gram-negative diplococcai Chlamydia trachomatis [41] Testing Sensitivity in Midstream urine specimens Inflammation of the epididymis and/or testis Varicocele and testicular torsion: The origin of nomenclature, clinical variants, presentation, and diagnostic criteria are shown for at a glance diagnosis in (table 3) [43,44] Changing levels of testosterone ColorDoppler ultrasound (CDU) [46] presence of a venous plexus and the sum of the diameters of veins in the plexus change of flow on Valsalva maneuver / manoeuvre (Fig. 4, fig. 5) Testicular torsion: [17,[47][48][49] Twisting of the spermatic cord resulting in ischemia of the testicles,

Congenital
Sudden, severe, testicular pain and tenderness in the groin and lower abdomen Clinical color ultrasound scan of the scrotum, eliciting absence of blood flow in the twisted testicle [50] Hydrocele

Diagnosis
Clinical variants [53] Presentation Diagnostic criteria Hydrocele Testis [51][52][53] Hydrocele testis a painless swelling of the scrotum due to circumscribed collection of fluid in the tunica vaginalis testis  [54] Apparent diffusion co-efficient (ADC) Reduced ADC values of testis, indicating reduced diffusion of the testis, with an increasing amount of fluid. (Figure 7a & b) Infantile hydrocele Infertility(?) [55] Congenital hydroceles Magnetic resonance imaging (MRI) [57] a diagnostic tool of high predictive value An exit/slipping of a bowel from the abdomen through the wall of the cavity into the scrotum [51,56] . It may either be direct or indirect hernias, which may or may not extend down to the scrotum.

Synopsis of differential diagnosis
Scrotal swellings may either be of dermis, subcutaneous tissue or contents of scrotum, the utility of this diversification may prove beneficial, while preparing the instant day to day clinical dissertation. Besides, the afore mentioned conditions sarcoidosis [58] presenting as hydrocele (vide supra) and juvenile dermatomyositis(JDM) [59] charactererised by edema of the penis and scrotum should also be considered.

Multiple choice questions (MCQs)
1. Which of these aspects of the clinical history would alert you to a possible diagnosis of hereditary angioedema in a patient with angioedema? a. Early onset of angioedema before early adulthood b. Angioedema but no wheals c. b. Is usually found affecting females. c. Is formed due to fluid collection in the femoral canal. d. Is seen in children as well as adults. e. Is a painful, translucent and reducible swelling.
Answer: b 6. Which of the following are not usually observed in epididymo-orchitis: a. The epididymal tail is often more swollen than the head. b. In the majority of case there is some oedema and swelling of the testis. c. In the majority of cases there is a large hydrocele containing debris. d. In some cases there is swelling of the spermatic cord. e. The mumps virus causes orchitis without epididymitis.
Answer: c & d 7. In torsion of the testicular appendix, which of the following is incorrect? a. The condition causes only mild pain. b. The testis is relatively hypo-vasular on Doppler Study. c. There is often swelling of the spermatic cord. d. The condition does not occur in adults.
Answer: a 8. Varicocele is more common in left testis because : a. Left testicular vein drains into IVC which has high pressure b. Left testicular vein drains into left renal vein and has poor valve mechanism c. Left testis is lower situated d. Compression of testicular vein by rectum Answer: b 9. Which of the following statements about the causes of inguinal hernia is correct? a. Excessive hydroxyproline has been demonstrated in the aponeuroses of herniapatients. b. Obliteration of the processus vaginalis is a contributing factor for the development of an indirect inguinal hernia. c. Physical activity and athletics have been shown to have a protective effect toward the development of inguinal hernias. d. Elevated levels of circulating serum elastase activity have been demonstrated in patients with direct herniation who smoke.
Answer: d