Why is the scrotum swollen and what to do?

A symptom such as scrotal edema can occur for various reasons in men at any age, it can be unilateral or bilateral, it can be accompanied by other symptoms, in particular, hyperemia and pain. 

Epidemiology

The most common causes of scrotal edema in boys are hydrocele and inguinal hernia. According to some reports, dropsy of the testicle occurs in about 10% of male newborns. In general, the prevalence of this pathology among men and boys is estimated at 31.7 million cases annually.

At the same time, up to a quarter of all cases of acute scrotal syndrome in boys under 10 years old are due to acute idiopathic edema. [1]

According to foreign clinical observations, approximately one out of 4-4.5 thousand boys of 12-17 years old suffers from testicular torsion, often as a result of a blow to the groin (during a game or sports activities).

Schönlein-Genoch purpura, with its peak incidence at the age of 4-5 years, affects the scrotum in 2-38% of patients.

Causes of the swelling of the scrotum

The appearance of a symptom in the form of scrotal edema (Latin - scrotum) - acute or chronic - is caused by various reasons, including:

• an inflammatory process in the tissues of the scrotal wall and its subcutaneous tissue, most often caused by Streptococcus pyogenes (beta-hemolytic streptococcus);
• acute and chronic inflammation of the testicles (orchitis) of any etiology, which in most cases is combined with inflammation of the epididymis - epididymitis and is diagnosed as epididymoorchitis or  orchiepididymitis ; [2]
• dropsy of the testicle or hydrocele - an accumulation of fluid in the tissue around the testicle (which in older men and older boys can develop due to trauma or inflammation of the scrotum);
• post-traumatic accumulation of blood in the scrotum - hematocele;
• epididymis cyst  - spermatocele;
• expansion of the venous vessels of the testicle -  varicocele ;
• vesiculitis  - inflammation of the seminal vesicles;
• damage to the scrotum in systemic sarcoidosis;
• an infection of the soft tissues of the genital organs - fasciitis of the scrotum and groin, called  Fournier's gangrene ;
• contusion and dislocation of the penis ;
• insect bites;
• lymphatic filariasis (filariasis), known as elephantiasis, resulting from transmissible infestation by parasitic roundworms (nematodes) of the Filariodidea family.

Unilateral or bilateral scrotal edema can be a sign of urinary tract pathology (for example, nonspecific urethritis or urethral perforation), malignant neoplasms. In men with allergic diseases, as well as with an increased immune response of the body (atopy), allergic or angioedema of the scrotum may occur. [3]

Due to the stagnation and accumulation of lymphatic fluid in the tissues - with chronic infectious inflammation, traumatic injury, neoplasm or after surgery, lymphatic edema of the scrotum or secondary lymphedema may develop - edema of the scrotal skin due to deterioration of lymph outflow. This is the nature of the scrotal edema after radiation therapy for pelvic cancer.

In chronic venous insufficiency,   scrotal lymphostasis , in  acute and chronic nephrotic syndrome , congestive heart failure, edema of the legs and scrotum is observed. 

How are heart failure and scrotal edema related? In the case of congestive heart failure, blood flow to the heart can be disrupted and its reverse (reflux) circulation can occur, as well as a deterioration in the outflow of lymphatic fluid. 

Often there is scrotal edema after surgery / postoperative scrotal edema: after removal of a scrotal cyst, surgical interventions on the testicles and vas deferens, and as a  complication after removal of an inguinal hernia . [4]

By the way, the inguinal hernia itself and the scrotal edema are combined in cases of entrapment of an inguinal or  inguinal-scrotal hernia . Also read:  Inguinal Hernia in Men

Risk factors

As well as the reasons, the risk factors for the development of scrotum edema are different. So, closed injuries and injuries of the scrotum and testicle predispose to the appearance of this symptom  . [5]

Often provoking are inflammatory processes in the scrotum, testicles and their appendages, which arise as a result of urinary tract infections, diseases transmitted during sexual intercourse (chlamydia, gonorrhea, etc.), as well as in the presence of infectious foci of various localization in the body, for example, tuberculosis.

The likelihood of allergic edema of the scrotum is much higher with sensitization of the body. [6]

Malignant tumors of the scrotum and testicles, accompanied by tissue edema, often develop with prolonged exposure to carcinogens, a hereditary tendency to develop neoplasms, or as a result of lymphogenous metastasis of prostate cancer and pelvic organs. The risk of scrotal lymphedema is increased in congenital lymphatic insufficiency, severe obesity, recurrent infections in immunocompromised or diabetic patients, cancer, after radiation, catheterization, and groin surgery.  [7]

For example, after placement of peritoneal dialysis catheters for renal failure, patients may develop scrotal edema due to abdominal drainage through the inguinal canal.

Pathogenesis

Doctors explain the pathogenesis of scrotal edema by deterioration or cessation of normal lymph circulation or venous blood flow, depending on its cause.

There are several mechanisms for the development of edema: as a result of an increase in the hydrostatic pressure in the capillaries and the permeability of their walls, a decrease in the oncotic pressure of blood plasma, and the cessation of the outflow of lymphatic fluid.

For example, in congenital hydrocele in boys, edema is the result of the accumulation of fluid in the vaginal membrane due to incomplete closure of the vaginal peritoneal process during the prenatal period. In adults, fluid accumulation can be caused by infection, trauma, swelling, an imbalance between the secretory and absorption capacities of the scrotal tissue, or obstruction of the flow of lymph or venous blood into the spermatic cord. [8]

The general pathogenetic characteristics of the process, the formation of edema of various origins, are considered in the publications:

• Causes of edema
• Lymphatic drainage disorders

Symptoms of the swelling of the scrotum

The accompanying symptoms also depend on the etiology of scrotal edema. With orchitis and epididymitis, this is swelling and redness of the scrotum, high fever with chills, and serous-purulent discharge from the urethra is possible.

In cases of acute idiopathic edema of the scrotum in children, erythema first appears in the perineum or groin area, and then passes to the scrotum.

Edema of the penis and scrotum can appear with injuries, diseases of the genitourinary system, with inflammation of the head of the penis and foreskin (balanitis and balanoposthitis).

The swelling can be painless or very painful. In the case of orchitis, epididymitis, or varicocele, patients complain of discomfort and mild  pain in the scrotum ; with torsion of the testicles, the pain is acute and very strong (one-sided), may be accompanied by a sharp decrease in blood pressure and vomiting. The first signs of deterioration of tissue blood supply (ischemia) may also appear: hyperemia of the skin of the scrotum, followed by its cyanosis. [9]

In some cases, large swelling can spread to the groin, perineum, and anterior abdominal wall.

Swelling of the scrotum in a child

Swelling of the scrotum in a child can be triggered by acute orchitis (orchiepididymitis), which often develops as a complication of rubella,  mumps (mumps),  or scarlet fever.

Frequent causes can be  torsion of the testicular hydatid and its epididymis , and spermatocele, and funicocele - a congenital cyst of the spermatic cord, and an inguinal hernia.

Boys aged 5-10 years may experience acute idiopathic (of unknown etiology) scrotal edema, which does not cause pain and usually disappears on its own within three to six days. [10]

Scrotal pain and swelling due to testicular inflammation are common in childhood systemic vasculitis, including purpura or  Schönlein-Henoch disease . [11]

The scrotum swells in cases of testicular teratoma or teratoblastoma, paratesticular rhabdomyosarcoma and other neoplasms.

Unilateral scrotal edema in newborns revealed during the initial physical examination is a sign of congenital hydrocele, that is,  dropsy of the testicles in newborn boys , and swelling may also be due to  testicular torsion .

Complications and consequences

Significant swelling of the scrotum with certain diseases and pathologies can give complications and cause negative consequences.

Read -  Orchitis in men: consequences and complications

Progressive edema, especially of a chronic nature, is complicated by problems with urination and sexual function, as well as various changes in the skin of the scrotum (due to a deterioration in its blood supply), which increase the risk of developing infections and can lead to tissue necrosis.

The hydrocele can expand, which poses a threat to the development of a hernia of the intestine.

What complications are possible with scrotal edema in a child? If the swelling is associated with the expansion of the venous vessels of the testicle, then if untreated, male infertility may develop over time. When the edema is caused by testicular torsion, its complete loss is possible after forced removal. [12]

Diagnostics of the swelling of the scrotum

Diagnostics is aimed at determining the cause of edema, which is far from always obvious. A complete history of the patient is required, including urological and surgical.

The physical examination should include examination and palpation of the abdomen, testicles, epididymis, scrotum, and groin. During physical examination and palpation, an increase in the size of the scrotum, thickening of its wall and skin redness are most often detected.

To make the correct diagnosis, general clinical blood and urine tests, a blood test for immunoglobulins (antibodies), urine culture and urethral smear culture are needed to identify possible pathogens, and other laboratory tests. If necessary, a testicular biopsy is done  .

Instrumental diagnostics includes transillumination (transillumination) of the scrotum,  ultrasound of the scrotum and testicles , color Doppler ultrasonography of blood vessels (or nuclear scintigraphy), CT of the pelvic organs with intravenous contrast, CT / MRI of the abdominal cavity. If there is a suspicion of urinary tract infection or inflammation of the epididymis, ultrasound of the kidneys and bladder and vocal cystourethrography are performed.

Differential diagnosis

To exclude less probable causes of acute and chronic scrotal edema, a differential diagnosis is carried out based on the results of the examination.

Treatment of the swelling of the scrotum

The correct treatment for scrotal edema is treating the diseases that cause it, that is,  treating orchitis , STDs and urinary tract infections,  treating inguinal hernia , congestive heart and venous insufficiency, allergies or malignant neoplasms, mumps or Fournier's gangrene.

Taking into account the cause of the edema, appropriate medications are used: antibiotics (for bacterial infection), pain relievers (analgesics and NSAIDs), decongestants (in particular, diuretics), antihistamines (if the edema is allergic).

Hydrocele, often seen in newborn boys, usually disappears without treatment by the end of the first year of life.

If conservative measures are not effective, surgery may be required - up to  orchiectomy . First of all, surgical treatment is used for pinching a hernia and torsion of the testicle, and in the second case, within 6 hours after the onset of symptoms, since the likelihood of preserving the testicle decreases as the duration of torsion increases. [13]

Although, for other pathologies, they resort to surgical interventions, for example, for varicocele, microsurgical varicocelectomy is performed.

Physiotherapy treatment - a comprehensive anti-edema physiotherapy performed using a combination of various physiotherapy procedures - greatly helps patients with lymphatic edema.

At home, it is recommended to use cold compresses: applying an ice pack for 10 minutes (several times during the first day). It is also recommended to do sitz baths, and in case of swelling of the legs, keep them in an elevated position (put a roller in the supine position).

In some cases, as additional measures, doctors may recommend treatment with herbs with a diuretic effect (in the form of ingested decoctions), using horsetail, creeping wheatgrass, bearberry, lingonberry leaf, corn silk.

Prevention

Without a doubt, prevention of sexually transmitted diseases is possible. Measures can be taken to avoid traumatic injury to the groin, but more often it is difficult or almost impossible to prevent diseases (and the resulting swelling of the scrotum).

Forecast

For the outcome of diseases in which scrotal edema may appear, the prognosis cannot be equally favorable, since it is determined by a number of factors, including the peculiarities of the origin of the pathological process, timely seeking medical help and adequate treatment.