Why does my scrotum swell and what to do?

A symptom such as swelling of the scrotum can occur for various reasons in men of any age, can be unilateral or bilateral, and 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 data, hydrocele of the testicle occurs in approximately 10% of male newborns. In general, the prevalence of this pathology among men and boys is estimated at 31.7 million cases annually.

Moreover, up to a quarter of all cases of acute scrotum syndrome in boys under 10 years of age are due to acute idiopathic edema. [ 1 ]

According to foreign clinical observations, approximately one in 4-4.5 thousand boys aged 12-17 years experiences testicular torsion, often as a result of a blow to the groin (during play or sports).

Henoch-Schonlein purpura, which peaks in incidence at 4-5 years of age, affects the scrotum in 2-38% of patients.

Causes scrotal edema

The appearance of a symptom in the form of swelling of the scrotum (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 ]
• hydrocele, or dropsy of the testicle, is a collection of fluid in the tissue around the testicle (which in adult men and older boys can develop due to injury or inflammation of the scrotum);
• post-traumatic accumulation of blood in the scrotum - hematocele;
• epididymal cyst – spermatocele;
• dilation of the venous vessels of the testicle - varicocele;
• vesiculitis – inflammation of the seminal vesicles;
• scrotal lesions in systemic sarcoidosis;
• infection of the soft tissues of the genitals - fasciitis of the scrotum and groin, called Fournier's gangrene;
• contusion and dislocation of the penis;
• insect bites;
• Lymphatic filariasis (filariasis), known as elephantiasis, caused by transmissible infection with parasitic roundworms (nematodes) of the Filariodidea family.

Unilateral or bilateral swelling of the scrotum may 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 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 - swelling of the skin of the scrotum due to deterioration of lymph drainage - can develop. This is the nature of scrotal swelling after radiation therapy for pelvic cancer.

In chronic venous insufficiency, scrotal lymphostasis, acute and chronic nephrotic syndrome, and congestive heart failure, swelling 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 may be disrupted and its reverse (reflux) circulation may occur, as well as deterioration of the outflow of lymphatic fluid.

Postoperative scrotal swelling/postoperative scrotal swelling often occurs: 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 swelling of the scrotum are combined in cases of strangulation of the inguinal or inguinoscrotal hernia. Also read: Inguinal hernia in men

Risk factors

Like the causes, the risk factors for the development of scrotum edema are different. Thus, closed injuries and trauma to the scrotum and testicle predispose to the appearance of this symptom. [ 5 ]

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

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

Malignant tumors of the scrotum and testicles, accompanied by tissue edema, most 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 with congenital lymphatic insufficiency, severe obesity, recurrent infections in patients with weakened immunity or diabetes, cancer, after radiation, catheterization, and surgery in the groin area. [ 7 ]

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

Pathogenesis

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

There are several mechanisms for the development of edema: as a result of increased 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, the swelling results from fluid accumulation in the tunica vaginalis due to incomplete closure of the processus vaginalis during the prenatal period. In adults, fluid accumulation may be caused by infection, trauma, tumor, imbalance between the secretory and absorptive capacities of the scrotal tissue, or obstruction of lymphatic or venous blood flow in the spermatic cord.[ 8 ]

General pathogenetic characteristics of the process of formation of edemas of various origins are considered in the publications:

• Causes of edema
• Lymphatic drainage disorders

Symptoms scrotal edema

The etiology of scrotal edema determines the accompanying symptoms. In cases of orchitis and epididymitis, this is edema and redness of the scrotum, high fever with chills, and possible serous-purulent discharge from the urethra.

In cases of acute idiopathic scrotal edema in children, erythema first appears in the perineum or inguinal region and then spreads to the scrotum.

Swelling of the penis and scrotum may occur due to injuries, diseases of the genitourinary system, inflammation of the head of the penis and foreskin (balanitis and balanoposthitis).

The swelling may be painless or very painful. In the case of orchitis, epididymitis or varicocele, patients complain of discomfort and moderate pain in the scrotum; in the case of testicular torsion, the pain is sharp and very strong (one-sided), and may be accompanied by a sharp drop 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, severe swelling may extend to the groin, perineum and anterior abdominal wall.

Swollen scrotum in a child

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

Common causes may include torsion of the hydatid of the testicle and its appendage, spermatocele, funicocele (a congenital cyst of the spermatic cord), and inguinal hernia.

In boys aged 5 to 10 years, acute idiopathic (of unknown etiology) swelling of the scrotum may occur, which does not cause pain and usually resolves on its own within three to six days. [ 10 ]

Scrotal pain and swelling due to testicular inflammation are characteristic of childhood systemic vasculitides, including Henoch -Schönlein purpura or disease.[ 11 ]

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

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

Complications and consequences

Significant swelling of the scrotum due to certain diseases and pathologies can lead to complications and cause negative consequences.

Read - Orchitis in men: consequences and complications

Progressive swelling, 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 deterioration of its blood supply), which increase the risk of developing infections and can lead to tissue necrosis.

A hydrocele can expand, which creates a risk of developing an intestinal hernia.

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, in the absence of treatment, male infertility may develop over time. When the swelling is caused by testicular torsion, its complete loss is possible after forced removal. [ 12 ]

Diagnostics scrotal edema

Diagnostics is aimed at determining the cause of the edema, which is not always obvious. A complete patient history is required, including urological and surgical.

The physical examination should include inspection and palpation of the abdomen, testicles, epididymis, scrotum, and inguinal area. Physical examination and palpation most often reveal an increase in the size of the scrotum, thickening of its wall, and hyperemia of the skin.

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

Instrumental diagnostics include transillumination (translucence) 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 urinary tract infections or inflammation of the epididymis are suspected, ultrasound of the kidneys and bladder and voiding cystourethrography are performed.

Differential diagnosis

To exclude less likely causes of acute and chronic scrotal edema, differential diagnostics are performed based on the examination results.

Treatment scrotal edema

The correct treatment for scrotal edema is to treat the underlying conditions that cause it, such as orchitis, STDs and urinary tract infections, inguinal hernia, congestive heart failure, venous insufficiency, allergies or malignancies, mumps or Fournier's gangrene.

Depending on the cause of the swelling, appropriate medications are used: antibiotics (for bacterial infections), painkillers (analgesics and NSAIDs), decongestants (in particular, diuretics), antihistamines (if the swelling is allergic).

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

If conservative measures are ineffective, surgery may be required, including orchiectomy. First of all, surgical treatment is used for strangulated hernia and testicular torsion, 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 other pathologies also involve surgical interventions, for example, microsurgical varicocelectomy is performed for varicocele.

Physiotherapy treatment – complex anti-edematous physiotherapy, carried out using a combination of various physiotherapeutic procedures – significantly helps patients with lymphatic edema.

At home, it is recommended to use cold compresses: apply an ice pack for 10 minutes (several times during the first 24 hours). It is also recommended to take sitz baths, and if your legs are swollen, keep them elevated (put a bolster under them when lying down).

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

Prevention

Prevention of sexually transmitted diseases is certainly possible. Measures can be taken to avoid traumatic injuries to the groin area, but more often than not, preventing diseases (and the swelling of the scrotum that they cause) is difficult or virtually impossible.

Forecast

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