Differential diagnoses: Scrotal lesions

Dr Nigel Stollery outlines differential diagnosis of scrotal lesions including inguinal scrotal hernia, hydrocoele, angiokeratomas of Fordyce, and steatocystoma multiplex.

Inguinal scrotal hernia

Presentation

  • Scrotal swelling which extends up into the body
  • Soft, fluctuant and usually non-tender
  • May be reducible when patient is lying flat
  • Bowel sounds may be present
  • Does not transilluminate when light applied
  • May be bilateral or unilateral
  • Strangulation may occur, leading to severe pain

Management

  • Surgery is the treatment of choice in large, symptomatic cases
  • Laparoscopic repair increasingly common
  • Support/truss may help where surgery not an option

Hydrocoele

Presentation

  • Swelling within the scrotum which is localised and does not extend into the body
  • Testes cannot be felt separately as lie within the hydrocoele
  • Usually soft, non-tender, cystic
  • Transilluminates when light applied
  • Caused by excess fluid in tunica vaginalis
  • May be congenital or develop later in life

Management

  • Most only require reassurance
  • Larger ones can be aspirated
  • If tumour suspected, aspiration should be avoided - it increases risk of metastatic spread
  • In very large or recurrent cases, surgery is usually curative

Angiokeratomas of Fordyce

Presentation

  • Small red/purple papules in scrotal skin
  • Also found in penile shaft, inner thighs and lower abdomen
  • Histologically, composed of ectatic thin-walled vessels in superficial dermis with overlying epidermal hyperplasia
  • Scaly surface often present
  • Usually 2-5 mm in diameter, although size can vary
  • Generally multiple
  • May bleed with minimal trauma, otherwise usually asymptomatic

Management

  • Treatment not usually required
  • Where bleeding occurs, cautery, hyfrecation or laser effective

Steatocystoma multiplex

Presentation

  • Uncommon disorder of pilosebaceous unit
  • Typically produces multiple sebum-containing dermal cysts
  • Can be inherited as autosomal dominant condition, but most cases are sporadic
  • Cysts usually non-tender and asymptomatic
  • Size can vary from 3mm to 3cm
  • Cysts lack punctum and more common in sebum-rich areas
  • Secondary infection may occur

Management

  • Treatments include cryotherapy, aspiration and surgical excision
  • If secondary infection occurs, tetracyclines can be effective
  • Dr Stollery is a GP in Kibworth, Leicestershire

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This is an updated version of an article that was first published in November 2014

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