This patient’s presentation is consistent with a left-sided hydrocele. The diagnosis of hydrocele is confirmed through a positive illumination test and a scrotal ultrasound, which can differentiate solid masses from fluid.
Hydrocele often occurs due to failed obliteration of the processus vaginalis, the communication between the tunica vaginalis and the peritoneum. Fluid, such as serous fluid, blood (hematocele), or sperm (spermatocele), accumulates in the tunica vaginalis of the scrotum, resulting in the enlarged appearance. Hydrocele is often associated with indirect inguinal hernia. Surgery is indicated to close the patent processus vaginalis.
Galejs discusses the diagnosis and management of scrotal abnormalities. In evaluating such patients, physical examination should include inspection and palpation of the abdomen, testes, epididymis, scrotum, and inguinal region. Urinalysis should routinely be performed; however, scrotal imaging such as ultrasound should only be pursued when the diagnosis remains unclear after initial evaluation.
Lao et al. address the management of hydrocele in very young patients, concluding that hydroceles are relatively common in infants and often resolve without operative intervention. As a general rule, hydroceles should be expected to resolve by 1 year of age. After this time period, surgery should be pursued to close a persistent patent processus vaginalis and thereby decrease the risk of future complications such as inguinal hernias.
Illustration A depicts a positive transillumination test demonstrating the presence of hydrocele. Illustration B shows the appearance of hydrocele on ultrasound.
Answer 1: These tumor markers would be useful in the diagnosis of a testicular tumor; generally one or both would be expected to be increased, depending on the type of tumor present.
Answer 3: This finding is consistent with testicular torsion, which would present with a sudden onset of acute testicular pain.
Answer 4: Serum testosterone levels would not be expected to be disturbed by a hydrocele.
Answer 5: No abnormalities would be anticipated on urinalysis, therefore, it is unlikely to be helpful.
Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam Physician. 1999 Feb 15;59(4):817-24.
PMID:10068706 (Link to Abstract)
Lao OB, Fitzgibbons RJ Jr, Cusick RA. Pediatric inguinal hernias, hydroceles, and undescended testicles. Surg Clin North Am. 2012 Jun;92(3):487-504, vii.
PMID:22595705 (Link to Abstract)
USMLE World Step 1 QBank Question #1827. Copyright © USMLEWorld, LLC 2012