Patient Education
This is another common condition noticed by the mother while dressing or bathing her son. There are two basic types of swellings in the scrotum:
First Type of Scrotal Swelling
There is a gradually increasing size of one side of the scrotum; there is no associated pain, discomfort, redness or fever, nor any local injury. The swelling varies in size from time to time. It is very minimal early in the day when the child has just got out of bed, and it gradually increases in size during the day as the boy stands, walks runs & plays. The maximum size of the swelling is usually reached towards the evening. This is classically a Hydrocele. The reason for this is, like in hernia, the passage for the testis remains open but not as widely as hernia and prevents the intestines from coming out but only the fluid in the abdomen is able to come out & down into the scrotum. The diagnosis must be confirmed by a Pediatric Surgeon. The contents of this swelling being only the fluid, there is no hurry to get the operation done early, as complications as in a hernia are not seen. If the swelling comes up before the age of 1 year, we always wait to see if the passage may close down by itself. If, however, the swelling persists beyond 1 year or suddenly increases in size then surgery will be required. The operation is very much the same as that for a hernia; the passage is tied off so that the fluid from the abdomen cannot go down into the scrotum. The child is sent home on the day of the operation. Healing occurs by 5 - 7 days and the child can attend school by 8 - 10 days. Here too, look for the swelling on the other side, which may come later.
Second Type of Scrotal Swelling
This is a sudden onset of the scrotal swelling; there may be some injury to the part while playing or during school hours. The swelling is associated with severe pain, redness; the boy may not allow the parent to even touch the part. There may be fever, or burning while passing urine. This swelling is much more dangerous than the first group and the possible cause may be one of two:
Torsion of testis
The testis on that side, has twisted on its vertical axis. This leads to the twisting of its blood vessels too and this cuts off the blood supply to the testis. There may be 2 or more turns to the testis, the more the turns, the faster the cut-off of the blood and more chances of early death or infarction of that testis resulting in irreversible damage that may require the testis to be taken out permanently. This is an absolute emergency where no time should be lost and the Pediatric Surgeon must be consulted for the therapy. If the surgery is done early, then the testis can be untwisted and saved. Further, the testis is now fixed in a normal position to prevent it from rotating again later. Additionally, the opposite testis is also fixed with a stitch so that in the future, that testis does not undergo torsion as this one did. If there has been a delay, then the surgeon may have no option but to remove the testis.
Inflammation
Infection of the testis and adjacent structures could also give an identical presentation. The differentiation is very difficult but the therapy is essentially non-surgical and by rest, fomentation and antibiotics, and anti-inflammatory drugs. Thus, the main problem is to differentiate one from the other, and there is no single definite investigation that can do so. Color Doppler can show the blood flow to the testis - if this is decreased or absent it points to torsion, but if adequate or excess - this is in favor of inflammation. But the risk is of treating torsion as inflammation and ending up losing a testis that could have been saved. The safest way out is by exploring when in doubt even if it means an operation for an inflammatory condition, rather than medicines for a definitely surgical condition.
