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SU30.3-5 | Epididymo-Orchitis, Varicocele and Hydrocele — SDL Guide (Part 2)

Principles of Management

Treatment follows the diagnosis, with the safety net that any unresolved suspicion of torsion goes to theatre. Epididymo-orchitis is treated with empirical antibiotics chosen by the likely organism — covering Chlamydia/gonococcus in sexually active young men (with partner treatment and STI counselling) and urinary coliforms in older men or those with urinary tract disease — together with analgesia, scrotal support, rest and, where relevant, treatment of any underlying obstruction; if torsion cannot be confidently excluded, the patient undergoes urgent surgical exploration rather than a trial of antibiotics. Varicocele is often managed conservatively with reassurance and a scrotal support when it is asymptomatic and fertility is not in question; intervention — surgical varicocelectomy (ligation of the dilated veins) or radiological embolisation — is reserved for significant pain, a varicocele causing testicular atrophy in an adolescent, or selected subfertile men with abnormal semen parameters; and any suspicious right-sided or non-decompressing varicocele is investigated for an underlying renal/retroperitoneal cause. Hydrocele in an adult that is small and asymptomatic may simply be observed; a large, tense or symptomatic primary hydrocele is treated surgically (e.g. Jaboulay's procedure — eversion of the sac — or Lord's plication), which is preferred to repeated aspiration; a secondary hydrocele is managed by treating its cause (infection, and crucially any underlying tumour) — one must never simply aspirate a hydrocele and reassure when a testicular tumour beneath it has not been excluded. In children, a congenital (communicating) hydrocele often resolves spontaneously by about two years and is otherwise treated by herniotomy (ligation of the patent processus vaginalis), not by aspiration.

Provided image

Condition	Definition	Key clinical sign	Principal investigation	Main management
Epididymo-orchitis	Infection/inflammation of epididymis ± testis	Tender swelling, fever, Prehn's sign positive, reflex preserved	Urinalysis/culture + STI screen; Doppler US	Organism-directed antibiotics, analgesia, scrotal support, partner treatment; explore if torsion not excluded
Varicocele	Dilated pampiniform plexus (usually left)	'Bag of worms', worse standing, decompresses lying	Standing exam/Valsalva; semen analysis; image new/right-sided	Reassurance/support; varicocelectomy or embolisation for pain/atrophy/subfertility
Hydrocele	Serous fluid within the tunica vaginalis	Transilluminant, can get above it	Transillumination; ultrasound to assess testis	Observe (small); Jaboulay/Lord's surgery; treat the cause of a secondary hydrocele (exclude tumour)

Check Your Understanding

Bring the three patients from the hook back and run the reasoning. The 28-year-old with a two-day tender, hot, swelling hemiscrotum, fever, dysuria and relief on elevation has epididymo-orchitis: Prehn's sign is positive and the cremasteric reflex is preserved, so you would screen the urine and (given his age) for STIs, start organism-directed antibiotics with analgesia and scrotal support, and treat his partner — reasoning from 'gradual, febrile, eases on lifting' to 'infection, treat appropriately'. The 19-year-old with sudden, severe pain, a high-riding tender testis and an absent reflex has testicular torsion until proven otherwise: you would proceed to urgent surgical exploration without letting imaging delay theatre — reasoning from 'sudden, no relief, absent reflex, teenager' to 'emergency'. The 32-year-old with a soft, painless, transilluminant swelling you can get above has a hydrocele, which you would scan to exclude an underlying tumour before deciding between observation and surgery. Now self-test the competency directly. Can you give the applied anatomy behind the left-sided varicocele and the tunica-vaginalis origin of a hydrocele? Can you list the clinical features and the bedside signs (get-above-it, transillumination, Prehn's sign, cremasteric reflex, standing/Valsalva) that separate the three swellings — and torsion — from one another? Can you name the targeted investigations and the principles of management for each, including the rules to exclude torsion, exclude a tumour beneath a hydrocele, and image a suspicious varicocele? The questions that follow check these links.