Differential Diagnosis for Scrotal Swelling
The patient presents with swelling of the scrotum, which can be caused by various conditions. Here's a differential diagnosis based on the provided information:
Single Most Likely Diagnosis
- Hydrocele: The presence of a non-tender, vertical seal on the right scrotum that does not change in size with position suggests a hydrocele. Hydroceles are common in older men and can be primary (idiopathic) or secondary due to other conditions such as trauma, infection, or tumor.
Other Likely Diagnoses
- Varicocele: Given the patient's age and smoking history, a varicocele is possible. Varicoceles are more common on the left side but can occur on the right. They are typically described as a "bag of worms" and can be tender.
- Epididymitis: Although the patient's scrotal swelling is non-tender, epididymitis should be considered, especially if there's any history of urinary tract infection or sexually transmitted infection.
- Spermatocele: A spermatocele is a cystic structure that contains sperm and can cause scrotal swelling. It's usually non-tender and can be transilluminated.
Do Not Miss Diagnoses
- Testicular Tumor: While less likely given the non-tender nature of the swelling, testicular tumors can present with a painless scrotal mass. It's crucial to examine the testes carefully and consider ultrasound if there's any suspicion.
- Renal Cell Carcinoma with Venous Tumor Thrombus: This condition can cause a varicocele or scrotal swelling due to obstruction of the testicular vein. A history of flank pain, hematuria, or a palpable abdominal mass could suggest this diagnosis.
Rare Diagnoses
- Lymphoma: Testicular lymphoma is rare and typically occurs in older men. It can present with scrotal swelling, but other symptoms like weight loss, fever, or night sweats might also be present.
- Filariasis: In endemic areas, filariasis can cause scrotal swelling due to lymphatic obstruction. The patient's travel history and exposure to endemic areas would be relevant in considering this diagnosis.
The question specifically asks which of the following suggests a diagnosis of Renal Cell Carcinoma. Given the patient's presentation, a varicocele that does not decrease in size when the patient is in the supine position could suggest a diagnosis of renal cell carcinoma with venous tumor thrombus, as this would indicate obstruction of the testicular vein.