What to do when an elderly patient presents with a growing scrotal swelling?

Evaluation and Management of Growing Scrotal Swelling in Elderly Patients

Immediate Priority: Rule Out Surgical Emergencies

In an elderly patient with growing scrotal swelling, immediately assess for testicular torsion (though rare in this age group), Fournier's gangrene, and incarcerated inguinal hernia, as these require urgent surgical intervention. 1, 2

Critical Red Flags Requiring Emergency Action

• Fournier's gangrene presents with severe pain, rapidly progressive scrotal swelling, skin necrosis/crepitus, and systemic toxicity (fever, tachycardia, hypotension) - this requires urgent surgical debridement and broad-spectrum antibiotics 2
• Testicular torsion is extremely rare over age 35 but must still be excluded if acute severe pain is present, as testicular viability is compromised after 6-8 hours 1, 2
• Look for abrupt onset of severe unilateral pain, nausea/vomiting, and negative Prehn sign (pain NOT relieved by elevating the testis) 1, 2

Diagnostic Algorithm for Non-Emergency Presentations

Step 1: Focused Clinical Assessment

Determine the tempo of swelling onset and associated symptoms:

• Gradual onset over weeks to months suggests chronic processes: hydrocele, varicocele, inguinal hernia, or tumor 3, 4
• Subacute onset over days suggests epididymitis/epididymo-orchitis, which is the most common cause of scrotal pain and swelling in adults 1, 2
• Associated pain characteristics: Gradual pain onset favors epididymitis; sudden severe pain suggests torsion (though rare in elderly) 1

Physical examination must include:

• Transillumination to identify fluid collections (hydrocele) 4
• Palpation to distinguish intratesticular versus extratesticular masses - the majority of extratesticular lesions are benign while the majority of intratesticular lesions are malignant 3
• Assessment for reducibility (inguinal hernia) 4
• Inspection for skin changes, erythema, or necrosis 2
• Abdominal examination to exclude referred pathology 4

Step 2: Urinalysis and Initial Laboratory Work

• Perform urinalysis on all patients - pyuria and bacteriuria support epididymitis, but normal urinalysis does not exclude it 1
• Consider inflammatory markers (WBC, CRP) if infection or Fournier's gangrene is suspected 2

Step 3: Scrotal Ultrasound with Doppler

Ultrasound is the first-line imaging modality and should include:

• Grayscale examination to determine if the mass is intratesticular versus extratesticular, cystic versus solid, and to assess for the "whirlpool sign" in torsion 1, 3
• Color and Power Doppler to assess testicular perfusion and identify hyperemia (increased flow suggests epididymitis; decreased/absent flow suggests torsion or infarction) 1, 3
• Comparison to the contralateral testis as an internal control for blood flow assessment 1

Management Based on Diagnosis

Epididymitis (Most Common in Elderly Men)

In elderly patients, epididymitis is typically caused by enteric organisms (E. coli) from urinary tract sources rather than sexually transmitted infections:

• Treat with fluoroquinolones (ofloxacin 300 mg orally twice daily for 10 days) or cephalosporins for enteric organisms 5, 2
• Add bed rest, scrotal elevation, and analgesics until fever and inflammation subside 5
• If no improvement within 3 days, reevaluate for abscess, tumor, testicular cancer, or tuberculous/fungal epididymitis 5

Hydrocele (Common Benign Cause)

• Ultrasound shows fluid collection surrounding the testis with normal testicular architecture and blood flow 3
• Conservative management for small, asymptomatic hydroceles 4
• Surgical repair (hydrocelectomy) for large, symptomatic, or tense hydroceles 4

Inguinal Hernia

• Clinical diagnosis confirmed by reducibility and ultrasound showing bowel in the scrotum 4
• Surgical repair is indicated, especially if incarcerated or causing symptoms 4

Testicular Tumor (Critical to Exclude)

Any solid intratesticular mass on ultrasound must be considered malignant until proven otherwise:

• The majority of intratesticular lesions are malignant, requiring urgent urology referral 3
• Obtain tumor markers (AFP, β-hCG, LDH) and proceed to radical inguinal orchiectomy for diagnosis and treatment 3

Tuberculous Epididymo-orchitis

• Consider in patients with risk factors (immunosuppression, endemic areas, systemic TB) 5, 3
• Ultrasound may show heterogeneous enlarged epididymis with calcifications 3
• Treat with combination drug therapy: 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by 4 months of isoniazid and rifampicin 2

Varicocele

• Ultrasound shows dilated pampiniform plexus veins (>3 mm diameter) that increase with Valsalva 3, 6
• Conservative management unless causing pain or fertility concerns 4

Critical Pitfalls to Avoid

• Do not assume all scrotal swelling in elderly patients is benign - testicular cancer can occur at any age, and intratesticular masses require urgent evaluation 3
• Do not delay imaging in unclear cases - ultrasound is readily available, non-invasive, and highly informative 1, 4
• Do not miss Fournier's gangrene - any signs of skin necrosis, crepitus, or systemic toxicity require immediate surgical consultation 2
• Remember that normal urinalysis does not exclude epididymitis or torsion 1
• Ultrasound has a 30% false-negative rate for partial testicular torsion - if clinical suspicion is high, proceed directly to surgical exploration 1, 2
• Scrotal swelling can be a rare complication of acute pancreatitis - consider abdominal pathology if the clinical picture is atypical 7