AKT · Renal & urology/Scrotum & male GUlow yield

Hydrocoele, varicocoele & epididymal cyst

Benign scrotal swellings — fluid around the testis / dilated pampiniform veins / epididymal fluid cyst

Overview

The common benign scrotal swellings whose examination findings distinguish them — and flag the few that need action. Hydrocoele = fluid around the testis (transilluminates). Varicocoele = dilated pampiniform plexus veins ('bag of worms', usually left). Epididymal cyst = fluid-filled cyst separate from and above/behind the testis. The key catches: a hydrocoele can hide a tumour, and a right-sided or non-decompressing varicocoele needs imaging.

Recognise

Hydrocoele: smooth, non-tender swelling that TRANSILLUMINATES; you can get above it; can be reactive to underlying tumour/infection
Varicocoele: soft 'bag of worms' along the cord, usually LEFT-sided, more prominent on standing/Valsalva, decompresses lying down; may cause a dull ache or subfertility
Epididymal cyst: smooth fluctuant lump SEPARATE from and above/posterior to the testis, transilluminates

Red flags

A hydrocoele that obscures the testis, or any doubt → ultrasound to exclude an underlying tumour (especially new in a young man)
A RIGHT-sided varicocoele, or one that does NOT decompress lying down → image to exclude a retroperitoneal/renal mass obstructing the vein

Differentials & how to tell them apart

Testicular tumoursolid, doesn't transilluminate, part of the testis — a reactive hydrocoele can hide one

Inguinoscrotal herniacan't get above it, bowel sounds, reducible/cough impulse

Epididymo-orchitis / torsionpainful, tender — acute scrotum

Investigations

Examination (transillumination, can you get above it, relation to the testis); scrotal ultrasound if the testis can't be felt, the diagnosis is uncertain, or a tumour is suspected; for an atypical varicocoele, imaging of the retroperitoneum/kidney.

Management

Reassure (exclude tumour first); treat if large/symptomatic or atypical varicocoele

1Distinguish by examination (transillumination + relation to the testis). Reassure benign swellings — but if you cannot feel the testis, the diagnosis is uncertain, or a tumour is possible, get a scrotal ultrasound.Gate: A reactive hydrocoele can HIDE a testicular tumour; a RIGHT-sided or non-decompressing varicocoele can signal a retroperitoneal/renal mass — image both.
2Treat large/symptomatic hydrocoeles/cysts surgically; embolise/operate on varicocoeles causing pain, subfertility or atrophy; investigate atypical varicocoeles.

Reassurance + conservative management — most are benign and need no treatment once a tumour is excluded

Hydrocoele: surgical repair if large/symptomatic — treat any underlying cause; exclude tumour first

Varicocoele: embolisation/surgery if painful, affecting fertility, or testicular atrophy — and investigate atypical (right-sided/non-decompressing) ones

Epididymal cyst: excision if large/symptomatic — otherwise reassure

Key points

Examination distinguishes them: hydrocoele transilluminates + you can get above it; varicocoele = 'bag of worms', LEFT, decompresses lying down; epididymal cyst sits separate/above the testis. Catches: a hydrocoele can hide a TUMOUR (USS), and a RIGHT-sided/non-decompressing varicocoele → image for a renal/retroperitoneal mass.

Monitor & prognosis

Resolution/recurrence; fertility for varicocoele; surveillance if a cause is found.

Benign; the importance is excluding the sinister mimics.

Source: BAUS; cross-ref renal cancer (varicocoele)