Photo Quiz

Massive Scrotal Swelling


Am Fam Physician. 2022 Jan ;105(1):77-78.

A 64-year-old man presented with a 10-year history of severe scrotal swelling. The swelling fluctuated in size but was enlarging. The area was tender to touch but otherwise not painful. He reported no hematuria, voiding difficulties, or urinary frequency or retention. He was unable to obtain an erection.

On physical examination, his vital signs were normal. His abdomen was soft, with normal bowel sounds. There was no hepatosplenomegaly or abdominal tenderness, including no costovertebral angle tenderness. Slight suprapubic swelling was detected.

Genital examination revealed a volleyball-sized scrotal swelling that engulfed the penis (Figure 1). The left testicle was displaced, and the right testicular anatomy was distorted, with the testicle possibly located in the inguinal canal. The scrotal skin was tender, thickened, and hyperpigmented.




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Femoral artery aneurysm.

  • B. Hydrocele.

  • C. Inguinal hernia.

  • D. Testicular torsion.

  • E. Varicocele.


The answer is C: inguinal hernia. Inguinal hernias are protrusions of the abdominal contents into the inguinal canal via an abdominal wall defect. Inguinal hernias are commonly direct or indirect. A direct inguinal hernia projects through the deep inguinal ring, medial to the inferior epigastric vessels through the posterior wall. Indirect inguinal hernias project through the internal inguinal ring, lateral to the inferior epigastric vessels, with potential descent into the inguinal canal. Direct hernias typically develop in adulthood and are more likely to recur than indirect hernias.1,2

Although imaging is not needed to diagnose most inguinal hernias, ultrasonography can distinguish hernias from other causes of groin pain. Inguinal hernias, especially indirect types, are often asymptomatic. Both types may cause bulging, localized fullness, or heaviness in the groin that increases over time. These hernias may be reducible and decrease when supine. Associated symptoms can include a burning or dull aching sensation and increased pain with Valsalva maneuvers (coughing, straining, lifting). Severe acute pain suggests an incarcerated hernia.

A true femoral artery aneurysm involves all three layers (intima, media, and adventitia) and is often associated with other peripheral aneurysms and arteriosclerotic conditions. In contrast, a pseudoaneurysm consists of an outpouching of one or two layers of the vessel wall. Femoral artery aneurysms often present as asymptomatic leg or groin swelling but may cause tenderness, pain, a pulsatile mass, or ecchymosis. Possible complications include expansion, rupture, embolization, extravasation with arterial wall compression, and ischemia.3

A hydrocele is a collection of fluid in the space surrounding the testicle between the layers of the tunica vaginalis.4 It may be communicating (patent processus vaginalis with free flow of fluid) or noncommunicating (usually scrotal and may extend to the external inguinal ring).1 Hydroceles present as painless scrotal swellings anterior to

Address correspondence to Taryn Thomas, MD, MEd, at Reprints not available from authors.

Author disclosure: No relevant financial relationships.


show all references

1. Doudt AD, Kehoe JE, Ignacio RC, et al. Abdominoscrotal hydrocele: a systematic review. J Pediatr Surg. 2016;51(9):1561–1564....

2. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403.

3. Dwivedi K, Regi JM, Cleveland TJ, et al. Long-term evaluation of percutaneous groin access for EVAR. Cardiovasc Intervent Radiol. 2019;42(1):28–33.

4. AHRQ. Comparative effectiveness of surgical options for inguinal hernia. Accessed March 23, 2021.

5. Fujita N, Tambo M, Okegawa T, et al. Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Res Rep Urol. 2017;9:169–174.

6. Paick S, Choi WS. Varicocele and testicular pain: a review. World J Mens Health. 2019;37(1):4–11.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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