The scrotum

Prepenile scrotum

Prepenile scrotum is an exceedingly rare congenital condition in which the scrotum is suspended from the mons pubis in front of the penis.

Idiopathic scrotal oedema is described above.

Idiopathic scrotal gangrene

Idiopathic scrotal gangrene (syn. Fournier’s gangrene) is an uncommon and nasty condition (Fig. 68.19). It is a vascular disaster of infective origin which is characterised by:

  sudden appearance of scrotal inflammation;

rapid onset of gangrene leading to exposure of the scrotal contents;

  absence of any obvious cause in over half the cases.

It has been known to follow minor injuries or procedures in the perineal area, such as a bruise, scratch, urethral dilata­tion, injection of haemorrhoids or opening of a periurethral abscess.

The haemolytic streptococcus (sometimes microaerophilic) is associated with other organisms (staphylococcus, E. coli, Clostridium welchii) in a fulminating inflammation of the subcutaneous tissues which results in an obliterative arteritis of the arterioles to the scrotal skin (cf. gangrene of the abdominal wall, Chapter 62).

Clinical features

There is sudden pain in the scrotum, prostration, pallor and pyrexia. At first only the scrotum is involved but if unchecked, the cellulitis spreads until the entire scrotal coverings slough leaving the testes exposed but healthy.

Treatment. Expert microbiological advice should be obtained. The organisms are usually sensitive to gentamicin and a cephalosporin which should be given until the bacteriological report is available. Wide excision of the necrotic scrotal skin provides the best possible drainage and stops the spread of the gangrene. Many patients die despite active treatment.

Filarial elephantiasis of the scrotum

Filarial elephantiasis of the scrotum is due to obstruction of the pelvic lymphatics by Wuchereria bancrofti with superadded infection and lymphangitis. In long-standing cases, the enormously swollen scrotum may bury the penis (Fig. 68.20). There is no medical treatment for the condition. The principle of surgical treatment is the construction of new lymphatic pathways using plastic surgery. In very advanced cases excision of the affected skin with implantation of the testes into the thighs and a skin graft to the penis may be the only curative treatment.

Nonfilarial elephantiasis

Nonfilarial elephantiasis can result from fibrosis of the lymphatics due to lymphogranuloma venereum.

Sebaceous cysts

Sebaceous cysts are common in the scrotal skin. They are usually small and multiple (Fig. 68.21).

Carcinoma of the scrotum

In the nineteenth century squamous epithelioma of the scrotum was the chimney sweep’s cancer described by Percival Pott. With mechanisation of the cotton industry, impure lubricating oil from the spinning machine soaking the crutch of the mule spinners’ trousers proved even more carcinogenic than soot. Today a few cases of scrotal cancer occur in tar and shale oil workers but the majority of cases arises with no obvious aetiological factor. It is remarkable that, unlike carcinoma of the penis, carcinoma of the scrotum is almost unknown in India and Asiatic countries.

Clinical features

The growth starts as a wart or ulcer (Fig. 68.22). As it grows it may involve the testis.

Treatment

The growth is excised with a margin of healthy skin. If associated enlargement of the inguinal nodes does not subside with antibiotics, a bilateral block dissection should be carried out up to the external nodes.