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Differential diagnosis of a
scrotal mass
ADAM BROMBY AND JOANNE CRESSWELL

The authors discuss the

various presentations of
scrotal swellings, explaining
how a careful clinical
assessment and use of
ultrasound can aid diagnosis a b c
and management of this
common problem.

crotal swellings are a common problem

S among men of all ages. The cause of
swelling may be malignant or benign
(Figure 1). A careful assessment of the
patient is essential in diagnosis and d e f
management (Box 1). Examination of the
patient can also often elucidate the cause of
the scrotal mass (Box 2). Initial investigation
of a swelling may include an ultrasound
scan, which has a high sensitivity and
specificity, particularly for testicular tumours
(Figure 2).1
g h
PAINFUL MASSES
Torsion of the testis
Torsion of the testis is a twist of the Figure 1. Schematic representation of scrotal masses: (a) normal; (b) testicular torsion;
spermatic cord causing avascularity of (c) torsion of a testicular appendage; (d) epididymal cyst; (e) testicular tumour; (f) hydrocoele;
the testis and is a urological emergency. (g) varicocele; (h) inguinoscrotal hernia
It has an annual incidence of 3.8 per
100 000 in boys less than 18 years of age.2 in presentation may result in infarction of
There is a bimodal distribution of age, the testis and secondary swelling.
occurring in neonates or around puberty
and young adulthood.3 The emergency management of a suspected
torted testis is scrotal exploration to allow Adam Bromby, MRCS(Ed), MA, MB BChir,
Sudden-onset scrotal pain is the most detorsion of the testis to restore vascularity, Core Surgical Trainee, Department of
common presenting symptom; a tender testis combined with bilateral orchidopexy. Urology; Joanne Cresswell, FRCS(Urol),
riding high in the scrotum is suggestive on Ultrasound scanning should not delay PhD, MB BS, BMedSci, Consultant Urologist,
examination. Although torsion does not exploration as it has only 84 per cent James Cook University Hospital, Middlesbrough
typically present as a scrotal swelling, delay sensitivity.4 Optimum results are obtained

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present in only 10 per cent.6 The torted

BOX 1. Key points in the history of a BOX 2. Key points in the examination
appendage may be excised with diathermy at
man with scrotal swelling of a man with scrotal swelling
exploration. The natural history of a torted
l Site appendage if not excised is 4872 hours of
l Age
l Size pain and swelling.
l Duration of swelling
l Onset of swelling (sudden or l Tenderness
l Irregular/smooth Trauma (scrotal haematoma)
gradual)
l Solid/soft/fluctuant Trauma to the testis may result in swelling of
l Presence of pain
l Can upper border be palpated? the testis. This is most commonly caused by
l Associated lower urinary tract or
l Transilluminescence haematoma formation. With significant
infective symptoms
l Scrotal appearance trauma there may also be testicular rupture.
l Recent trauma
l Auscultation An ultrasound scan may allow assessment of
l Previous scrotal surgery including
l Inguinal lymphadenopathy the underlying testis to visualise any rupture
orchidopexy
(for superficial pathology) of the tunica albuginea. With testicular
l Previous testicular tumour
rupture or expanding haematoma, scrotal
l Family history
exploration may be advised to repair rupture
Torsion of testicular appendage and evacuate haematoma. If the testis is
within six hours of onset of symptoms; (hydatid cyst of Morgagni) non-viable, orchidectomy may be necessary.
certainly after 24 hours, chances of salvage Torsion of the testicular appendage is a Antibiotic prophylaxis with haematoma may
of the testis are minimal.5 If the testis is common cause for painful swelling in the be considered to prevent secondary infection
non-viable, orchidectomy is necessary with paediatric patient. It is caused by a twist of and abscess formation.
fixation of the contralateral testis. the testicular appendage with consequent
infarction. Peak incidence is between 10 and PAINLESS MASSES
Epididymo-orchitis and 13 years of age. Clinical presentation may be Testicular tumour
scrotal abscesses similar to testicular torsion and may be Although testicular tumours are rare,
Epididymo-orchitis may affect all age diagnosed only on scrotal exploration. accounting for fewer than 1 per cent of all
groups. Children and men over 35 years of Although a blue dot sign is specific, it is cancers, they are the most common solid
age may have epididymo-orchitis secondary
to urinary pathogens; in adolescents and
young adults sexually transmitted infections
should also be considered. Swelling and
tenderness are most commonly localised to
the epididymis.

Complications may include abscess

formation, which may be palpable as a
tender, fluctuant, warm, erythematous a b
swelling. There may be accompanying
infective symptoms of dysuria, frequency,
pyrexia or urethral discharge.

Treatment is usually an extended course

of antibiotics (such as ciprofloxacin for
14 days). Ultrasound may be a useful adjunct
in confirming the diagnosis, excluding
abscess formation and examining the
renal tract for underlying abnormality or c1 c2
predisposing factors for developing urinary
Figure 2. Ultrasound is a useful tool to aid clinical assessment of the patient with a scrotal
tract infections. Associated urinary infection mass. (a) A pT1 classical seminoma in a 30-year-old man with a previous history of
in men should be investigated as for complex undescended testes; (b) 46-year-old man with 2.4mm right epididymal head cysts;
urinary tract infections. (c) 66-year-old man with left varicocele

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tumours to affect young men aged 1544 Treatment of testicular tumours may involve
years, with 1871 cases in England in 2010.7 inguinal orchidectomy with excision of the
The incidence is rising among Caucasian testis and cord at the level of the internal
populations.8 Testicular tumours are treatable, ring, with or without the insertion of a
with 97 per cent overall five-year survival.9 testicular prosthesis. Adjuvant chemotherapy
or radiotherapy may also be beneficial
Risk factors for testicular tumours include dependent upon staging and grading of
age, Caucasian ethnicity, cryptorchidism the tumour.11
(increased relative risk persists even after
orchidopexy), family history and a history of Poor prognostic factors for non-
testicular tumour in the contralateral testis. seminomatous tumours include mediastinal a
primary disease, non-pulmonary visceral
Ninety-five per cent are germ cell in origin metastases, or significantly raised AFP,
(of which 45 per cent are seminomas, 50 per b-hCG or LDH (greater than 10 000ng/ml,
cent non-seminomatous germ cell tumours 50 000IU/l [10 000ng/ml], 10 x upper limit of
[NSGCT]), 4 per cent lymphomas, and 1 per normal, respectively). For seminomas the
cent other rare histological types.10 presence of non-pulmonary visceral
metastasis is a poor prognostic factor.12
Presentation may be with a painless Mixed germ cell tumours should be treated
unilateral lump within the testis. Twenty as for NSGCT.
per cent present with pain, with symptoms
mimicking epididymo-orchitis or more Abnormal semen analysis may be found in
acute pain suggestive of haemorrhage. men with testicular tumours, and fertility
b
Gynaecomastia may be the presenting is often affected by chemotherapy or
symptom in 7 per cent as a result of radiotherapy. Prior to commencing
paraneoplastic syndrome. treatment, patients should be offered fertility
testing and cryopreservation of sperm.11
Tumour markers may be useful in initial
investigation of a suspicious scrotal Hydrocoele
swelling. Alpha-fetoprotein (AFP) may be A hydrocoele is a collection of fluid between
produced by NSGCTs. Beta-human chorionic the visceral and parietal layers of the tunica
gonadotrophin (b-hCG) may be produced vaginalis around the testis. In the paediatric
by teratomas and seminomas. Lactate population hydrocoeles are most commonly
dehydrogenase (LDH) may be elevated in a result of a patent processus vaginalis (PPV),
patients with advanced testicular tumours. and treatment is therefore PPV ligation.
Elevated tumour markers are a prognostic In adults hydrocoeles usually form as a
c
indicator, as is the degree to which they result of imbalance between secretion and Figure 3. (a) 75-year-old man with 15cm right
are elevated. AFP, b-hCG and LDH may absorption of fluid by the tunica. Care must epididymal cyst; (b) seen at ultrasound; (c) seen
also be used in monitoring patients be taken to exclude a reactive hydrocoele during surgical excision. Usually epididymal cysts
are small and palpable separate to the testis, most
following treatment. secondary to an underlying testicular
commonly at the epididymal head
tumour. Treatment may be by Lords or
Ultrasound is both a specific and sensitive Jaboulay procedures. Surgical treatment within the epididymis, most commonly
modality for investigation of testicular may not always be necessary, particularly found within the head of the epididymis,
tumours.1 Staging with computed if the hydrocoele is small in size or the but also in the body and tail. Epididymal
tomography (CT) scan of the chest, abdomen patient asymptomatic. cysts may be multiple; most require
and pelvis is used for assessment of no formal treatment, with the patient
retroperitoneal, thoracic and mediastinal node Epididymal cyst being reassured of their benign nature.
disease and also for hepatic metastases. Brain Epididymal cysts are common benign cysts Occasionally epididymal cysts may be the
CT or magnetic resonance imaging and bone outside the testis, found within the cause of scrotal pain or be large in size
scans should be performed if there is clinical epididymis. Clinically epididymal cysts (Figure 3). Surgical treatment with excision
suspicion of metastases to these organs. present as painless smooth round lumps of the cyst is possible; however, there is a

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the scrotum (Figure 4), bowel loops may ultrasound utilised to aid assessment and
be palpated, and bowel sounds may be guide management.
auscultated within the swelling. Although
usually asymptomatic, pain, tenderness or Declaration of interests: none declared.
change in bowel habit may be suggestive
of incarceration. Surgical repair may be REFERENCES
indicated. 1. Lau MWM, Taylor PM, Payne SR. The
indications for scrotal ultrasound. Br J Radiol
SCROTAL DISORDERS AFFECTING 1999;72:8337.
THE SKIN 2. Zhao LC, Lautz TB, Meeks JJ, et al. Paediatric
Figure 4. An 87-year-old man with a right Scrotal oedema testicular torsion epidemiology using a
inguino-scrotal hernia, shown as a palpable Acute idiopathic scrotal oedema may present national database: incidence, risk of
mass with the upper border not palpable
within the scrotum but extending to the as a unilateral or, more commonly, bilateral orchiectomy and possible measures toward
inguinal region. Bowel sounds could be swelling of the scrotum, often with improving the quality of care. J Urol 2011;
auscultated associated erythema and warmth. The 186:200913.
swelling is usually non-tender and may 3. Somani BK, Watson G, Townell N. Easily
significant risk of subfertility following the extend to the penis or perineum. Boys under missed? Testicular torsion. BMJ 2010;341:
procedure, and the patient therefore should the age of 10 years are the most commonly c3213.
receive careful prior counselling. affected. The condition is self-limiting and no 4. Yu KJ, Wang TM, Chen HW, et al. The dilemma
specific treatment is necessary. in the diagnosis of acute scrotum: clinical
Varicocele clues for differentiating between testicular
Abnormal dilatation of veins within the The scrotum may also be oedematous in torsion and epididymo-orchitis. Chang Gung
pampiniform plexus may result in a association with other causes of lower limb Med J 2012;35:3845.
varicocele. Varicoceles may be asymptomatic, oedema such as congestive cardiac failure or 5. Visser AJ, Heyns CF. Testicular function after
cause scrotal pain, or be associated with nephrotic syndrome. torsion of the spermatic cord. BJU Int 2003;
subfertility. Clinically varicoceles are palpable 92:2003.
as a tortuous mass of veins, which may be Sebaceous cyst 6. Makela E, Lahdes-Vasama T, Rajakorpi H, et al.
more prominent when the patient is standing Sebaceous cysts may present as mobile, A 19-year review of paediatric patients with
or during a Valsalva manoeuvre. firm, smooth swellings within the skin acute scrotum. Scand J Surg 2007;96:626.
of the scrotum. They may be multiple and 7. Office for National Statistics. Cancer statistics
Ninety-seven per cent of varicoceles are usually painless unless infected. Surgical registrations, England, series MB1, no. 41,
present on the left; this is because of the excision may be considered if the patient 2010, 2012.
anatomy of the left testicular vein draining is symptomatic. 8. Huyghe E, Matsuda T, Thonneau P. Increasing
into the left renal vein perpendicularly. When incidence of testicular cancer worldwide: a
a varicocele is present on the right, it is often Carcinoma of the scrotum review. J Urol 2003;170:511.
in conjunction with a left-sided varicocele. Carcinomas of the scrotum are rare and may 9. Office for National Statistics. Cancer survival
present as an ulcerating lesion on the skin of in England patients diagnosed 20052009
Doppler ultrasound can be used in the the scrotum. Lesions are usually squamous and followed up to 2010, 2011.
diagnosis of varicocele. It also allows cell carcinomas, although melanoma, basal 10. Cancer Research UK. Testicular cancer
assessment of the kidney for tumours, cell carcinoma, or Kaposi sarcoma may also incidence statistics. www.cancerresearchuk.
which can rarely present with a varicocele be found. Squamous cell carcinomas of the org/cancer-info/cancerstats/types/testis/
caused by venous obstruction. Embolisation scrotum may be associated with exposure to incidence/
is the most commonly used treatment of industrial oils and tar, or with chronic 11. Albers P, Albrecht W, Algaba F, et al. European
the varicocele. Surgical varicocelectomy is inflammatory skin conditions. Surgical Association of Urology guidelines on
an alternative. excision may offer the possibility of cure. testicular cancer. Uroweb 2012. www.uroweb.
org/gls/pdf/10_Testicular_Cancer.pdf
Inguino-scrotal hernia SUMMARY 12. International Germ Cell Cancer Collaborative
Occasionally large inguinal hernias may Scrotal masses are common and often Group. International Germ Cell Consensus
extend down into the scrotum. These are cause the patient considerable anxiety. Classification: a prognostic factor-based
usually indirect inguinal hernias. Examination However, with careful clinical assessment, staging system for metastatic germ cell
may reveal a soft swelling that extends above a diagnosis can usually be made, with cancers. J Clin Oncol 1997;15:594603.

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