Scrotal Mass
Robert L. Hatch
Scrotal masses are common, occurring in all age groups, from infants to elderly men. In fact, up to 20% of adult males have varicocele (1). Many scrotal masses are benign and require no treatment, whereas others require immediate recognition and emergency treatment.
Approach
When evaluating scrotal masses, the primary objective is to rapidly identify and refer patients who require immediate intervention. Testicular torsion is a true emergency, as the best results occur if patients are in the operating room within 6 hours of onset of symptoms (1). Strangulated inguinal hernias also present urgent situations, whereas testicular cancers and incarcerated hernias require prompt but less urgent treatment. The diagnosis is often apparent, based on the history and physical examination alone. Ultrasound, laboratory studies, and other imaging procedures can be used to confirm or exclude certain diagnoses (Chapter 10.8).
History
A. Pain. Is the mass painful? How painful? Testicular torsion usually presents with severe pain. Torsion of a testicular or epididymal appendage, strangulated hernias, orchitis, or epididymitis can also be very painful. Varicocele, hydrocele, spermatocele, and testicular tumors are typically painless, but may at times present with a dull ache or heaviness of the scrotum.
B. Inciting event. Did the mass first appear after vigorous activity or testicular trauma? Torsion is often precipitated by one of these factors, whereas a new swelling following minor trauma can suggest bleeding associated with a tumor.
C. Patient age. Based on a review of 238 testicular masses in children, torsion of an appendage is the most common cause of acute masses in children aged up to 13 years. Above this age epididymitis and testicular torsion become more common (2). The incidence of testicular torsion peaks in the age group 13 to 15 years (2), but it can also occur in both middle-aged males and neonates. Indeed, torsion accounts for 83% of acute scrotal masses in children aged less than 1 year (2). The average age for patients with testicular cancer is 32 years (1). Hydrocele, epididymitis, varicocele, and hernias are more common in adults; as with most scrotal masses, however, they occur over a wide range of ages.
D. Duration. How long has the mass been present? Torsion typically presents with sudden onset of symptoms, leading patients to seek care soon after appearance of the mass. Other acute conditions can also have an abrupt onset. Many benign scrotal masses have been noted for some time by the patient. Abrupt appearance of a varicocele in an older man can signal venous obstruction. In such cases, consider renal tumor with spermatic vein occlusion if the varicocele is on the left and vena cava obstruction if it is on the right.
E. Symptoms of infection. Is there a history of fever, penile discharge, mumps, or any other infection recently? Epididymitis often presents with discharge and mild fever. A high fever often accompanies orchitis. Mumps orchitis typically occurs 3 to 4 days after the parotitis. Many other infections, including tuberculosis and syphilis, can produce epididymitis or orchitis.
F. Previous history. Have the symptoms previously appeared? Patients with torsion may have had similar, milder symptoms in the past (torsion that spontaneously resolved). Patients with chronic epididymitis generally describe an initial severe bout that has been followed by milder recurrences.
G. Other associated symptoms. Are there any other symptoms? Nausea often accompanies torsion and orchitis.
Physical examination
A. Palpation of scrotum and contents:
1. Determine the orientation of the testicle. A torsed testicle is usually retracted upward and rotated to an abnormal position. This may be indicated by an epididymis that appears to lie in an abnormal location (normally, the head of the epididymis lies at the superior pole of the testicle and its body extends posterolateral along the testicle). Comparison with the other testicle may help with this determination. Normal position does not rule out torsion, however, as the testicle may have rotated a full 360°, or swelling can make accurate assessment of the position difficult.
2. Assess for swelling and tenderness. Torsion, orchitis, and epididymitis all develop swelling and tenderness soon after onset. The swelling often obscures normal anatomy.
3. Determine location of mass. Appendices of the epididymis and testicle can extend from the superior pole of either structure. Spermatocele is most commonly found superior and posterior to the testicle. Varicocele occurs in a similar location, most commonly on the left side. In epididymitis, the epididymis is usually diffusely swollen, which makes it difficult to distinguish epididymis from testicle.
4. Assess the consistency of the mass. A varicocele typically has the consistency of a bag of worms. Hydrocele and spermatocele usually have a cystic consistency. Hydrocele can become tenser as the day progresses (because of the dependent position).
B. Assess the cremasteric reflex. When the inner thigh is lightly stroked, the testicle on that side should rise noticeably. Absence of this reflex suggests torsion of the testicle (3).
C. Elevate the testicle. This usually relieves the pain of epididymitis but not of torsion (3).
D. Transilluminate the mass. Hydrocele and spermatocele will transilluminate.
E. Examine the patient in both the supine and standing positions. Hernias and varicocele usually become more prominent on standing. Have the patient perform the Valsalva maneuver while standing, which may further accentuate these findings.
F. General examination. Tumors can be associated with metastases or gynecomastia (Chapter 14.2).
Testing
Either radioisotope scans or color Doppler ultrasound can be used to confirm or rule out testicular torsion. Specificities of 95% and 97% are reported (2). False-negative results do occur, however, producing lower sensitivities (86% and 80%, respectively) (2). In this series, most false-negative results occurred either in cases of prolonged torsion in which the testicles were no longer salvageable or in cases of intermittent torsion. Ultrasound can be helpful in differentiating some masses (e.g., hydrocele from solid mass, testicular from extratesticular). However, ultrasound showed a disappointing ability to differentiate malignant from benign masses in children (4). Aspiration of a spermatocele usually reveals dead sperm (1). Pyuria is almost always present in epididymitis, but it has also been found in up to 27% of patients with torsion ( >five white blood cells per high power field) (5). Similarly, leukocytosis suggests an infectious cause but it has also been found in 33% of patients with torsion (5).
Diagnostic assessment
Each type of scrotal mass has a typical presentation, and most can be readily diagnosed based on history and physical examination. However, considerable overlap is seen in the presentation and laboratory or imaging studies of these conditions, which makes establishing a diagnosis challenging in some cases. If the diagnosis of testicular torsion cannot be rapidly and confidently excluded, emergent referral is strongly recommended. If testicular torsion is not suspected but a diagnosis is not clear after the history, physical examination, and appropriate studies, less urgent consultation is recommended.
References
1. Junnila J, Lassen P. Testicular masses. Am Fam Physician 1998;57:685–692.
2. Lewis AG, Bukowski TP, Jarvis PD. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30:277–282.
3. Son KA, Koff SA. Evaluation and management of the acute scrotum. Prim Care 1985;6:637–646.
4. Aragona F, Pescatori E, Talenti E. Painless scrotal masses in the pediatric population: prevalence and age distribution of different pathological conditions—a 10-year retrospective multicenter study. J Urol 1996;155:1424–1426.
5. Kattan S. Spermatic cord torsion in adults. Scand J Urol Nephrol 1994;28:277–279.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
Other Book Chapters Related to Testicle symptoms
Read excerpts from these other book chapters related to Testicle symptoms:
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Testicle symptoms
» Next page: Scrotal Pain (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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