Evaluation of Scrotal Pain, Masses, and Swelling

A mass, generalized enlargement, or acute pain involving the scrotum may be noted by the patient or discovered incidentally on physical examination. Patients with scrotal complaints are often concerned about the loss of sexual function and the possibility of cancer. The primary physician needs to be able to recognize torsion and epididymitis promptly and to differentiate benign masses from those suggestive of testicular malignancy, which require referral for urologic evaluation.

PATHOPHYSIOLOGY AND CLINICAL PRESENTATION (1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11)

Testicular Cancer

Almost all testicular neoplasms are malignant and of germ-cell origin. Fortunately, these tumors are uncommon, accounting for less than 1% of all deaths from neoplasms in men. However, testicular cancers are the most common malignancy in male patients of age 15 to 35 years, with an estimated incidence of 3 in 100,000. Incidence is increased in those with an undescended testicle and remains high even if orchiopexy is performed or the testicle is removed; the risk seems to be genetically determined. Peak incidence occurs between ages 20 and 40 years. In patients older than age 60 years, testicular lymphoma is the most common testicular malignancy.

Typically, the tumor presents as a hard, heavy, firm, nontender testicular mass that does not transilluminate, but sometimes, it is smooth or even resilient in nature, and so it may be mistaken for a benign lesion, even though it blocks the transmission of light. Although these lesions are usually painless, about 20% cause some discomfort in the scrotum, and frank pain may be reported and tenderness noted, especially if hemorrhage into the tumor is present.

Metastasis to the retroperitoneum may cause vague pain in the back or abdomen. Spread to the chest can lead to dyspnea, cough, or hemoptysis. A palpable left supraclavicular node or epigastric mass may be noted. On occasion, extensive metastasis occurs with little evidence of the primary tumor. The metastatic lesion may be histologically different from the primary lesion. A few of these malignancies produce human chorionic gonadotropin (HCG) or estrogen and are associated with gynecomastia (see Chapter 99).

Nonmalignant Testicular Disease

Testicular torsion presents with acute pain and a firm, tender mass in a young patient, most commonly during puberty. The annual incidence is 1 in 4,000 males younger than 25 years. The intense pain may be associated with nausea and vomiting and may be confused with an abdominal process. The condition is mostly one of adolescent boys and young men. A history of recurrent episodes of testicular pain is often present. The testicle dangles within an abnormally enlarged tunica, likened to the clapper of a bell. An attack can come on during sleep; a history of antecedent trauma is present in only 4% to 8% of cases. Torsion initially obstructs venous return, with subsequent equalization of arterial pressures leading to ischemia in as little as 4 hours.

Testicular trauma produces acute testicular pain and swelling similar to that associated with torsion or infection. However, if the pain following trauma lasts more than 1 hour, one must consider the possibility of trauma-induced torsion. Mumps orchitis is usually seen 7 to 10 days after parotitis; most often, it is unilateral and accompanied by fever, swelling, pain, and tenderness. On occasion, parotitis is absent. The condition is more common in adults than in children.

Cystic and Vascular Scrotal Masses

Cystic masses containing fluid or sperm often develop spontaneously. They are slow growing and usually painless, and they may be large and fluctuant. Hydroceles are cystic accumulations of clear or straw-colored fluid within the tunica vaginalis or processus vaginalis. Epididymal cysts are common and benign. Spermatoceles are intrascrotal cysts containing sperm that derive from the small tubules of the epididymis. The space between the testicle and the tunica vaginalis may also fill with fluid secondary to impaired drainage or inflammation.

Varicoceles arise from incompetent venous valves. They occur on the left in 97% of cases because the left spermatic vein empties directly into the renal vein, and considerable hydrostatic pressure is transmitted into the scrotum when the valves are incompetent and the patient stands. A right-sided varicocele may occur in the context of venous obstruction or renal carcinoma. Varicoceles have a “bag of worms” appearance and are usually nontender; they decrease in size when the patient is recumbent.

Epididymitis

In men younger than age 35 years, epididymitis may occur as a consequence of gonococcal or chlamydial infection. Ureaplasma infection has also been implicated. Because it is a sexually transmitted disease, it may be accompanied by symptoms of urethritis (dysuria, discharge). In older men, the cause is more likely to be prostatitis, recent urinary instrumentation, or a structural lesion. Epididymitis can occur with carcinoma of the testes. Initially, tenderness and swelling are confined to the epididymis, but as the condition progresses, the inflammation may spread to the adjacent testicle, making for a large, ill-defined, tender scrotal mass.

Nontesticular Intrascrotal Malignancies

Nontesticular intrascrotal malignancies are rare and usually firm, and they do not transilluminate, which differentiates them from benign extratesticular scrotal pathology.

Inguinal Herniation

Inguinal herniation can lead to scrotal enlargement and discomfort as bowel tracks through the inguinal canal and pushes down into the scrotum.

Referred Pain

Extrascrotal sources can cause scrotal pain by stimulating one of the nerves (genitofemoral, iliofemoral, or posterior scrotal) supplying the scrotum. Scrotal examination is unremarkable.

DIFFERENTIAL DIAGNOSIS (2,4,6,7)

The differential diagnosis can be considered in terms of the clinical presentation. A clearly extratesticular, soft scrotal mass that transilluminates may represent a hydrocele, spermatocele, epididymal cyst, or even generalized edema. A “bag of worms” presentation is characteristic of a varicocele. A tender, inflamed extratesticular mass is likely to be early epididymitis. Acutely painful testicular swelling may represent epididymitis, orchitis, torsion of the spermatic cord, trauma, or hemorrhage into a testicular cancer. A firm, nontender testicular nodule that does not transilluminate represents carcinoma until proven otherwise. A malignancy also has to be considered in the setting of a nontransilluminating extratesticular nodule, although benign etiologies are more common.

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