Daniel A. Blaz Scrotal pain may be a symptom of an underlying pathologic condition of the scrotum or testis. The pain may be described as sharp, dull, aching, uncomfortable, or tender, and it is characterized as mild, moderate, or severe. The pain may be sudden in onset, remitting, or progressively escalating in severity. Scrotal pain may be the chief complaint or an incidental finding during the history and physical examination. It is necessary to determine the cause of the pain to evaluate the need for emergent referral or intervention and to exclude potentially life-threatening or fertility-threatening conditions. Scrotal masses may be nodules or cystic changes on the skin of the scrotum; may involve intrascrotal contents, such as the testis, epididymis, spermatic cord, and tunica vaginalis; or may be the result of herniation of abdominal structures into the scrotal sac. Palpation may reveal single or multiple nodules of varying sizes with consistencies that range from soft to firm. The mass may be freely movable or fixed and may range from nontender to extremely painful to touch or manipulation. Masses may be found during testicular self-examination (TSE) or are discovered during examination and palpation of the scrotum by a health care provider. The mass may go undetected if it is small, if enlargement is gradual, or if discomfort is minimum or absent. Scrotal swelling, or edema, may involve only one side of the scrotum (left or right hemiscrotal edema) or both sides (bilateral scrotal edema) and may indicate an underlying pathologic condition. Edema caused by a hydrocele may be benign, whereas swelling related to testicular torsion or a malignant tumor of the testis may be potentially life-threatening. The clinical presentation of testicular cysts and dysplasia is enlarged testes, and both are clinically interpreted as neoplasms until otherwise evaluated. Testicular malignancy has doubled over the past 40 years and accounts for approximately 1% of all malignant neoplasms in men in the United States.1,2 The epidemiology of scrotal pain, masses, and swelling depends on the cause of the disorders that manifest these symptoms. Specific disorders may occur more often in certain age groups. The causes of scrotal pain, masses, or swelling discussed in this chapter are limited to those most commonly encountered in primary care: varicocele, epididymitis, epididymo-orchitis, spermatocele, hydrocele, hematocele, testicular torsion and torsion of the appendix testis, trauma, scrotal hernia, and testicular tumors. A varicocele is an abnormal dilation of the pampiniform plexus and spermatic veins in the spermatic cord.3–5 The cause of a varicocele has been determined to be a multifactorial process that involves anatomic variations (the left gonadal vein is longer than the right, and the left testicular vein inserts at an angle into the left renal vein) and incompetent valves within the pampiniform venous plexus, which results in a backflow of blood and venous pooling.3,4 Varicoceles usually develop slowly, are often symptomatic, and can lead to testicular damage or dysfunction and male infertility.5 They occur in less than 1% of boys younger than 10, but this gradually increases to 15% in the young adult male age range.4,6 Varicoceles are commonly identified in men with primary infertility, with approximately 35% to 40% of infertile males being diagnosed with a left-sided varicocele.3,5,6 In addition, the prevalence of varicocele increases as men age, with 42% of the geriatric population having an identified varicocele.4 Although the majority of varicoceles are left sided, bilateral varicoceles occur in approximately 30% to 80% of males.5 A right-sided varicocele is a rare occurrence and should raise concern for a secondary cause of the varicocele, specifically an abdominal, pelvic, or retroperitoneal mass.4,5 Epididymitis is an acute or chronic inflammation of the epididymis and is the most common cause of acute scrotal pain in men, with the majority of cases occurring at ages 14 to 35.7 The cause may be bacterial, viral, parasitic, chemically induced, or related to trauma, and it is further categorized as a nonspecific or specific infection or traumatic injury. Nonspecific infections are caused by gram-negative rods, gram-positive cocci, or anaerobic bacteria associated with a group of diseases with similar symptoms. Inflammation of the epididymis is occasionally caused by trauma or urinary reflux from the urethra through the vas deferens.7,8 The two most common causes, especially in younger men, are Chlamydia trachomatis and Neisseria gonorrhoeae.7,9 Other causative agents include Escherichia coli, Haemophilus influenzae, tuberculosis, cryptococci, and Brucella organisms in men who engage in unprotected anal intercourse.7,10 Epididymitis has several nonsexually transmitted causes, including Enterobacteriaceae and Pseudomonas aeruginosa, which are associated with urinary tract infections and prostatitis.10 In men older than 35 years, epididymitis is most often associated with urinary tract pathogens, structural abnormalities, and urologic procedures or instrumentation, such as transurethral resection of the prostate and urethral catheterization.10,11 Epididymitis can also spread to the entire testicle (epididymo-orchitis) as a result of many of the same pathogens (C. trachomatis, N. gonorrhoeae, and E. coli) that cause epididymitis or from reflux of urine from straining, although the exact cause is unclear.12,13 Orchitis is a systemic, blood-borne infection that results in an acute inflammation of one or both testicles. It may coexist with infections of the prostate and epididymis; be a consequence of systemic viral infections, such as mumps; or be a complication of syphilis, mycobacterial infections, or fungal infections.9 Orchitis is commonly caused by C. trachomatis and N. gonorrhoeae in adolescents and urinary tract pathogens such as E. coli in men older than 35.12,14 When orchitis is a complication of mumps, it is seen in 25% of postpubertal males and may be accompanied by a hydrocele and scrotal wall thickening.12,14 A spermatocele is a benign, painless sperm-filled cyst of the epididymis located between the head of the epididymis and the testes and arising from the tubules that connect the rete testis to the head of the epididymis.15,16 Spermatoceles typically form from the obstruction of the efferent duct and contain a milky fluid that consist of spermatozoa, lymphocytes, and debris.15,17,18 Spermatoceles have been reported to commonly occur after vasectomies and may be present in 30% of males.16,18 A hydrocele is an accumulation of fluid within the tunica vaginalis surrounding the testicle; it may also result from a patent processus vaginalis at birth and sometimes closes spontaneously within the first 1 to 2 years of life.16,19 Hydroceles are the most common cause of painless scrotal swelling; in adults they are often the result of trauma, a hernia, testicular tumor, or torsion or a complication of epididymitis.13,15,18 Similar to a hydrocele, a hematocele is a collection of fluid in the tunica vaginalis of the testes and manifests as a mass.18 However, a hematocele is a collection of blood (rather than serous fluid) and usually is precipitated by trauma and can be painful and tender on palpation.13,18,20 Testicular torsion is an obstruction of blood flow to the testes because of a twisting of the arteries and veins in the spermatic cord.21–23 Testicular torsion has an overall incidence of 1 in 4000, with the majority of cases occurring from 12 to 18 years of age.22 Testicular torsion is most often unilateral (commonly involving the left testis). There are two different types of torsion: extravaginal and intravaginal.22 Extravaginal torsion occurs with the twisting of the spermatic cord, testis, and process vaginalis; intravaginal torsion is failure of the testis to adhere to the scrotal wall, creating a “bell clapper deformity.”14,22 Extravaginal torsion is rare and is more commonly seen in neonates; intravaginal torsion is mostly seen in adolescents.14,22 An appendage (appendix testis) on the testicles that is vestigial tissue may twist, making it difficult to distinguish from a testicular torsion.21 The appendix testis is located at the superior pole of the testicle and is the most common cause of acute scrotal pain in children.14 Trauma to the scrotum and testicles results in 4% to 8% of testicular torsions.20 This condition results in congestion of venous blood flow and concomitant edema of the testis. Trauma to the scrotum can be caused by burns, blunt force, or penetrating injury or may be sports related; it can involve the testicle.20 The majority of blunt force testicular trauma is isolated, but approximately half of such injuries occur during sporting activities.20 Therefore, no matter what the mechanism is for testicular torsion, it should be included within the differential diagnosis for any scrotal trauma.20 A scrotal-inguinal hernia results when a segment of the bowel slips through the internal inguinal ring, where it may remain in the inguinal canal or pass into the scrotal sac. An inguinal hernia may occur as a result of a defect in the anterior abdominal wall or because of a patent process vaginalis.8 Inguinal hernias predominantly affect men (9:1) and have the highest incidence in men aged 40 to 59.24 A hernia may move freely between the abdomen and the scrotum or can be spontaneously reduced by digital manipulation.8 When a hernia becomes strangulated or is unreducible, this compromises the blood supply and requires emergent surgical reduction.8 Strangulation should be suspected when a tender mass is palpated in the scrotum in addition to redness, nausea, and vomiting.24 The origin of testicular tumors can be divided into two primary categories: germ cell and stromal tumors.1 On the basis of the histologic and genetic origin of the tumor, neoplasms of germ cell origin may be further divided into seminomas and nonseminomas.1 Testicular malignant neoplasms are relatively uncommon in the general population and account for only 1% of all cancers in men in the United States.2 Testicular cancer occurs most often at ages 20 to 39 years and is the most common form of cancer in men aged 15 to 34 years, although these tumors have also been reported in infants and in older men.2,17,25 The risk for testicular cancer in Caucasian men is more than five times that of African-American men and more than double that of Asian men.17 Although the exact cause of testicular tumors is unknown, tumors have been associated with scrotal trauma, atrophy, undescended testicles (cryptorchidism), exogenous estrogen exposure, and family history of testicular cancer.2,17 Males that have an undescended testicle (cryptorchidism) have an approximately 17% higher incidence of developing testicular cancer than the general population.2 Germ cell tumors (GCTs) are the most common type of testicular tumor and account for 90% to 95% of all primary malignant neoplasms.1,17,25 Stromal tumors are rare and usually consist of Leydig and Sertoli cell tumor types.17 GCTs are associated with serum tumor marker products alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) and are critical to diagnosing, prognosing, staging, and monitoring treatment response of testicular cancer.1,25 Metastasis from testicular tumors occurs primarily through the lymphatic system, usually to the retroperitoneal lymph nodes.1,17 Elephantiasis is caused by a filariasis (parasitic disease) that affects the scrotum, causing massive scrotal lymphedema.26,27 Filariasis is caused by threadlike roundworms, called filariae, that are transmitted by various mosquitoes, flies, and biting midges and is most often caused by Wuchereria bancrofti.27 Although this is a rare cause of testicular problems in the United States, it should be considered in the differential diagnosis in persons who have recently traveled to Africa or Asia or in health care workers involved in humanitarian missions in those areas.27 With testicular disorders, the history and presenting symptoms often suggest the underlying pathologic condition. Because some disorders may not cause significant discomfort, however, all male patients should be queried about changes in testicular size or the presence of nodules or masses, pain, or penile discharge. The following disorders may be identified by the presenting complaint. There are usually no visible outward signs other than a blue color through light-colored scrotal skin. The patient may be asymptomatic or complain of a dull pain, ache, or heaviness in the affected hemiscrotum that worsens with activity or straining.4,15 Male patients may report enlargement in a testicle that decreases in the supine position; however, the mass may not be seen or palpable on lying down.5 The patient may have a low-grade fever, chills, and a heavy sensation.22 The history includes a sudden onset of severe pain that may be partially relieved by elevating the scrotum (Prehn sign).10,22 Additional signs and symptoms include blood in semen, penile discharge, lower abdominal discomfort, groin pain, lump in the testicle, and pain with intercourse or ejaculation. Symptoms may also include dysuria, flank pain, and testicular pain that is made worse by a bowel movement or straining.17 Hydroceles are usually painless and may be present for long periods, partially resolve, and recur before the patient seeks medical attention.15 Gradual enlargement of the scrotum occurs with marked edema, which may be uncomfortable because of the added weight. A hydrocele may occur secondary to a tumor when excess serous fluid accumulates in the scrotal sac.15 Testicular torsion, which involves twisting of the spermatic cord and resultant occlusion of the blood flow, is sudden in onset, is extremely painful, and may awaken the patient from sleep or be trauma induced.20,23 In addition to testicular pain, the patient may experience abdominal pain, nausea, and vomiting; 25% of patients have a fever.20 Two clinical signs that are suggestive of testicular torsion are a testicle that rides high in the scrotum and an absent cremasteric reflex on examination.20 The classic presentation is a gradual onset of unilateral testicular pain, edema, and tenderness over the head of the testicle.8,21 The “blue dot sign” is often present, in which a blue discoloration is noted on transillumination, usually indicating an infarcted or ischemic appendage.10,22 There may be a history of blunt or penetrating injury to the scrotum that may involve the scrotal contents, leading to severe pain, bruising, edema, nausea, vomiting, or syncope.20 Depending on the type and extent of the injury, the patient may be in excruciating pain, have minimal pain, have a noted hematocele, or have loss of normal testicular shape because of testis rupture. The patient usually seeks medical care for evaluation of an abnormal mass found during self-examination or has symptoms similar to those of epididymitis, orchitis, or hydrocele.25 The most common symptom or finding associated with a testicular tumor is a palpable mass that is often accompanied by edema or a sensation of fullness or heaviness in the scrotum.2,25 Complaints, such as back or abdominal pain, nausea, anorexia, or bowel and bladder symptoms, may occur with retroperitoneal lymph node involvement and suggest metastatic disease.1 Elephantiasis leads to massive scrotal lymphedema, thickened scrotal skin, and in severe cases skin ulcerations.27 Examination begins with inspection of the scrotum. Scrotal size can change with temperature variations because of the cremaster muscle response. Asymmetry is expected because the left hemiscrotum is normally positioned lower than the right.30 The skin of each hemiscrotum should be inspected carefully, spreading the rugae between the fingers. Care should be taken to inspect both the anterior and posterior surfaces to detect any lesions. Each hemiscrotum should be palpated with the thumb and first two fingers of both hands. The scrotal contents should be easily movable in a sliding fashion. The testes should be smooth, equal, firm but rubbery, and the shape is round in the newborn transitioning to ovoid during puberty.14 The size of a testicle after puberty is on average 4 to 5 cm in length, 2 to 4 cm in width, and 3 cm anteroposteriorly.30 The normal epididymis is divided into the head, body, and tail and is located in the superior, posterior portion of the testis.14,30 It is softer than the testis, nontender, and smooth. To palpate the spermatic cord, the provider should slide the fingers and thumb up from the epididymis. The cord should feel smooth and nontender. Documentation should include any tenderness or pain, discoloration, edema, or abnormal findings, such as those seen in the conditions discussed in the following sections.
Testicular Disorders
Definition and Epidemiology
Pathophysiology
Clinical Presentation
Varicocele
Epididymitis
Hydrocele
Testicular Torsion
Torsion of the Appendix Testis
Trauma
Testicular Tumor
Elephantiasis
Physical Examination
Testicular Disorders
Chapter 151
