Causes

Urological causes of scrotal swelling include:

• Testicular torsion (torsion of spermatic cord).
• Torsion of a testicular or epididymal appendage.
• Testicular cancer.
• Squamous cell carcinoma of the scrotum.
• Indirect inguinal hernia.
• Epididymo-orchitis (including epididymitis and orchitis).
• Haematocele.
• Epididymal cyst/spermatocele.
• Varicocele.
• Hydrocele.
• Some boys or men may present having discovered the normal epididymis for the first time.

Other causes of scrotal swelling include:

• Sebaceous cyst.
• Generalised oedema.
• Idiopathic scrotal oedema (mainly in children).
• Syphilitic gumma of the testis (round, hard, insensitive mass indistinguishable from a tumour).
• Filariasis.
• Henoch–Schönlein purpura.
• Kawasaki disease.
• Allergic contact dermatitis.
• Pancreatitis (owing to fluid tracking down the retroperitoneal compartment into the inguinal canal and scrotal sac).
• Complications of peritoneal dialysis and ventriculo-peritoneal shunts.
• Crohn's disease manifestations: erythema nodosum and pyoderma gangrenosum.
  Sarcoidosis.
• Metastases (mainly from penile lesions).
• Hidradenitis suppurativa.
• Congenital abnormalities of lymphatic vessels (Milroy's disease).

Assessment

• Have a very low threshold for suspecting testicular torsion in a boy or man presenting with acute, painful scrotal swelling, particularly if he is younger than 30 years of age.
• History, enquire about:
  • Presence of pain — painful scrotal swellings are more likely to need urgent intervention.
  • If pain is present, ask about site (torsion is usually unilateral), speed of onset (torsion is usually of rapid onset) duration, and severity (usually severe in testicular torsion), and any associated swelling (torsion does not always cause swelling).
  • Previous episodes of severe, self-limiting pain and swelling (described by some men and boys with testicular torsion).
  • Associated symptoms, including:
    • Nausea or vomiting (common with torsion, may occur with epididymo-orchitis).
    • Symptoms of a lower urinary tract infection, or urethral discharge (suggesting epididymo-orchitis).
    • Parotid swelling (suggesting mumps orchitis).
    • Back pain, breathlessness, or weight loss (may occur in metastatic testicular cancer).
    • Sexual history (if appropriate).
    • History of trauma (in haematocele and, rarely, testicular torsion), or strenuous physical activity.
• Examination, examine for:
  • Position of the swelling in relation to the testis (testicular, extra-testicular).
  • Testicular lie (suspect testicular torsion if high-riding or transverse).
  • Size of the testis (may be enlarged with a testicular tumour).
  • Symmetry of the testes, (in torsion the epididymis may be located anteriorly).
  • Tenderness (present in torsion and epididymo-orchitis).
  • Consistency of the swelling (for example, solid with testicular cancer, soft with a hydrocele).
  • Lymphadenopathy or an abdominal mass.
  • Prehn sign (relief of pain with elevation of the testes) — may suggest epididymitis, but does not rule out testicular torsion.
  • Transillumination (indicative of hydrocele).
  • Features of inguinal hernia (examine the person both lying and standing), including:
    • A positive cough impulse.
    • Palpable bulge in the inguinal canal.
  • Skin changes:
    • A raised papule, plaque, or ulcer suggests scrotal cancer, although this is extremely rare.
    • Erythema of the scrotal skin (associated with epididymo-orchitis).
    • A blue dot sign, where an inflamed and ischaemic torsed appendage can be seen through the scrotal skin.

Testicular torsion (torsion of spermatic cord)

See separate article on testicular torsion

Testicular cancer

• Background
  • Testicular cancer accounts for 1% of all cancers, and less than 1% of all cancer death in males.
  • Around 95% of testicular tumours are germ cell tumours. There are two main types of germ cell tumours, seminomas (40-45%) and non-seminomas (including teratoma, embryonal carcinoma, choriocarcinoma and yolk sac tumours).
  • In men older than 50 years of age, the most common testicular malignancy is lymphoma.
• Risk factors:
  • Age 25–35 years.
  • White ethnicity.
  • Other risk factors include:
    • Family history in father or a brother.
    • Cryptorchidism.
    • A history of undescended testis, even after surgery.
    • Infertility.
    • Klinefelter's syndrome.
    • Contralateral tumour.
    • Testicular intraepithelial neoplasia.
• Clinical features:
  • Onset is chronic, but the lump may have only just been discovered.
  • Often painless and non-tender, or there may be a dragging sensation in the scrotum. Pain is present in 20–27% of people with testicular cancer.
  • Most common in men 20–40 years of age, but can occur in older men, when it is usually a lymphoma.
  • Usually presents with testicular enlargement.
  • On palpation, there is a solid, firm swelling involving all or part of testis.
  • There may be associated back or flank pain, breathlessness, supraclavicular lymphadenopathy, abdominal mass (enlarged para-aortic lymph nodes), weight loss, gynaecomastia, epididymo-orchitis, or a hydrocele.
• Management:
  • Refer for an urgent outpatient appointment with a urologist, to be seen within 2 weeks.
  • Consider measuring the following tumour markers whilst awaiting an urgent urology appointment, or follow local guidelines:
    • Alpha-fetoprotein (AFP) levels.
    • Human chorionic gonadotrophin (hCG) levels.

Squamous cell carcinoma of the scrotum

• Background:
  • Squamous cell carcinoma of the scrotum is extremely rare.
  • It is primarily an occupational condition, caused by exposure to carcinogens (for example in the textile milling and metalwork industries). It can occur as a complication of PUVA (psoralen plus ultraviolet A) therapy for psoriasis.
  • Risk factors include poor hygiene and chronic irritation.
  • The frequency increases with age — peak incidence is at 75 years of age.
• Clinical features:
  • Onset is chronic.
  • Painless.
  • Presents as a raised papule, plaque, or ulcer on the scrotal wall, and is often purulent.
  • Inguinal lymphadenopathy may be present (as metastases or in response to infection).
• Management:
  • Refer for an urgent outpatient appointment with a urologist or dermatologist, to be seen within 2 weeks.

Indirect inguinal hernia

See separate article on abdominal hernias

Epididymo-orchitis (including epididymitis and orchitis)

See separate article on epididymo-orchitis

Haematocele

• Background:
  • Haematoceles typically result from direct trauma to the scrotum (including iatrogenic trauma from aspiration of a hydrocele), although idiopathic cases have been reported.
  • Patients usually present following trauma, with pain and an acute scrotal swelling similar to a hydrocele.
• Clinical features:
  • Onset may be sudden or chronic.
  • Usually associated with pain and tenderness.
  • May transilluminate to a lesser extent than a hydrocele.
  • Usually caused by trauma, sometimes in association with testicular rupture, but can also occur (chronically) with testicular cancer.
• Management:
  • If the haematocele follows acute trauma, admit immediately.
  • If the haematocele does not follow trauma or is chronic, refer for urgent ultrasound of the scrotum.
  • Small haematoceles (smaller than three times the size of the contralateral testis) can be managed conservatively.
  • For large haematoceles surgery is often required, as non-operative management often fails.

Epididymal cyst/spermatocele

• Background:
  • Epididymal cysts and spermatoceles are benign, usually small, non-painful cystic swellings of the epididymis, which may be multiple and are frequently bilateral.
  • If the cyst contains spermatozoa (usually seen on histology only), it may be referred to as a spermatocele.
  • They are usually encountered in men in middle-age.
  • The causes are not known.
• Clinical features:
  • Onset is chronic.
  • Presents as a painless, non-tender, soft, fluctuant, smooth, round nodule in the epididymis. It is usually small, but can become large.
  • Does not usually transilluminate.
• Management:
  • If confident of the diagnosis:
    • Reassure the man that epididymal cysts/spermatoceles are common, harmless, rarely cause any symptoms, and rarely need treatment.
    • If the man has bothersome symptoms, offer referral for a routine outpatient appointment with a urologist.
  • If there is diagnostic uncertainty, refer for ultrasound.

Varicocele

• Background:
  • A varicocele is an abnormal dilatation of the internal spermatic veins and the pampiniform venous plexus of the spermatic cord.
  • Varicoceles are classically described as feeling like a bag of worms.
  • Varicoceles are often asymptomatic and are present in about 15% of adolescent boys and men, and 40% of men with fertility problems.
  • Around 90% occur on the left side, and 10% of cases are bilateral.
• Clinical features:
  • Onset is chronic.
  • Often painless and non-tender, but there may be a dull, dragging discomfort.
  • May be a 'bag of worms' consistency.
  • Disappears on lying and reappears on standing.
• Management:
  • For adolescents with:
    • Subclinical or grade I varicocele — no treatment is necessary, provide advice and reassurance.
    • Grade II or III varicocele and symmetrical testes — observe with annual examinations, the primary indication for surgery is testicular growth arrest.
    • Grade II or III and asymmetrical testes — refer to a urologist for possible surgery.
  • For men with:
    • Sub-clinical or grade I varicocele — no treatment is necessary, offer semen analysis if fertility is a concern.
    • Grade II or III asymptomatic varicocele and normal semen parameters — observe with semen analysis every 1–2 years.
    • Grade II or III symptomatic varicocele, or with abnormal semen parameters — refer to a urologist for possible surgery.

Hydrocele

• Definitions:
  • A simple hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers of the membrane (tunica vaginalis) that surrounds the testis, or along the spermatic cord.
  • An abdominoscrotal hydrocele is a rare diagnosis in which a simple hydrocele enlarges through the inguinal canal resulting in an abdominal component.
  • A hydrocele of the spermatic cord occurs when the processus vaginalis closes segmentally, trapping fluid anywhere along the spermatic cord.
  • A communicating hydrocele occurs when persistence of the processus vaginalis allows peritoneal fluid to freely communicate with the scrotal portion of the processus. Communicating hydroceles are, by definition, congenital, but may manifest for the first time in older boys and men, when they may be precipitated by increased intra-abdominal pressure, continuous peritoneal ambulatory dialysis, or fluid overload. It affects 1–3% of male neonates, when it results from entrapment of fluid after closure of the processus vaginalis. A congenital, simple hydrocele typically spontaneously resolves within the first year of life. It is more prevalent in premature infants and in infants whose testes descend relatively late.
• Causes:
  • Causes in older boys and men include minor trauma, infection, epididymitis, testicular torsion, varicocele operation, and testicular tumour.
• Clinical features:
  • Onset can be acute or chronic.
  • Painless and non-tender.
  • Will transilluminate.
  • Most common in neonates, disappearing within the first 1–2 years of life, but may appear at any age.
  • Most common form presents as a fluctuant, ovoid swelling enveloping the testis or located above the testis along the spermatic cord (when a normal spermatic cord and inguinal ring can be felt above).
  • May accompany a varicocele, testicular torsion, testicular cancer, or an inguinal hernia, or be caused by trauma.
• Management:
  • Congenital hydrocele (present since birth)
    • Reassure the parents that the hydrocele is likely to resolve without treatment by 2 years of age.
    • Progression to hernia is rare and does not result in incarceration.
    • Refer to a paediatric surgeon if any of the following apply:
      • There is an underlying pathology.
      • Concomitant inguinal hernia is suspected — an incarcerated hernia may be difficult to distinguish from a hydrocele.
      • The hydrocele is localised to the spermatic cord.
      • There is also a palpable abdominal mass (suggesting an abdominoscrotal hydrocele).
      • A simple, non-communicating hydrocele either is not decreasing in size, or is still present after 2 years of age.
  • Non-congenital hydrocele
    • Consider whether the hydrocele may be due to an underlying cause, such as testicular torsion, testicular cancer, epididymo-orchitis, trauma, or varicocele operation.
    • Admit, or refer appropriately depending on the underlying cause.
    • If the man is 20–40 years of age, or the testis cannot be palpated, arrange an urgent ultrasound scan of the scrotum.
    • Consider managing idiopathic hydroceles with reassurance and scrotal support.
    • Refer men or boys with large, uncomfortable hydroceles for an outpatient appointment with a urologist or paediatric surgeon as they may require surgery. Aspiration and sclerotherapy is an alternative for people who are unfit for, or choose not to undertake, surgery.