Buy the Book PDA Download

Update Me E-mail alerts The Merck Manual Minute

Print This Topic Email This Topic

A painless scrotal mass is often noticed by the patient but may be an incidental finding on routine physical examination.

Scrotal pain and painful scrotal masses or swelling (see Approach to the Genitourinary Patient: Scrotal Pain) can be caused by testicular torsion, appendiceal torsion, epididymitis, epididymo-orchitis, scrotal abscess, trauma, strangulated inguinal hernias, orchitis, and Fournier's gangrene.

Etiology

There are several causes (see Table 10: Approach to the Genitourinary Patient: Some Causes of a Painless Scrotal Mass) of a painless scrotal mass but the most common include the following:

• Hydrocele
• Nonincarcerated inguinal hernia
• Varicocele (present in up to 20% of adult men)

Less common causes include spermatocele, hematocele, fluid overload, and occasionally testicular cancer. Testicular cancer is the most concerning cause of a painless scrotal mass. Although it is rare compared to the other listed causes, it is the most common solid cancer in men < 40 yr; because it responds well to treatment, prompt recognition is important.

Table 10
Some Causes of a Painless Scrotal Mass Cause Suggestive Findings Diagnostic Approach Hydrocele (communicating) Cystic swelling Increase in size when upright or when intra-abdominal pressure increases Usually congenital Transilluminates Clinical evaluation Ultrasonography if diagnosis is uncertain Hydrocele (noncommunicating) Cystic swelling Does not change in size with changes in position of intra-abdominal pressure Often a simultaneous scrotal abnormality (eg, tumor, epididymitis) Transilluminates Clinical evaluation Usually ultrasonography Spermatocele Cystic mass at the upper pole of the testis, adjacent to epididymis Transilluminates Clinical evaluation Ultrasonography if diagnosis is uncertain Inguinal hernia Increases in size when upright or when intra-abdominal pressure increases May disappear when recumbent or be reducible or compressible Possibly bowel sounds Absence of normal spermatic cord structures above the mass Possibly palpable in the inguinal canal Clinical evaluation Varicocele Palpable when standing, feeling like a bag of worms Usually on left side Possibly pain and fullness when standing Possibly testicular atrophy Clinical evaluation Hematocele Tender swelling Risk factors (eg, trauma, surgery, bleeding disorder or use of anticoagulants) Usually ultrasonography Fluid overload Diffuse, bilateral enlargement of scrotal sac Often pitting Often causative disorder evident (eg, heart failure, ascites) Transilluminates Clinical evaluation Ultrasonography if diagnosis is uncertain Lymphedema (eg, from filariasis, congenital, idiopathic) Diffuse scrotal swelling Often nonpitting Clinical evaluation Ultrasonography if diagnosis is uncertain Testicular cancer Mass attached to or part of testis Is solid or does not transilluminate Possibly dull, aching pain or acute pain due to hemorrhage Ultrasonography α-Fetoprotein β-Human chorionic gonadotrophin LDH CT of the abdomen

Evaluation

History: History of present illness should address duration of symptoms, the effect of upright position and increase in intra-abdominal pressure, and presence and characteristics of associated symptoms such as pain.

Review of systems should seek symptoms suggesting possible causes, including abdominal pain, anorexia, or vomiting (inguinal hernia with intermittent strangulation); dyspnea and leg swelling (right heart failure); abdominal distention (ascites); and decreased libido, feminization, and infertility (testicular atrophy with bilateral varicoceles).

Past medical history should identify existing disorders that can cause masses (eg, right heart failure, ascites causing bilateral lymphedema); known scrotal disorders (eg, testicular tumor or epididymitis causing hydrocele); and inguinal hernia.

Physical examination: Physical examination includes evaluation for systemic disorders that can cause edema (eg, heart failure, ascites) and detailed inguinal and genital examination.

Inguinal and genital examination should be done with patients standing and recumbent. The inguinal area is inspected and palpated, particularly for reducible masses. The testes, epididymides, and spermatic cords should be palpated for swelling, masses, and tenderness. Careful palpation can usually localize a discrete mass to one of these structures. Nonreducible masses should be transilluminated to help determine whether they are cystic or solid.

Red flags: The following findings are of particular concern:

• Nonreducible mass that obscures normal spermatic cord structures
• Mass that is part of or attached to the testis and does not transilluminate

Interpretation of findings: A nonreducible mass that obscures normal spermatic cord structures suggests an incarcerated inguinal hernia. If a mass is part of or attached to the testis and does not transilluminate, testicular cancer is possible.

Other clinical characteristics can provide important clues (see Table 10: Approach to the Genitourinary Patient: Some Causes of a Painless Scrotal Mass). For example, a mass that transilluminates is probably cystic (eg, hydrocele, spermatocele). A mass that disappears or becomes smaller when recumbent suggests varicocele, inguinal hernia, or communicating hydrocele. The presence of a hydrocele makes assessment for other scrotal masses by examination difficult. Rarely, a varicocele persists when the patient is recumbent or is present on the right side; either finding suggests inferior vena caval obstruction.

Testing: Clinical evaluation may be diagnostic (eg, in varicocele, lymphedema, inguinal hernia); otherwise, testing is typically done. Ultrasonography is done when

• The diagnosis is uncertain
• Hydrocele is present (usually—to diagnose causative scrotal lesions)
• The mass does not transilluminate

If ultrasonography confirms a solid testicular mass, further testing is done for testicular cancer (see Genitourinary Cancer: Diagnosis), including the following:

• β-Human chorionic gonadotropin level (hCG)
• α-Fetoprotein level
• LDH level
• CT of the abdomen

Treatment

Treatment is directed at the cause. No treatment is indicated for all masses. If inguinal hernia is suspected, reduction can be attempted (see Acute Abdomen and Surgical Gastroenterology: Hernias of the Abdominal Wall).

Key Points

• A nonreducible mass that obscures normal spermatic cord structures suggests an incarcerated inguinal hernia.
• A solid mass, one that does not transilluminate, or both mandates evaluation for testicular cancer.
• The cause of a hydrocele must be determined.

Last full review/revision September 2009 by Seyed-Ali Sadjadi, MD

Content last modified September 2009