Clinical features

Scrotal mass may present as an acute scrotal swelling or as a non acute scrotal swelling. Some common causes are mentioned below (1).

Acute scrotal swelling

• testicular torsion
  • there is severe pain which begins suddenly (except in neonates) (1), may radiate to inguinal and hypogastric areas (4)
  • nausea, vomiting, and a low-grade fever may follow pain (2)
  • presents with a tender testis and testis is often elevated in the scrotum and may have an abnormal lie (transverse lie) (3)
  • in newborns often there is discoloration and a hard painless mass in the scrotum on the affected side (2)
  • cremasteric reflex is usually not seen (3)
  • elevation of the scrotum does not relieve the pain (2)
• epididymitis/epididymo-orchitis
  • presents with subacute onset of pain and swelling (4)
  • epididymis can be felt separately from the testis as a tender enlarged structure (2)
  • pain is relieved when the testis is elevated - useful in differentiating epididymitis from torsion of the spermatic cord (2)
  • often seen together with symptoms of urinary tract infection and prostitis (1)
• trauma
• torsion of appendix testis/appendix epididymis
  • pain may develop gradually or acutely (1)
  • cremasteric reflex is present
  • a small hard nodule can be felt on the superior aspect of the testis
  • often there is bluish discolouration seen through the skin - "blue dot" sign (2)
• inguinal hernia
  • patient presents with pain and swelling (1)
  • may enlarge with Valsalva maneuver
  • reducible (unless incarcerated) (4)
  • bowel sounds on affected side may be heard (2)

Nonacute scrotal swelling

• hydrocele
  • onset may be acute or insidious
  • appears as painless unilateral scrotal swelling
  • it is fluctuant, ovoid, and nontender
  • transillumination is present (4)
• varicocele
  • chronic onset
  • asymptomatic or may present with a dull, dragging discomfort on the affected side
  • may present with 'bag of worms' consistency (4)
  • seen when standing and disappears on lying down (1)
• spermatocele
  • soft nodule located in the epididymal head
  • swelling felt superior and posterior to the testes
  • does not transilluminte (4)
• epidermoid cyst
  • non tender, palpable mass (2)
• tumor
  • usually painless but around 10% may have acute pain due to bleeding inside the tumor or associated epididymitis (5)
  • enlarged, nontender, firm mass
  • does not transilluminate (4)

Reference:

• 1. Woodward PJ, Schwab CM, Sesterhenn IA. From the archives of the AFIP: extratesticular scrotal masses: radiologic-pathologic correlation. Radiographics. 2003 Jan-Feb;23(1):215-40
• 2. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology. 2003;227(1):18-36
• 3. European Association of Urology (2008). Guidelines on Paediatric Urology
• 4. Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. 2008;78(10):1165-70
• 5. Kaufman DS et al. Case records of the Massachusetts General Hospital. Case 6-2007. A 28-year-old man with a mass in the testis. N Engl J Med. 2007 Feb 22;356(8):842-9