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Painless Scrotal Mass
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 Scrotal Pain) can be caused by testicular torsion, appendiceal torsion, epididymitis, epididymo-orchitis, scrotal abscess, trauma, strangulated inguinal hernias, orchitis, and Fournier gangrene.
There are several causes (see Some Causes of a Painless Scrotal Mass) of a painless scrotal mass but the most common include the following:
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 with 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.
Some Causes of a Painless Scrotal Mass
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 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.
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: 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.
Clinical evaluation may be diagnostic (eg, in varicocele, lymphedema, inguinal hernia); otherwise, testing is typically done. Ultrasonography is done when
If ultrasonography confirms a solid testicular mass, further testing is done for testicular cancer (see Testicular Cancer : Diagnosis), including the following:
Treatment is directed at the cause. Not all masses require treatment. If inguinal hernia is suspected, reduction can be attempted (see Hernias of the Abdominal Wall).
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