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Painless Scrotal Mass

by Anuja P. Shah, MD

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.

Etiology

There are several causes (see 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 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

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 gonadotropin

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: 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

  • Usually when hydrocele is present (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 Testicular 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. Not all masses require treatment. If inguinal hernia is suspected, reduction can be attempted (see 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.

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