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Painless Scrotal Mass

By

Geetha Maddukuri

, MD, Saint Louis University

Last full review/revision Jan 2021| Content last modified Jan 2021
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A painless scrotal mass is often noticed by the patient but may be an incidental finding on routine physical examination.

Etiology of Painless Scrotal Mass

  • 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 Testicular Cancer Testicular cancer begins as a scrotal mass, which is usually not painful. Diagnosis is by ultrasonography. Treatment is with orchiectomy and sometimes lymph node dissection, radiation therapy... read more 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 aged < 40 years; because it responds well to treatment, prompt recognition is important.

Table
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Evaluation of Painless Scrotal Mass

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 Hernias of the Abdominal Wall A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more Hernias of the Abdominal Wall with intermittent strangulation); dyspnea and leg swelling (right heart failure); abdominal distention (ascites Ascites Ascites is free fluid in the peritoneal cavity. The most common cause is portal hypertension. Symptoms usually result from abdominal distention. Diagnosis is based on physical examination and... read more ); and decreased libido, feminization, and infertility (testicular atrophy with bilateral varicoceles).

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 Testicular Cancer Testicular cancer begins as a scrotal mass, which is usually not painful. Diagnosis is by ultrasonography. Treatment is with orchiectomy and sometimes lymph node dissection, radiation therapy... read more Testicular Cancer is possible.

Other clinical characteristics can provide important clues (see table Some Causes of a Painless Scrotal Mass) Some Causes of a 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 can be caused by... read more . 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

  • The diagnosis is uncertain

  • Usually when hydrocele is present (to diagnose causative scrotal lesions)

  • The mass does not transilluminate

  • Beta-human chorionic gonadotropin level (hCG)

  • Alpha-fetoprotein level

  • Lactic dehydrogenase level

  • CT of the abdomen

Treatment of Painless Scrotal Mass

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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