Scrotal Swelling
Scrotal swellings can occur at any age. They arise most commonly from the testicle and its coverings, the spermatic cord and the skin. Greater awareness of testicular cancer has resulted in increasing numbers of young men attending the GP, usually with benign lumps.
Differential diagnosis
Common Diagnoses
- Inguinal Hernia
- Sebaceous Cyst
- Hydrocoele
- Epididymal Cyst
- Epididymo-Orchitis (EO)
Occasional Diagnoses
- Torsion of the Testis
- Iatrogenic Sepsis: Surgery and Catheterisation
- Haematocoele
- Varicocoele
- Congestive Heart Failure
- Post-Vasectomy Swelling (Aseptic), Including Haematoma, Inflammatory Reaction to Spilt Sperm
- Trauma: Haematoma
Rare Diagnoses
- Testicular Tumour (Seminoma, Teratoma)
- Ascites
- Inferior Vena Caval Thrombosis
- Tuberculosis and Syphilis (Not Rare Abroad)
- Elephantiasis (Filariasis)
Ready reckoner
Key distinguishing features of the most common diagnoses
| Hernia | Sebaceous Cyst | Hydrocoele | Epididymal Cyst | EO | |
|---|---|---|---|---|---|
| Can get Above Swelling | No | Yes | Yes | Yes | Yes |
| Testicle Tender | No | No | No | Possible | Yes |
| Swelling Fixed to Skin | No | Yes | No | No | No |
| Tender Groin Nodes | No | Possible | No | No | Possible |
| Transilluminates | No | No | Yes | Possible | No |
Possible investigations
Likely: Ultrasound.
Possible: Urinalysis, MSU.
Small Print: FBC, U&E, LFT, CXR, urethral swab, AFP and β-HCG.
- Ultrasound useful to distinguish solid from cystic swelling.
- Urinalysis may show signs of UTI, but may be negative in epididymo-orchitis, as may MSU.
- If urethra discharging, take urethral swab for gonococcus and Chlamydia.
- FBC, AFP and β-HCG essential baseline investigations if solid tumour suspected – would be arranged by the specialist after referral.
- CXR may show cannonball metastases if carcinoma has spread.
- May require further investigations such as U&E, LFT, syphilis serology if underlying pathology (e.g. ascites, cardiac failure, syphilis) suspected.
Top Tips
- Don’t forget that the patient’s main fear is likely to be cancer. Broach this even if the swelling is obviously benign.
- Examine the patient standing. Many lumps are easier to feel this way and some – especially varicocoeles – may disappear on lying down.
- In the older patient, with bilateral swelling, there is likely to be some underlying disease process such as cardiac failure.
- Consider arranging an ultrasound if a patient remains very anxious about an obviously cystic swelling, or if you have any doubt yourself – a normal result will relieve both parties.
Red Flags
- Seminoma may often feel smooth and mimic a large normal testis. Do not rely on the absence of clinical features of malignancy – if the patient feels there has been a change in the testis, act on it.
- It can be difficult to distinguish between hernias and hydrocoeles in babies. Hernias require surgical attention; hydrocoeles may resolve within the first year of life. If in doubt, refer.
- Remember that a hydrocoele may be caused by an underlying malignancy; in younger patients, always refer, while in the elderly, examine the testis carefully after aspiration.
- Left supraclavicular nodes may be involved after tumour spread to para-aortic nodes (can be massive). Examine the abdomen and chest if any suspicion of malignancy.
- If any suspicion of torsion – admit urgently.