Scrotal Swelling
Differential Diagnosis
Common Diagnoses
- Inguinal Hernia
- Sebaceous Cyst
- Hydrocoele
- Epididymal Cyst
- Epididymo-Orchitis
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.