Etiology
Features
Epidermoid or pilar cysts
Develop from epidermis or hair follicle and present as painless, slow growing, mobile, fluid-filled nodules; they occur most commonly in areas that have a lot of hair (e.g., scrotum, chest)
Squamous cell carcinoma (SCC)
Proliferation of squamous cells characterized by formation of keratin pearls; presents as ulcerated, nodular, mass with no telangiectasias; occurs in the 5th or 6th decade; associated with HPV and occupational exposure (soot, oil, and petroleum workers)
What is the Differential Diagnosis of Scrotal Masses Involving the Spermatic Cord?
Etiology | Features |
|---|---|
Indirect inguinal hernia | Mass increases in size with valsalva and emerges from internal ring, usually reducible (unless very large) |
Hydrocele | Painless, unilateral scrotal mass, does not extend up spermatic cord, normal testis, transilluminates with flashlight |
Varicocele | Feels like a “bag of worms,” more common on the left, associated with male infertility |
What is the Differential Diagnosis of Scrotal Masses Involving the Epididymis?
Etiology | Features |
|---|---|
Epididymitis | Painful, tender epididymis, associated with UTI/STD and scrotal erythema/cellulitis, positive “Prehn’s sign” (relief of pain with elevation) |
Spermatocele | Also called epididymal cyst, benign, typically painless, fluid-filled mass, cephalad and distinct from the testis, may transilluminate |
Torsion of testicular epididymal appendage (appendix testes) | Most common cause of acute painful hemiscrotum in a child; the epididymal appendage (appendix testis) is located at the head of the epididymis; blue-dot sign is a classic finding; onset of pain is more gradual; cremasteric reflex is maintained |
What is the Differential Diagnosis of Scrotal Masses Found Involving the Testes?
Etiology | Features |
|---|---|
Orchitis | Painful, tender testicle, most often viral (mumps) but also bacterial, associated with STD (in which case epididymis is also affected) |
Testicular torsion | Sudden, severe onset of pain, testis may become swollen and high-riding, negative Prehn’s sign (pain not alleviated with elevation), most common in pubescent males, also seen in neonates, loss of cremasteric reflex, surgical emergency |
Testicular cancer | Presents as firm, painless testicular mass that does not transilluminate; germ cell tumors are the most common type and are malignant |
What Is the Most Likely Diagnosis for this Patient?
In a 22-year-old male with a painless, firm, non-tender testicular mass, testicular cancer is the most likely diagnosis.
History and Physical
What Features on History and Physical Examination Favor the Diagnosis of Testicular Cancer?
Any painless mass within the testicle is cancer until proven otherwise. Most patients with testicular cancer present without symptoms, and most are young adults (average age between 20 and 35 years). On physical exam, the mass is within the testicle (as opposed to separate from it). Rarely, patients with testicular cancer may also have gynecomastia secondary to hormonally active tumors (secreting human chorionic gonadotropin).
What Is the Implication of Constitutional Symptoms in Association with a Painless Testicular Mass?
The presence of constitutional symptoms in association with a painless testicular mass is highly suggestive of metastatic testicular cancer. Symptoms such as back or abdominal pain, weight loss, and nausea suggest retroperitoneal lymph node metastasis, whereas cough and shortness of breath suggest pulmonary metastasis.
What Risk Factors for Testicular Cancer Should Be Obtained on History?
The vast majority of patients have no risk factors. The main risk factor is cryptorchidism (undescended testicle). Other risk factors include personal history of testicular cancer (contralateral testicle), family history of testicular cancer, Klinefelter’s syndrome, and white race.
What Features on Physical Examination Favor a Nonmalignant Etiology?
Masses that are extratesticular, bilateral, painful, mobile, fluid filled, and that transilluminate are less likely to be cancerous.
What Are the Main Diagnoses to Consider in the Presence of a Very Painful Scrotal Mass?
Epididymitis and/or orchitis would be highest on the differential. During pubescence, testicular torsion and torsion of the appendix testis would be high on the list. An incarcerated hernia can be extremely painful, but is separate from the testicle and epididymis.
What Benign Processes Are Typically Painless?
Spermatocele, varicocele, and hydrocele are usually painless. Careful examination will demonstrate that these masses are separate from the testicle itself.
What Physical Exam Maneuver Can Help Identify a Varicocele?
Patients with varicoceles will often have the mass disappear upon lying down and reappear when the patient stands up. A varicocele feels like a spongy bag of worms.
Watch Out
Varicocele is associated with infertility.
Pathology/Pathophysiology
Does Cryptorchidism Increase the Risk of Developing Testicular Cancer in the Undescended Testicle, the Contralateral Descended Testicle, or Both?
It is more likely to occur in the undescended testicle. However, in nearly 25 % of these cases, testicular cancer develops in the contralateral descended testicle. This suggests that an undescended testicle may not play a direct role in the development of testicular cancer, but rather, there is some other phenomenon that leads to both testicular cancer and abnormal descent of the testicles during embryologic development.
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