Definition
Any swelling in or on the scrotum or its contents.
Key Points
- Always evaluate scrotal swellings for extension to the groin. If present they are almost always inguinoscrotal hernias.
- Torsion is most common in adolescence and in the early twenties. Whenever the diagnosis is suspected, urgent assessment and usually emergency surgery are required.
- Young adult men: tumours, trauma and acute infections are common.
- Older men: hydrocele and hernia are common.
Differential Diagnosis
The causes and features are listed below.
Scrotum
- Sebaceous cyst: attached to the skin, just fluctuant, does not transilluminate, punctum.
- Infantile scrotal oedema: acute idiopathic scrotal swelling, hot, tender, bright red, testicle less tender than in torsion, most common in young boys.
Testis
Painful Conditions
- Orchitis: confined to testis, young men (mumps, brucellosis).
- Epididymo-orchitis: painful and swollen, epididymis more than testis, associated erythema of scrotum, fever and pyuria, unusual below the age of 25 years, pain relieved by elevating the testis. May be related to sexually transmitted disease.
- Torsion of the testis: rapid onset, pubertal males, often high investment of tunica vaginalis on the cord – ‘bellclapper testis’, testis may lie high and transversely in the scrotum, ‘knot’ in the cord may be felt.
- Torsion of appendix testis (hydatid of Morgagni): mimics full torsion, early signs are a lump at the upper pole of the testis and a blue spot on transillumination, later the whole testis becomes swollen, may require explorative surgery to exclude full torsion.
Hard Conditions
- Testicular tumour: painless swelling, younger adult men (20–50 years), may have lax secondary hydrocele, associated abdominal lymphadenopathy.
- Haematocele: firm, does not transilluminate, testis cannot usually be felt, history of trauma.
- Syphilitic gummata – firm, rubbery, usually associated with other features of secondary syphilis. TB – uncommon.
Soft Conditions
- Hydrocele: soft, fluctuant, transilluminates brilliantly, testis may be difficult to feel, new onset or rapidly recurrent hydrocele suggests an underlying testicular cause.
- Epididymal cyst: separate and behind the testis, transilluminates well, may be quite large.
- Varicocele: a collection of dilated and tortuous veins in the spermatic cord – ‘bag of worms’ on examination, more common on the left, associated with a dragging sensation, occasional haematospermia.
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