Many men present with lumps, bumps or pain in the scrotal area. Most are entirely benign but some conditions, such as testis tumours or torsion, need accurate and timely referral. Scrotal pain is an increasingly common symptom in young men.
Here we will look at scrotal pain and scrotal lumps separately. Hernias will not be considered.
Chronic testicular or epididymal pain
In many cases chronic scrotal discomfort presents in a similar way to prostatic type pain, with epididymal tenderness in the absence of overt infection. It is common in men who have had prior surgery or trauma to the scrotum. Although no tests give a specific diagnosis, ultrasound will help in reassuring that there is no underlying abnormality, since anxiety over this often plays a part. Any thickening or fluid collection in the epididymis should be further investigated to rule out chronic bacterial infection or TB. After exclusion, if appropriate, of STD or urinary infection, treatment with long-term quinolone antibiotics (I use at least three weeks of ciprofloxacin) may be of help, but this can be a difficult condition to treat.
Physical problems such as epididymal cysts or varicocoeles may cause scrotal pain but in many men the co-existence of a physical abnormality and pain are not linked.
For further info see www.london-urology.co.uk/scrotal_pain_ info.htm
This tends to present with severe, often bilateral, testicular pain and inflammation developing over a number of hours or days. In young men the condition is often linked to sexually acquired infection, particularly gonococcal, whereas older men will often have a urinary infection as the cause, possibly in association with bladder outflow obstruction.
IN younger men it may be impossible to differentiate from testicular torsion and immediate specialist referral may be needed. Treatment generally combines a tetracycline and a quinolone, the latter given for at least two weeks. IN older men (unless there are risk factors for STD) a broad-spectrum antibiotic may be most appropriate with the expectation that common urinary pathogens are implicated while awaiting urine culture results. Investigation of any bladder outflow problem is appropriate once the infection is settled.
IN some men the testis is hypermobile, with an excess of tissue lying within the sac of the tunica vaginalis. This may favour torsion of the testicle. The classic testicular torsion occurs in a teenage boy with a sudden onset of severe testicular pain associated with abdominal discomfort or nausea. However the condition may occur in neonates and in men in their forties. While high resolution Doppler ultrasound may be able to diagnose acute infection, it is impossible to exclude torsion of the testis by clinical examination and if there is doubt then emergency surgical exploration is always carried out. Timing is critical: nearly all testicles untwisted and fixed within six hours will survive; the majority treated after twelve hours will suffer at least some atrophy
Relatively commonly in children and adolescents the testicular appendix, (or hydatid of Morgagni) may tort and present with acute pain. This is a small developmental remnant, which sits just anterior to the head of the epididymis. Frequently a small tender spot will be palpable and ultrasound will be diagnostic, always assuming the boy will let anyone near his tender scrotum! Although this is a benign and self-limiting condition, the small cyst is often removed surgically in view of the difficulty in ruling out testicular torsion.
Intermittent torsion may occur, with the symptoms described above spontaneously improving. In this case a decision to operate and permanently fix both testicles (as is always done in acute torsion) is made on clinical grounds.
Other inflammatory conditions of the testis such as tuberculous, granulomatous or syphilitic orchitis are rarely seen in the UK and require specialist advice and treatment.
Lumps and bumps in the scrotum.
The key to diagnosis of a scrotal lump remains the test of whether the examining fingers can get above the lump. If so it is arising from the scrotum, although sometimes large tense hydrocoeles may mimic inguinal hernias. Ultrasound is the diagnostic test of choice, and may now even pick up pre-clinical lesions as we have shown in recent research. Hernias should nearly always be operated on in view of the low morbidity and high cure rate of modern herniorrhaphy, which usually can be carried out as a day case under local anaesthetic.
Swellings of the epididymis are common and will be found in a high percentage of men who have ultrasonograhpy. They may contain serous fluid or sperms. Most epididymal cysts do not cause pain but men can be alarmed on finding them and reassurance may be required.
Although these may be easily removed, a significant number of men will be left with obstructive azoospermia on the operated side. Similarly some men will develop postoperative scrotal pain. My general practice is not to operate on scrotal cysts unless:
They are of a significant size (they may physically “get in the way”)
The man does not plan more children
If pain is present, it should be relieved by fine needle aspiration of the cyst
There is usually a potential space around the testis lined by mesothelial cells, with a tiny amount of fluid that allows the testis to move freely. If this fluid increases a hydrocoele will develop (this differs from “infantile hydrocoeles” which still communicate with the peritoneal cavity). Hydrocoeles are usually idiopathic but may arise after trauma, infection or any surgery that affects the lymphatic drainage of the testis. Rarely a tumour may be the underlying cause.
If the testis within a hydrocoele is normal then nothing need be done, but if it is bothersome then surgery to invert or plicate the sac is a simple matter with a high success rate and no effect on fertility.
Scrotal and testicular tumours
One of the nightmares of many GP’s is that of missing a testicular tumour in a young man. Urologists, realising this, are happy to see any doubtful cases on an urgent basis. Although testis cancer is rare overall it is still the commonest cancer in men under 40. The classical presentation is with a painless lump in the body of the testis, although some men will notice the lump after an injury or infection. Most early testis cancers can be cured by surgery alone, but the need for chemotherapy (and its intensity) increases with delay in diagnosis if this Testis tumours fall into three groups, non-seminomatous (or teratoma), seminoma, and lymphoma (less common but to be considered in the elderly). Treatment varies depending on the clinical stage and risk factors associated with each tumour: in most patients in this country para-aortic radiotherapy is given to most seminoma patients without evidence of spread, to reduce the risk of microscopic metastases growing later. For patients with organ-confined non-seminoma, either observation or modified platinum based chemotherapy will be recommended. All patients with metastatic disease are treated with cytotoxic chemotherapy.
Again, although until relatively recently there was doubt about the place of ultrasound in the diagnosis of testis tumours, modern nigh resolution scanning will give a very accurate answer if a man present with a scrotal lump. In fact in our institution we now have a series of men in whom small tumours undetectable by the examining physician have been accurately diagnosed by ultrasound, and it appears that Doppler ultrasound can tell malignant from benign lesions by their neovascular pattern.
Cancers of the epididymis are very rare, and any solid lump outside the testis is likely to be inflammatory but must nonetheless be referred for specialist assessment.
This is really the only scrotal swelling which does not fit the rule of “can you get above it?” Varicocoele is much more common on the left side. On this side the testicular vein drains into the renal vein whereas on the right it goes straight into the vena cava. For reasons unknown, the one-way valves stopping reflux are more likely to become incompetent on the left. There is an association between the condition and poor sperm quality, presumably linked to abnormally high testicular temperature. Varicocoeles are very common, and seem to occur more often where there is a family history of varicose veins. Although a varicocoele may present in later life in association with a renal tumour this is rare.
Treatment depends on the patient: many varicocoeles are completely asymptomatic and do not affect a man’s fertility. However if a man is having discomfort or has a fertility problem treatment is justified. Traditionally open surgery was used, but this has a risk of chronic pain and also of missing the multiple blood vessels evident in the scrotum or inguinal canal.
We favour a retrograde transfemoral embolisation, which is a local anaesthetic procedure with, on the left side, a success rate of some 80%. However this success rate does depend on an expert interventional radiologist! For bilateral or recurrent varicocoele a laparoscopic approach will allow identification of all abnormal veins at the internal ring, and can be done as a day case.
Rarely, infestations such as filiariasis may affect the scrotum causing elephantiasis. Idiopathic scrotal oedema and congestive cardiac failure may also cause diffuse scrotal swelling. While rare, any skin cancer may affect the scrotal skin. The “Pott’s tumour” seen in chimney sweeps (and the first demonstration of environmental carcinogenesis) is, for obvious reasons, less common now than in Victorian times!
Testis USS: criss cross sign