Renal & Urology

Scrotal Lumps (overview)

Assess every scrotal lump by urgency, relation to the testis, fluid versus solid character and positional behaviour; first exclude torsion and malignancy, then manage the common benign lesions according to symptoms.

In a nutshell

For any scrotal lump, first exclude torsion and testicular cancer. Examine the testis itself, assess the mass standing and supine, and use ultrasound for unexplained/persistent symptoms or uncertainty. Hydrocoele surrounds the testis, epididymal cyst is separate, varicocoele decompresses supine, and a solid intratesticular mass needs urgent urology. Confirmed benign lesions are usually observed unless symptomatic or otherwise clinically important.

Classic presentation

A patient with a painless scrotal swelling: determine whether it is a solid intratesticular mass, a fluid collection around the testis, an epididymal cyst, a venous swelling or an inguinoscrotal hernia; a separate patient with sudden severe pain needs emergency torsion assessment.

Key points

Sudden severe pain with nausea/vomiting is torsion until proven otherwise: urgent surgical/urological assessment.
A non-painful enlargement or change in testicular shape/texture needs the suspected-cancer pathway.
Ask: can you get above it, does it transilluminate, is it separate from the testis, and does it decompress supine?
Use ultrasound for unexplained or persistent symptoms, an unexaminable testis or diagnostic uncertainty; do not delay torsion referral.
Hydrocoeles, epididymal cysts and varicocoeles usually need treatment only for symptoms, fertility-related indications or an underlying cause.

First-line investigation

Focused bilateral scrotal, groin and abdominal examination; scrotal ultrasound for unexplained/persistent symptoms or uncertainty.

Management

Exclude torsion and hernia

Sudden severe pain, nausea/vomiting, a high-riding testis or an acutely tender swollen scrotum requires immediate emergency/urological assessment.^1,2

Classify the anatomy and urgency

Examine standing and supine, palpate both testes and determine whether the mass is intratesticular, separate, around the testis or extending from the groin.^4,5
Arrange ultrasound for unexplained/persistent symptoms or uncertainty, and use the suspected-cancer pathway for non-painful testicular enlargement or an intratesticular mass.^3,5

Treat the confirmed cause

Observe benign lesions when symptoms are minimal; refer when pain, size, fertility, adolescent testicular development or a secondary cause makes treatment appropriate.^5,4

Exam traps

Do not let a known hydrocoele or cyst explain away a new acute pain episode.
Pain does not exclude testicular cancer, and absence of pain does not exclude cancer.
Do not use transillumination or a normal tumour marker to overrule an uncertain or suspicious mass.
Do not delay suspected torsion for routine ultrasound.
A right-sided or non-decompressing varicocoele needs specialist consideration of an abdominal/renal cause.

Illustrations

Sensitive clinical image, hidden — Large hydrocoele on scrotal ultrasoundLongitudinal scrotal ultrasound showing a large anechoic hydrocoele surrounding and compressing the testis.Mikael Häggström, M.D. Author info, Wikimedia Commons · CC0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.