EVIDENCE-BASED ANSWER
Perform a scrotal ultrasonography immediately to determine whether emergency surgery is necessary for patients with an exam or history that suggests testicular torsion or rupture (strength of recommendation [SOR]: B, based on cohort trials of patient oriented outcomes). In less urgent cases, ultrasound is also useful for verifying diagnoses made by physical exam, and to exclude conditions such as neoplasm, for which further workup is indicated (SOR: C, based on expert opinion).
In those cases in which ultrasound and clinical exam are inconclusive or conflicting, magnetic resonance imaging (MRI) can provide additional information to improve management and decrease unnecessary surgery (SOR: B, based on cohort trials of patient-oriented outcomes).
Clinical commentary
Acutely painful testicle? Involve a radiologist and urologist early on
Peter C. Smith, MD
Rose Family Medicine Residency, University of Colorado Health Sciences Center, Denver
One of the keys to managing testicular masses is to differentiate normal anatomical structures and benign peritesticular pathology (such as varicoceles and spermatoceles) from true testicular masses. Early in my career, after I counseled men to do testicular self-exams, they occasionally made return visits concerned about a mass. These were almost always the testicular appendix, the epididymis, or scrotal inclusion cysts. I now describe these findings as a routine part of my counseling. Given the devastating consequences of a missed or delayed diagnosis of torsion, infarction, and cancer, I always make 2 phone calls early on when a patient has an acutely painful testicle or a true testicular mass: I call the radiologist and the urologist. These 2 phone calls can substantially reduce the risk of diagnostic delay.
Evidence summary
A wide variety of conditions can cause scrotal masses (see TABLE 1 for a list of causes of acute scrotal swelling and TABLE 2 for causes of nonacute swelling).1,2 Many just require that you reassure the patient; however, some conditions do need diagnostic testing to determine appropriate treatment.
TABLE 1
Causes of acute scrotal swelling1,2
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Epididymitis | • Severe swelling and pain | • Edema, tenderness, erythema • Positive urinalysis because it’s often associated with urinary tract infection or prostatitis • Can result in abscess formation |
| Testicular torsion | • Severe pain sudden in onset (except in neonates) | • Usually occurs in post-pubertal and neonatal age group • Often presents with an asymmetric high riding testis or transverse orientation of affected testis • Cremasteric reflex usually absent • Not relieved with elevation • Surgical emergency |
| Trauma | • Associated with wide spectrum of injuries | • May result in testicular rupture or torsion, which are surgical emergencies |
| Torsion of appendix testis | • Gradual onset of pain | • Usually pre-pubertal age group • Cremasteric reflex preserved • Tenderness often localized to anterosuperior testes • Surgery not required in majority of cases |
| Inguinal hernia | • Pain and swelling | • May hear bowel sounds on affected side |
TABLE 2
Causes of nonacute scrotal swelling1
| CONDITION | CLINICAL PRESENTATION | PHYSICAL EXAM/CLINICAL COMMENTS |
|---|---|---|
| Hydrocele | • Painless mass that may increase in size throughout the day | • Can be transilluminated • Reactive hydrocele may be associated with testicular neoplasm, epididymitis, orchitis, or torsion |
| Testicular cyst | • None | • Benign incidental finding • Nonpalpable |
| Varicocele | • Scrotal swelling secondary to dilation of spermatic veins • May present as infertility • May present with pain if intratesticular | • Usually left-sided • Described as a bag of worms superior to the testicle • Noticeable when standing or with Valsalva maneuver |
| Spermatocele | • If painful, relieved with elevation | • Often an incidental finding on exam • Freely mobile • Usually located in epididymal head |
| Epidermoid cyst | • Painless mass | • Found anywhere in epididymis • Often surgically removed because it may be difficult to differentiate from malignancy |
| Primary testicular tumor1,9 | • Solid mass • Classically painless but may produce testicular discomfort | • 10% present acutely with hemorrhage • Most common malignancy in males between ages 18 and 40 |
| Metastatic tumor | • Painless mass | • Possible primary cancers include leukemia lymphoma, melanoma, lung, prostate, kidney, GI tract |