Scrotal Lumps
Summary
Scrotal lumps are a common presentation. The vast majority are benign (Hydrocele, Varicocele, Cyst), but the primary clinical imperative is to exclude Testicular Cancer which presents as a painless solid lump in young men. A structured examination (position, transillumination, reducibility) can distinguish most causes. [1,2]
Key Diagnoses
- Hydrocele: Fluid within the tunica vaginalis.
- Epididymal Cyst: Fluid-filled sac arising from epididymis (usually head).
- Varicocele: Dilatation of the pampiniform venous plexus.
- Inguinal Hernia: Bowel protruding into scrotum.
- Tumour: Solid malignancy of the testis (Seminoma / Non-Seminoma).
Clinical Pearls
"Can you get above the swelling?": The most important discriminator.
- NO: It is an Inguinal Hernia (comes from abdomen).
- YES: It is a purely Scrotal Lump.
The Red Flag Varicocele: 90% of varicoceles are on the LEFT (because the Left Testicular Vein drains perpendicularly into the Left Renal Vein, creating high pressure).
- A RIGHT-sided varicocele is rare and suspicious (retroperitoneal mass?).
- A SUDDEN ONSET left varicocele in an older man is suspicious (Renal Cell Carcinoma invading the Renal Vein).
Aspiration of Hydroceles: Generally avoided. Fluid re-accumulates within weeks, and there is a high risk of introducing infection (pyocele) or causing adhesions that make future surgery difficult.
Demographics
- Hydrocele: Bimodal. Common in neonates (patent processus vaginalis) and elderly men.
- Varicocele: 15% of all adult males. 40% of men with infertility.
- Tumour: Peak incidence 20-40 years (most common solid cancer in this group).
Mechanisms
- Hydrocele: Imbalance between fluid production and absorption by tunica vaginalis. Primary (idiopathic) or Secondary (to tumour/trauma/infection).
- Varicocele: Valvular incompetence in the spermatic vein -> Reflux -> Pooling of blood -> Elevated scrotal temperature -> Impaired spermatogenesis.
History
Signs Table
| Condition | Position | Consistency | Transilluminates? | Distinct from Testis? |
|---|---|---|---|---|
| Hydrocele | Surrounds Testis | Soft/Tense | YES | No (testis inside) |
| Cyst | Upper Pole | Soft/Firm | YES | YES (palpable separately) |
| Varicocele | Upper/Lateral | "Bag of Worms" | No | YES |
| Hernia | From above | Soft/Gurgling | No (usually) | N/A |
| Tumour | Body of Testis | HARD | No | NO (part of testis) |
- Inspection: Standing and Lying. (Varicoceles collapse when lying flat).
- Palpation: Get above it?
- Transillumination: Shine torch from behind.
- Red Glow = Fluid (Hydrocele/Cyst).
- Opaque = Solid (Tumour/Blood/Hernia).
- Cough Impulse: Hernia.
Imaging
- Scrotal Ultrasound: The Gold Standard.
- Distinguishes solid vs cystic.
- Localises lump (Intra vs Extra-testicular).
- Can visualise blood flow (Doppler).
Bloods
- Tumour Markers: If solid lump found.
- Alpha-Fetoprotein (AFP).
- Beta-HCG.
- LDH.
Management Algorithm
SCROTAL LUMP
↓
EXAM: CAN YOU GET ABOVE IT?
┌───────┴───────┐
NO YES
(Inguinal Hernia) ↓
↓ TRANSILLUMINATES?
REFER SURGERY ┌─────┴─────┐
YES NO
(Fluid) (Solid/Blood)
↓ ↓
ULTRASOUND ULTRASOUND
(Non-urgent) (URGENT - 2WW)
Specific Treatments
1. Hydrocele
- Infants: Observe until age 2 (processus vaginalis often closes). Repair (PPV ligation) if persistent.
- Adults:
- Conservative: If small/asymptomatic.
- Surgery: Jaboulay Procedure (sac eversion) or Lord's Procedure (plication).
2. Epididymal Cyst
- Conservative: Benign. Surgery often causes chronic pain or damage to epididymis (fertility risk). Only operate if very large/bothersome.
3. Varicocele
- Indications for Treatment:
- Pain/Discomfort.
- Testicular Atrophy (child/adolescent).
- Infertility.
- Methods:
- Embolisation: Radiology guided coiling (Day case).
- Surgery: Open or Laparoscopic ligation.
4. Testicular Tumour
- Radical Orchidectomy (Inguinal approach). NEVER biopsy through the scrotum (risks seeding lymphatics).
- Infertility: Varicocele (heat), Tumour (therapy), Mumps Orchitis.
- Haematoma: Common compilation of scrotal surgery (baggy skin fills with blood).
- Infection: Pyocele.
- Benign Lumps: Good. Low recurrence after surgery (less than 5%).
- Varicocele: fertility improves in ~70% after repair.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Paediatric Urology | EAU | Repair congenital hydrocele if present >2 years. |
| Male Infertility | AUA (USA) | Treat varicocele if palpable and abnormal semen analysis. |
Landmark Evidence
1. Varicocele Repair
- Cochrane reviews suggest repair improves pregnancy rates in couples where the man has a varicocele and poor sperm quality, though evidence is mixed.
What is a Hydrocele?
It is a collection of fluid around the testicle, like water in a balloon. It is harmless. We usually leave it alone unless it gets so big it causes embarrassment or discomfort.
What is a Varicocele?
It is a cluster of varicose veins in the scrotum (like varicose veins in the leg). It feels like a "bag of worms". It can sometimes overheat the testicle and lower sperm count.
I found a hard lump.
This is urgent. Most lumps are cysts, but a hard lump on the testicle needs an urgent scan to rule out cancer. Testicular cancer is highly curable if caught early.
Primary Sources
- Jungwirth A, et al. EAU Guidelines on Paediatric Urology. 2016.
- Dohle GR, et al. EAU Guidelines on Male Infertility. 2010.
Common Exam Questions
- Diagnosis: "Bag of worms?"
- Answer: Varicocele.
- Technique: "Cannot get above the lump?"
- Answer: Inguinoscrotal Hernia.
- Anatomy: "Why left varicocele?"
- Answer: Left testicular vein -> Left Renal Vein (Perpendicular angle). Right -> IVC (Oblique).
- Red Flag: "Non-transilluminating, painless, hard lump?"
- Answer: Testicular Cancer.
Viva Points
- Hydrocele of the Cord: Fluid trapped in the middle of the processus vaginalis (encysted). Lump is in the inguinal canal, moves with the cord on traction.
- Transillumination: Why? The fluid (clear) diffuses light. Blood or solid tissue absorbs it.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.