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MikaRaitanen

Enlarged Scrotum or Palpable Mass in Scrotum

Essentials

  • Most masses in the scrotum are easy to diagnose by palpation and by transillumination of the scrotum with a torch.
  • Lesions that are felt outside the testicle and that are transparent to light usually are benign, but a solid and non-transilluminating lesion should be considered as testicular cancer until proven otherwise.
  • If cancer is suspected the patient is referred to a specialist without delay.
  • If the mass can be located outside the testicle
    • identify a hydrocele and spermatocele without special investigations
    • identify a varicocele (may affect fertility)
    • detect a hernia and refer the patient for surgery.
  • Scrotal ultrasonography is the primary investigation if clinical assessment concerning the nature of the mass remains ambiguous.
  • Of benign changes, only those causing symptoms need treatment.

Hydrocele

  • A hydrocele is a collection of fluid inside the tunica vaginalis surrounding the testicle and appendix testis.
  • In transillumination, fluid is seen around the testicle.
  • The diagnosis can be verified by ultrasonography if needed and if the finding remains uncertain at palpation of the testicle.
  • Often asymptomatic but when enlarging may cause pain, sensation of pressure and mechanical discomfort
  • A symptomatic hydrocele is treated with sclerotherapy or by surgery.
    • The agent used in sclerotherapy is either lauromacrogol (polidocanol; 2 ml of 3% solution diluted in 5 ml of 1-2% lidocaine) or doxycycline 500 mg mixed in 2 ml of water and further diluted in 5 ml of lidocaine). Doxycycline may be somewhat more effective but causes more pain Polidocanol Vs Tetracycline for Sclerotherapy of Testicular Hydrocele or Epididymal Cyst. Therefore, lauromacrogol (polidocanol) is the preferred agent.
    • A fine (e.g. 1.0 mm, 20G) cannula is used for puncturing the hydrocele or spermatocele which is then aspirated almost empty and the sclerosing agent is injected there through the same cannula (videos Sclerotherapy for Hydrocoele and Ultrasonography and Sclerotherapy of Hydrocoele). Immediately before injecting it must be ensured that the tip of the cannula is positioned inside the fluid cavity: clear (not bloody) fluid is obtained by aspiration. The procedure may be repeated.
    • Sclerotherapy is a usable form of treatment if the surgical risk is increased because of significant overweight, diabetes or anticoagulant therapy, for example.
    • In the operation, the surface area of the fluid-forming tunica (tunica vaginalis) is reduced by removal or plication. A haematoma and inflammation are possible complications of the operation.
  • Treatment merely by needle aspiration is not beneficial in the long term as the fluid collection recurs.

Spermatocele

  • Prevalence 10-30%
  • A round, rather soft, transilluminating mass. Usually located above the testicle separated from it. May be multilocular.
  • A small symptomless spermatocele needs no treatment.
  • An annoyingly large spermatocele is treated with sclerotherapy in association with its aspiration or by surgery. See hydrocele above.

Varicocele

  • The most common manifestation of venous insufficiency in men. Prevalence 15-24%.
  • Usually left-sided
  • Dilatated veins can be seen as worm-like swellings around and above the testicle when the patient is standing. The Valsalva manouvre may be helpful in doubtful cases. In the supine position dilated veins disappear.
  • Usually symptomless and found incidentally. Symptoms may include pain as well as a sensation of pressure and heat in the scrotum. Usually the symptoms are absent in the morning, but they often become worse towards the evening and on exertion (see also article on testis pain Testis Pain).
  • A symptomless varicocele in an adult needs no treatment. Treatment may be considered in boys of growing age or undergoing puberty, if there is a risk that the testicle may remain smaller than the other one. If the varicocele is found in association with investigations for infertility, treatment is indicated Surgery or Embolisation for Varicocele in Subfertile Men.
  • In a middle-aged or elderly patient a rapidly appearing left-sided varicocele may indicate renal vein thrombosis (which can be caused by renal carcinoma). Right-sided varicocele may indicate obstruction of the inferior vena cava. In these situations abdominal ultrasonography is recommended.
  • Primary treatment is blocking of the testicular vein by a radiological procedure. The vein may also be surgically closed.

Inguinal hernia

  • Visible as a swelling at the orifice of the inguinal canal. Reposition by pressing with fingers is usually easy. Read more about herniasHernias in Adults

Testicular cancer

  • The most common form of cancer in men in the age range of 15 to 34 years
  • An enlarged, solid testicle or a non-transilluminating nodule in the testis is the typical finding.
  • A biopsy through the scrotum or a diagnostic puncture must not be performed but the patient is urgently referred to a urologist.
  • The prognosis is good with the combination of surgery, irradiation and chemotherapy (see also Bladder Cancer).

    References

    • Persad E, O'Loughlin CA, Kaur S, et al. Surgical or radiological treatment for varicoceles in subfertile men. Cochrane Database Syst Rev 2021;4:CD000479. [PubMed]
    • Silay MS, Hoen L, Quadackaers J, et al. Treatment of varicocele in children and adolescents: a systematic review and meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. Eur Urol 2019;75:448-61. [PubMed]
    • Shakiba B, Heidari K, Jamali A, et al. Aspiration and sclerotherapy versus hydrocoelectomy for treating hydrocoeles. Cochrane Database Syst Rev 2014;11:CD009735. [PubMed]
    • Kroese AC, de Lange NM, Collins J, et al. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev 2012;10:CD000479. [PubMed]