Scrotal masses

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Chapter 38 SCROTAL MASSES

Theodore X. O’Connell

General Discussion

Evaluation of a scrotal mass should include classifying it as extratesticular or intratesticular, solid or cystic, and painless or painful. A painful scrotal mass requires immediate action because torsion of the spermatic cord is a urologic emergency. The dictum that a painful scrotal mass is torsion until proven otherwise should be heeded. Other painful scrotal lesions include orchitis, epididymitis, trauma, incarcerated hernia, torsion of the appendix testis or appendix epididymis, and acute bleeding into a testicular tumor.

Masses that arise from the testicle are more likely to represent malignancies, whereas extratesticular masses are more likely to be benign. An intratesticular lesion should be considered a malignancy unless proven otherwise. Solid masses are much more likely to represent neoplastic conditions, especially when painless. Transillumination using a handheld light source may help to differentiate between solid and cystic structures. Extratesticular tumors are uncommon but do occur in the form of paratesticular rhabdomyosarcoma and ademomatoid tumors of the epididymis.

Cystic lesions of the scrotum are much more common than solid lesions. A cystic mass within the epididymis is usually a spermatocele. A cyst within the spermatic cord usually represents a hydrocele. A cystic mass that surrounds the entire testicle usually represents a hydrocele. When careful physical examination, including transillumination, fails to distinguish the exact location and nature of the lesion, then scrotal ultrasonography is of great value, especially when the testis is not palpable and a hydrocele is present. Ultrasonography can confirm the location of the mass and differentiate between solid and cystic lesions.

Most extratesticular masses are benign, and most intratesticular lesions are malignant. Sonography has been shown to have nearly 100% sensitivity for detecting testicular neoplasia. Testicular microlithiasis is a rare finding that can be associated with subsequent development of germ cell tumors of the testis. Careful follow-up is warranted if testicular microlithiasis is found on ultrasonography.

The most common painless scrotal masses in infants, children, and adolescents include indirect inguinal hernias, hydroceles, varicoceles, and spermatoceles. Testicular tumors, perinatal testicular torsion, acute idiopathic scrotal edema, and soft tissue tumors of the spermatic cord are less common causes. Figure 38-1 provides a clinical approach to the painless scrotal mass.

Figure 38-1 Clinical approach to the painless scrotal mass.

(From Skoog SJ. Benign and malignant pediatric scrotal masses. Pediatr Clin North Am 1997;44:1229-1250, with permission.)

A testicular tumor usually presents as a painless mass, although the patient may complain of scrotal heaviness or a dull ache. Physical examination should be performed with the patient in the upright and supine position because communicating hydroceles, hernias, and varicoceles are accentuated in the upright position and with the Valsalva maneuver. If testicular cancer is suspected, the patient should also be examined for lymphadenopathy, gynecomastia, and abdominal masses.

Cystic and Painless Extratesticular Masses

Hernias and hydroceles represent the greatest percentage of scrotal masses in pediatric patients. The incidence of inguinal hernias in the pediatric population is 10 to 20 per 1000 live births. Prematurity and low birth weight significantly increase the risk for hernias. Pediatric hernias and hydroceles are seen as bulges or swelling in the groin or scrotum and may be more visible when the child is crying.

A hydrocele is a collection of peritoneal fluid between the layers of the tunica vaginalis surrounding the testicle, with or without communication with the abdomen. A hydrocele usually presents as a painless scrotal swelling that can be transilluminated. The presence of an inguinal hernia or communicating hydrocele in the pediatric age group is an indication for surgical repair because of the risk of development of incarceration or strangulated hernia.

A varicocele is present in up to 20% of all males and is a tortuous and dilated pampiniform venous plexus and internal spermatic vein. Varicoceles often are described as a “bag of worms” superior to and distinct from the testicle. Varicoceles usually first appear near midpuberty and are rarely detected before 10 years of age. Most varicoceles occur on the left side and usually are asymptomatic. Varicoceles have been associated with male-factor infertility and may result in growth arrest of the left testicle. The dilatation and tortuosity are most noticeable when the patient is upright and may be accentuated if the patient performs a Valsalva maneuver. Once a scrotal mass has been identified as a varicocele, it is important to assess its effects on testicular size. A volume difference of greater than 2 cm³ is considered significant and serves as the minimal requirement for surgical repair of the adolescent varicocele. If a right-sided varicocele is identified, vena cava obstruction must be ruled out.

Spermatoceles and epididymal cysts usually present as a painless cystic mass superior and posterior to the testis. This mass is separate from the testis, is freely mobile, and transilluminates easily. No surgical intervention is necessary if the spermatocele is small and painless. However, larger lesions may cause discomfort, in which case scrotal exploration and excision may be indicated.

Solid Painless Extratesticular Masses

The epididymis, spermatic cord, and scrotal wall may be the source of various lesions that manifest as solid scrotal or inguinal masses. Solid lesions of the epididymis are most commonly benign, but malignancy cannot be excluded on clinical grounds. The adenomatoid tumor constitutes 70% of the benign lesions. Because of the possibility of paratesticular rhabdomyosarcoma, solid extratesticular lesion must be approached surgically.

Paratesticular rhabdomyosarcoma is the most common malignant paratesticular lesion presenting as a scrotal mass in childhood. The age of incidence ranges from infancy to early adulthood. The identification of a solid extratesticular lesion is managed by radical orchiectomy. A metastatic evaluation, including computed tomography (CT) scan of the chest and retroperitoneum, is performed if the diagnosis of rhabdomyosarcoma is made. Bone marrow examination and bone scans may be indicated.

Acute idiopathic scrotal edema most commonly affects boys between 2 and 11 years of age. It is a self-limited disorder resulting in scrotal erythema and swelling that manifests as a scrotal mass. Acute idiopathic scrotal edema occurs unilaterally two thirds of the time and bilaterally in one third of cases. Examination reveals thickened, edematous scrotal skin. The testis may not be palpable; however, the testis, epididymis, and tunica vaginalis are normal. If the testis cannot be palpated, ultrasonography reveals normal testicular parenchyma and blood flow but thickened scrotal skin. Urinalysis and white blood cell count (WBC) are normal. Acute idiopathic scrotal edema usually resolves in 72 hours and always by 4 days, although recurrence may occur.

Painless Intratesticular Masses

Testicular tumors in infants and children represent only 1% of all pediatric solid tumors. The most common presentation is a painless scrotal mass. The presence of a secondary hydrocele may lead to misdiagnosis, so ultrasonography should be performed on all painless scrotal masses if the testis is not palpable because of a hydrocele.

The initial evaluation of a child with a solid testicular mass includes a thorough physical examination as outlined below. If an intratesticular mass is seen on ultrasound, α-fetoprotein (AFP) may be helpful in identifying a yolk sac carcinoma (see below), but surgery is required to establish a histologic diagnosis.

Teratoma is the second most common prepubertal testis tumor and is one of the few tumors that may be seen in the neonatal period. It is managed with radical orchiectomy or testis-sparing surgery.

Gonadal stromal tumors represent 8% of prepubertal testicular tumors and may result in signs of precocious puberty because of their hormonal activity. Leydig cell tumors often produce testosterone, whereas Sertoli cell tumors are most often hormonally inactive, though they may be associated with gynecomastia.

Gonadoblastoma is a rare tumor that occurs in patients with intersex and dysgenetic gonads.

Acute lymphoblastic leukemia with infiltration of the testis may present as a prepubertal testicular mass and should be suspected in a patient with known history of leukemia who has painless testicular enlargement.

Neonatal torsion may be the result of prenatal torsion noted at birth with a painless scrotal mass or as postnatal torsion presenting with torsion after normal scrotal testes have been documented. Neonatal torsion classically presents as a hard, nontender testicular mass noted at birth that does not transilluminate. Ultrasonography shows mixed echogenicity of the testicular parenchyma with an absence of testicular blood flow. Because the testis is almost always nonviable, exploration can be performed electively with orchiopexy of the remaining solitary testis. If the infant had a documented normal testis at birth and suffered perinatal torsion, emergency inguinal exploration is necessary.

Key Historical Features

Duration of the mass

Pain

Constitutional symptoms such as weight loss, fever, chest pain, cough, headache

Past medical history

Past surgical history

Family history

Suggested Work-Up

Scrotal ultrasound

To help define suspected lesions and differentiate between intratesticular and extratesticular lesions

Additional Work-Up

Serum	Elevated in more than 80% of patients with yolk sac testicular tumors. It is not elevated in pediatric patients with testicular teratomas. Normal serum levels of AFP remain elevated for the first 8 months after birth.
Serial follow-up and serum AFP	If testicular microlithiasis is seen in association with testicular enlargement
Chest radiography and CT scan of the abdomen and chest	Indicated if the diagnosis of a yolk sac tumor is made
Serum human chorionic gonadotropin (hCG)	Little or no value in pediatric patients