Sebaceous cyst

The patient may complain of several painful lumps on the scrotal skin. There may be a history of one or more of them becoming red, inflamed and tender with discharge.

Indirect inguinal hernia

The patient will be often aware of what the lump is. He may be able to reduce it. The hernia may present with a painful, irreducible swelling and signs of intestinal obstruction.

Hydrocele

An idiopathic hydrocele usually presents as a painless scrotal swelling which may become quite large. They usually occur over the age of 50 years. Occasionally, there may be pain and discomfort if there is underlying testicular disease. A younger patient presenting with a hydrocele should raise the suspicion of an underlying malignancy.

Epididymal cyst

This presents as a painless scrotal swelling. Epididymal cysts may slowly enlarge over many years. They may be bilateral.

Epididymo-orchitis

The patient complains of pain and swelling, usually unilaterally. There are usually constitutional symptoms of malaise and fever. It may be accompanied by urinary tract infection with dysuria and frequency.

Testicular torsion

This usually occurs around puberty. It is rare over 25 years of age. There is sudden onset of pain in the scrotum and groin, which may radiate into the lower abdomen. This may be accompanied by nausea and vomiting. There may be a history of violent exercise, e.g. straining in the gymnasium, lifting or even masturbation. Always ascertain the exact time of onset of symptoms. To be sure of testicular salvage, surgery should be carried out within 6–8 hours of onset of symptoms.

Testicular tumour

Teratomas occur between 18 and 30 years, seminomas between 30 and 45 years. The common presentation is a feeling of heaviness in the scrotum accompanied by a painless swelling. Occasionally, symptoms are due to secondary deposits, e.g. abdominal pain from enlarged retroperitoneal lymph nodes. Occasionally, distant lymphadenopathy, e.g. cervical, may be a presenting symptom.

Varicocele

The patient (or partner) may notice varicose veins in the scrotum. Often the only symptom is a dragging ache in the scrotum and groin. Subfertility may be a presentation and is associated with bilateral varicoceles. A varicocele is more common on the left.

Haematocele

There will be a clear history of trauma.

Sperm granuloma

This may develop 2–4 months after vasectomy. The patient will complain of a small tender nodule at the site of vasectomy.

TB

This is now rare in the UK. A scrotal lump with associated dull, aching pain is the usual presentation. There may be a history of pulmonary or renal TB. There may be malaise, weight loss, haemoptysis or haematuria.

Gumma

This is extremely rare. There is a painless swelling of the testis. It needs to be distinguished from a testicular tumour. Other signs of syphilis may be present.

Sebaceous cyst

A small swelling or multiple small swellings occur in the scrotal skin. They are tense and spherical. Because of the thinness of the scrotal skin stretched over the swelling, the cheesy yellow material contained within them can be seen. There may be a small punctum surmounting the cyst.

Indirect inguinal hernia

Hernias that descend in the scrotum are invariably indirect. They may be reducible. It is impossible to get above the swelling. There is an expansile cough impulse and bowel sounds may be heard over the hernia.

Hydrocele

A hydrocele is usually unilateral. It may become very large. A hydrocele is fluctuant, transilluminates and is dull to percussion. If large enough there may be a fluid thrill. The testis cannot be palpated separately from the hydrocele. It is possible to get above the swelling except with infantile hydroceles, when the fluid extends up to the deep inguinal ring.

Epididymal cyst

An epididymal cyst usually occurs above and behind the testis. The testis can be palpated separately from it. An epididymal cyst frequently feels lobulated because often the fluid is in locules. They are fluctuant. Those containing clear fluid transilluminate. Those containing a milky opalescent fluid are called spermatoceles and do not transilluminate.

Epididymo-orchitis

The scrotal skin is hot, red and oedematous. The tenderness is initially confined to the epididymis but eventually spreads to involve the testis.

Testicular torsion

The scrotal skin is usually hot, red and oedematous. The testis is extremely tender and is often drawn up towards the groin.

Testicular tumour

There is a firm, irregular swelling in the scrotum. Often the patient notices the lump when it is very small but in other cases it may become very large before the patient presents. Rarely the tumour has been allowed to advance so far that it is attached to the scrotal skin. Check for palpable para-aortic nodes. Examine the cervical nodes, especially in the left supraclavicular fossa. Testicular tumours metastasise to the para-aortic nodes, to the mediastinal nodes, and occasionally into the cervical nodes. Inguinal nodes are not involved unless the tumour has invaded the scrotal skin, which is rare.

Varicocele

This can only be palpated with the patient standing up. The dilated veins then become visible and palpable. They are said to feel like ‘a bag of worms’ but actually feel more like lukewarm spaghetti. The left side is more commonly affected.

Haematocele

There is a tense, tender, fluctuant swelling. There may be obvious scrotal bruising. The testis cannot be felt separately as the blood surrounds it within the layers of the tunica vaginalis.

Sperm granuloma

There is a small, tender, painful nodule at the site of previous vasectomy.

Tuberculosis

The swelling is usually confined to the epididymis, where there is a hard lump. The spermatic cord and vas are thickened. Occasionally a sinus may have formed. Check the chest for signs of pulmonary TB. Check the neck for scars (lymph node drainage for cold abscess) or lymphadenopathy.

Gumma

A gumma is a painless swelling of the whole testis. Other signs of syphilis may be present.

■ FBC, ESR
Hb ↓ chronic disease, e.g. TB. WCC ↑ inflammation, e.g. epididymo-orchitis, torsion. ESR ↑ TB, syphilis, tumour.

■ CXR
TB. Secondary deposits from testicular tumour.

■ MSU
UTI associated with epididymo-orchitis.

■ US
Solid versus cystic. Hydrocele versus epididymal cyst. Always arrange an ultrasound of the underlying testis in the young patient with a lax hydrocele as there may be an underlying tumour.

■ Tumour markers
AFP, βHCG, LDH.

■ EMSU
TB.

■ VDRL
Gumma.

■ US abdomen
Carcinoma of left kidney invading the left renal vein, associated with left varicocele.

■ Laser Doppler*
Torsion versus orchitis.

■ Technetium scan*
Torsion versus epididymo-orchitis.

■ Surgery
Distinction between torsion and epididymo-orchitis.

■ MRI
Abdominal and chest MRI scan may confirm lymphadenopathy associated with secondary deposits from testicular tumours.