EVALUATION OF A

SCROTAL MASS
DR. MUNGUTI
ANATOMY
HISTORY
• Age
• Presence or absence of Pain: onset, character, radiation, alleviating factors
• Duration of swelling
• Onset of swelling
• Associated lower urinary tract infection/infective symptoms: urethral discharge, dysuria, pyuria
• Recent trauma
• Previous scrotal surgery
• Previous testicular tumour
• Family history
• history of undescended testis
• STD’s
• Systemic signs and symptoms
• Symptoms of bladder outlet obstruction
PHYSICAL EXAMINATION
• General examination: lymphadenopathy
• Scrotal examination: (while patient is standing)
• Inspection: skin, scars, swelling, discolouration, discharging sinus, Ulceratiion, rash
• Palpation:
• Site:Location of mass (testis, epididymis, scrotum)
• Size
• Tenderness
• Consistency
• Irregular/smooth
• Can I go above it
• Transilluminance
• Scrotal appearance
• Auscultation
• Inguinal lymphadenopathy
• Palpate the spermatic cord
• Penile examination:
• Discharge
• Position of meatus/ urethra
• Chest/Abdomen examination:
• Gynaecomastia
• Organomegaly/tenderness
• Inguinal hernia
• hypospadias
PHYSICAL EXAMINATION
 Epididymitis
Definition: inflammation of the epididymis

Incidence: 1.2 per 1000 boys (2 -13 yrs)

Young adults (29 -39 years) associated with STI
>35 years: E. Coli is the most common course

Acute vs chronic: acute <6 weeks

Pathogenesis: reflux of urine into the ejaculatory ducts

Risk factors: UTI/STI, anatomicl abnormalities (bladderoutlet obstruction), prostate, urinary tract surgeries,
prolonged sitting, cycling, trauma
Causative organisms:
<14 years:
anatomic abnormalties with urine reflux to ejaculatory ducts;
Post infectious syndrome from mycoplasma pneumoniae, enterovirus, adenovirus
14 -35 years; chlamydia, N. Gonorrhea
Patients with HIV: CMV, salmonella, toxoplasmosis, ureaplasma urealyticum, Corynebacterium, mycoplasma
• Presentation:
• Gradual onset scrotal pain over 1- 2 days, radiating to the
lower abdomen
• swelling and inflammation, fever
• Hematuria, dysuria, urinary frequency
• Physical examination: tenderness of epididymis, swelling and
inflammation of the scrotum, Prehn’s sign (elevation of scrotum
may relieve pain), cremasteric reflex is present
• Investigations; urine m/c/s, scrotal doppler ultrasound
• Ultrasound:
• increased testicular size
• Associated scrotal reactive hydrocele
• Increased blood flow through the epididymis
• Scrotal wall thickening
• Treatment:
• 14-35 years: ceftriaxone and doxycycline
• >35 years: ceftriaxone and levofloxacin
• NSAIDS
 Orchitis
Commonly occurs with epididymitis and prostatitis

Causative organism:
• Viral orchitis: Mumps, cocksackie virus, infectious
mononucleosis, varicella, echovirus
• Bacterial: N. Gonorrhea, C. Trachomatis (14- 35
years), E. coli (>35 years)
• Others: pseudomonas aeruginosa, staphylococcus,
streptococcus
Symptoms:
• post viral may develop several days (4 -7 days post
parotitis
• Assoc systemic symptoms; fatigue, malaise, myalgia,
fever chills, nausea, headache
Physical findings:
Testicular enlargement
Tenderness
Erythematus/edematous scrotal skin
 Hydrocele
Definition: fluid collection anywhere within the path of testicular
decent
Etiology:
• Imbalance between absorption and production of lymphatic
fluid
• Disruption of lymphatic system
Causes:
Congenital, trauma, tumor, infection (parasitic), congenital,
inflammatory
Classification: communicating vs non communicating
Complications:
• Partial arrest of spermatogenesis
• Sexual dysfunction and infertility
• Rupure
• Pain
• Pyocele
• Infection
• Hematocele
• assessment:
• transillumination test positive
• Scrotal ultrasound

• Management:
• Hydrocelectomy
• Aspiration
• sclerotherapy
Spermatocele
Definition: benign cystic accumulation of sperm
that arises from head of epididymis.
Can occur in various locations: testicle, vas,
intrascrotal, paratesticular

Presentation:
Asymptomatic
Progressive increase in size
Discomofort/pain

Examination:
Intrascrotal, Para testicular
Trans illuminates
Does not increase in size with Valsalva

Management: Excision in symptomatic patients

 Varicocele
Definition: Dilatation of the pampiniform venous plexus
and internal spermatic vein

Incidence:
15 -20% of healthy males
35% men with primary infertility
80% men with secondary infertility

Clinical presentation:
Asymptomatic
Pain in 2-10%

Indications for surgery:

Clinical varicocele
Oligospermia
Infertility >2years
Unexplained infertility
Adolescents with progressive failure of testicular
development
• Grading;
• Grade 1: only palpable during valsava
• Grade 2: easily palpable+/- valsava but not visible
• Grade 3: easily palpable+ detected on visual inspection
• Indication for surgery:
• Oligospermia
• Infertility > 2 years
• Unexplained infertitliy
• Adolescents with progressive failure of testicular development
• Management:
• Surgical ligation: retroperitoneal, inguinal, subinguinal
• Conservative management: NSAIDs, scrotal support
Epididymal cyst
Definition: fluid filled collection at the head of the
epididymis

Histology: cyst lined with pseudostratified columnar

epithelium

Etiology: cystic degeneration of the epididymis

Incidence: mostly in males > 40 years

Presentation:
scrotal pain
Awareness of a scrotal mass
Transillumination – positive
Palpable mass separate from the testis

Management: excision (symptomatic)

Testicular torsion
Definition: twisting of the spermatic cord leading to
decreased blood flow to the testicle resulting in
ischemia, infarction and tissue necrosis

Types: intravaginal and extra vaginal testicular

torsion

Clinical presentation:
Sudden onset acute testicular pain
Associated nausea and vomiting
High riding horizontal lie testicle
Absent cremasteric reflex
Prehn’s sign negative
Testicular salvage rate 90% in 6-8 hours

Management: urgent scrotal exploration and

detorsion
Testicular appendage torsion
• Testicular appendage – remnant of
Mullerian duct; vestigial structure
• Mean age: 9 years
• Presentation:
• Acute scrotal pain located on the superior
pole of the testis
• Nausea and vomiting
• Clinical examination:
• Blue dot sign
• Scrotum edemetous/erythematous
 Testicular tumour
Accounts for 1-2% of cancers among adults in the U.S, but is the
most common malignancy in males aged 20 – 45 years.

Incidence: influenced by environmental and genetic factors

Varying incidence based on geographical location

>95% germ cell tumours

Risk factors:
White race
Cryptorchidism
Family history of testicular cancer
Personal history of testicular cancer
Germ cell neoplasia in situ
Hypospadias
Androgen insensitivity syndrome
Genetic predisposition
Clinical manifestation:
Nodule or painless swelling of one testicle
Acute pain - 10%

Systemic manifestations:
• Supraclavicular lymph node metastasis
• Cough/dyspnea –lung metastases
• Anorexia, nausea, vomiting, GI
haemorrhage
• Lumbar back pain
• Bone pain
• Lower extremity swelling
• Gynaecomastia – 5% (leydig tumors
secondary toBHCG production)
• Paraneoplastic syndrome: hyperthyroidism,
limbic encephalitis

Physical examination:
Increased size of testis
Seminoma – painless, rubbery enlargement
Embryonal Cell Carcinoma –irregular mass
with ill defined margins
+/- hydrocele
• Diagnostic evaluation:
• Bilateral Scrotal ultrasound
• Cystic/fluid filled mass
• Hypoechoic mass without cystic areas
• Inhomogenous mass with calcifications, indistinct margins
• microlithiasis
• CT Chest/Abdomen
• Regional metastase
• Retroperitoneal lymph node metastases
• Serum tumor markers: BHCG, AFP, LDH
• MRI brain: if brain metastases suspected
TUMOR MARKERS
DIAGNOSIS/TREATMENT
• Radical inguinal orchiectomy
• Histological diagnosis
• Control of local primary tumour
• Retroperitoneal lymph node dissection (RPLND)
• The only reliable method to assess micrometastasis
• Gold standard for pathological staging
staging
• Management:
• Seminoma
• Clinical stage 1: radical orchiectomy
• Clinical stage 2:
• 2A: radical orchiectomy plus radiotherapy
• 2B/C: radical orchiectomy + cisplatin based
chemotherapy

• Non seminoma GCT

• Clinical Stage 1:
• High risk: orchiectomy, RPLND,
chemotherapy
• Low risk: orchiectomy, active surveillance

• Clinical Stage 2/3:

• Chemotherapy, surgery,
CASE PRESENTATION
• 23 year old male patient presents with 3 months history of right testicular
pain.

• What further history would you like to ask for?

• Past medical history?

• Family/social history?

• Systemic inquiry?
PHYSICAL EXAMINATION
• General examination:

• Chest/abdominal examination:

• Inguinal/genital examination:

• Laboratory investigations:
IMAGING
Imaging: Scrotal ultrasound

What features are we looking for?

Laboratory investigations:
ASSIGNMENT
• Differentials of an acute scrotum