Scrotal swellings can occur in all age groups and may be testicular or non-testicular. Testicular causes include torsion, epididymo-orchitis and cancer.
Extra-testicular causes include epididymal cyst, varicocoele, hydrocoele or haematocoele, inguinal hernia, trauma and scrotal carcinoma. Generalised oedema, sebaceous cysts, allergic contact dermatitis and TB are other possibilities.
Important elements of the patient's history include age, the timing of the onset of swelling, associated symptoms and a sexual health record.
1. Testicular torsion
Twisting of the spermatic cord may occur in any age group, but is most common in boys aged 13 to 17. The onset of pain can be sudden, severe, and there may be nausea and vomiting.
There may be a history of trauma or previous attacks of pain. On examination there is usually diffuse testicular tenderness, an absent cremasteric reflex, and the testis may be elevated and lie transversely.
Torsion should be suspected in any patient with an acutely swollen and painful scrotal swelling, particularly if he is less than 30 years old and presents less than six hours after the onset of symptoms. Suspected torsion should be admitted for immediate assessment, as the viability of the testicle begins to fall dramatically after six hours.
Epididymo-orchitis can be difficult to differentiate from torsion, but the onset tends to be more gradual (hours to days) and is associated with pain and tenderness that may be relieved by elevation of the testis. In TB, the swelling is often painless.
Epididymo-orchitis can be associated with a urethral discharge, urinary symptoms and vomiting. A history of parotid swelling would suggest mumps orchitis. There may be erythema or oedema on the affected side.
Management depends on the likely causative organisms, but possibility of testicular torsion requires a low threshold of referral in order to exclude it.
In sexually active men below the age of 35, the most likely causes are chlamydia or gonorrhoea, and ideally a GUM assessment should be arranged within 24 hours. If this is not possible, an MSU and urethral swab should be taken and the patient started empirically on doxycycline (plus ciprofloxacin if gonorrhoea is suspected), with GUM follow-up.
In men over 35 and non-sexually active men under 35, enteric organisms associated with lower UTI, such as Escherichia coli, are the likely cause. Treatment is with 10 days of ciprofloxacin with a review at the end of the course. Other measures include analgesia, bed rest and supportive underwear.
3. Testicular cancer
Testicular cancer accounts for 1-2 per cent of all male cancers, but is one of the most common malignancies in men between the ages of 20-40 years and the incidence is increasing. Testicular cancer in older men is likely to be a lymphoma.
There is usually a gradual onset of scrotal swelling, but the patient may only just have noticed the enlargement as it is usually painless. Pain can occur in up to 30 per cent of cases. Respiratory symptoms, weight loss and back pain suggest metastases.
The whole or just part of the testicle will have a solid firm consistency and there may be an associated epididymo-orchitis or hydrocoele. A general examination should be done to check for respiratory involvement, supraclavicular lymphadenopathy and abdominal masses due to para-aortic lymphadenopathy. Any solid testicular swelling should be referred urgently.
Testicular cancers are highly curable, even in patients with metastatic disease at diagnosis. The prognosis depends on the histology. Treatment involves chemotherapy and radiotherapy.
4. Other causes
Epididymal cysts are common in men over 40 and are usually painless, non-tender, smooth cystic swellings in the epididymis that do not transilluminate. They can be multiple and bilateral and if asymptomatic, no treatment is required.
Hydrocoeles (excess fluid in the tunica vaginalis) may have an acute or chronic onset.
Examination usually reveals a non-tender fluctuant scrotal swelling that transilluminates.
Hydrocoeles are common in neonates and disappear within a year or two, and only require referral if they persist, unless there are fluctuations in size, an abdominal mass (suggesting an abdominal-scrotal hydrocoele) or if an inguinal hernia cannot be confidently excluded.
Non-congenital hydrocoeles may be secondary to testicular torsion, epididymo-orchitis, testicular cancer and hernias.
If a hydrocoele presents in a man age 20 to 40 ultrasound is helpful, but if there is a strong suspicion of cancer, an urgent urology referral is needed.
Haematocoeles can be the result of trauma, but also occur with testicular cancer. They are normally painful and tender and do not transilluminate.
Inguinal scrotal hernias can be painless. It is not possible to get above the swelling on examination and bowel sounds may present. Elective surgical repair is possible unless symptoms suggest strangulation.
Varicocoeles have a chronic onset and are painless, but may be associated with a dragging sensation. Their consistency is described as 'a bag of worms' and the swelling normally disappears on lying down.
If the onset is sudden and the varicocoele remains tense on lying, a tumour must be excluded urgently. Diagnostic uncertainty or a distressed or anxious patient justifies routine referral.
- Dr Porter is a salaried GP in Rochford, Essex