Differential diagnoses: Scrotal lesions

Dr Nigel Stollery outlines differential diagnosis of scrotal lesions including inguinal scrotal hernia, hydrocoele, angiokeratomas of Fordyce, and steatocystoma multiplex.

Inguinal scrotal hernia


  • Scrotal swelling which extends up into the body
  • Soft, fluctuant and usually non-tender
  • May be reducible when patient is lying flat
  • Bowel sounds may be present
  • Does not transilluminate when light applied
  • May be bilateral or unilateral
  • Strangulation may occur, leading to severe pain


  • Surgery is the treatment of choice in large, symptomatic cases
  • Laparoscopic repair increasingly common
  • Support/truss may help where surgery not an option



  • Swelling within the scrotum which is localised and does not extend into the body
  • Testes cannot be felt separately as lie within the hydrocoele
  • Usually soft, non-tender, cystic
  • Transilluminates when light applied
  • Caused by excess fluid in tunica vaginalis
  • May be congenital or develop later in life


  • Most only require reassurance
  • Larger ones can be aspirated
  • If tumour suspected, aspiration should be avoided - it increases risk of metastatic spread
  • In very large or recurrent cases, surgery is usually curative

Angiokeratomas of Fordyce


  • Small red/purple papules in scrotal skin
  • Also found in penile shaft, inner thighs and lower abdomen
  • Histologically, composed of ectatic thin-walled vessels in superficial dermis with overlying epidermal hyperplasia
  • Scaly surface often present
  • Usually 2-5 mm in diameter, although size can vary
  • Generally multiple
  • May bleed with minimal trauma, otherwise usually asymptomatic


  • Treatment not usually required
  • Where bleeding occurs, cautery, hyfrecation or laser effective

Steatocystoma multiplex


  • Uncommon disorder of pilosebaceous unit
  • Typically produces multiple sebum-containing dermal cysts
  • Can be inherited as autosomal dominant condition, but most cases are sporadic
  • Cysts usually non-tender and asymptomatic
  • Size can vary from 3mm to 3cm
  • Cysts lack punctum and more common in sebum-rich areas
  • Secondary infection may occur


  • Treatments include cryotherapy, aspiration and surgical excision
  • If secondary infection occurs, tetracyclines can be effective
  • Dr Stollery is a GP in Kibworth, Leicestershire

Click here to take a test on this article and claim a certificate on MIMS Learning

This is an updated version of an article that was first published in November 2014

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins


Already registered?

Sign in