Red Flag Symptoms: Scrotal problems

Dr Lizzie Croton explains the symptoms that may give cause for alarm.

Inguinal hernia in a young boy
Inguinal hernia in a young boy

Many patients with testicular problems tend to delay presentation because of embarrassment and may not seek medical attention until the symptoms become unbearable. A good history and examination are vital.

Click here to browse our resource of Red Flag alert symptoms

Red flag symptoms
  • Pain
  • Swelling
  • Erythema
  • Urinary symptoms
  • Irreducible groin lump

Children and adolescents
Babies and toddlers may present with vague symptoms and an unclear history. It is sensible to ask the parents about testicular symptoms in young children and examine the genitalia in those presenting with abdominal pain, urinary symptoms or a high temperature without an obvious focus of infection.

Important acute testicular presentations that must not be missed include testicular torsion and a strangulated inguinal or femoral hernia.

Symptoms of torsion include an exquisitely tender scrotum with lower abdominal pain. The affected testicle may lie higher than normal.

Torsion may occur at any age but is most common in adolescents. Prompt surgical exploration is mandatory in suspected torsion to preserve the viability of the testes.

A strangulated inguinal hernia in children is most common in the first six months of life, where 25 per cent of inguinal herniae obstruct if not treated.

Symptoms of strangulation include an initially irreducible groin lump that then becomes tender and erythematous. Features of bowel obstruction typically develop over the next few hours.

It is good practice to refer asymptomatic inguinal herniae in children for elective repair.

Symptoms in adults
Symptoms of malignancy must not be missed.

Testicular tumours are the most common tumours in men aged between 20 and 40, with 92 per cent being malignant. In 80 per cent of cases a painless lump is noticed in the testes.

Associated features may include a hydrocele containing blood-stained fluid, unexplained testicular pain and the presence of metastases either in the lung or abdomen. Enlarged para-aortic nodes may present as an abdominal mass.

It is not necessary to refer every patient with a hydrocele unless the diagnosis is uncertain or a malignancy is suspected.

An ultrasound is helpful in making the diagnosis and most radiology departments would be amenable to arranging an urgent scan if a sinister cause for hydrocele is suspected.

The most common malignant tumours are seminomas (40 per cent) and teratomas (30 per cent). Seminomas have a peak incidence at 30-40 years and teratomas 20-30 years. A mixed seminoma/teratoma tumour has a peak incidence at 25-35 years.

Testicular lymphomas (usually non-Hodgkin's type) peak at 60-70 years.

Any suspicious testicular lump requires urgent assessment.

Epididymitis
In epididymitis, the epididymis is tender and swollen. As the infection progresses the testicle may become swollen, making it difficult to palpate the testes and epididymis separately.

Clinically the presentation can mimic torsion and so any doubt necessitates a surgical referral. Bacterial infections are the most common aetiology in epididymitis. In younger men these are commonly sexually transmitted pathogens whereas in older men Escherichia coli secondary to bladder outflow obstruction is most common.

  • Dr Croton is a salaried GP in Birmingham
POSSIBLE CAUSES
  • Testicular torsion
  • Strangulated inguinal hernia
  • Epididymitis
  • Testicular tumour

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