TABLE 3-13. SCROTAL MASSES: ETIOLOGIES AND CLINICAL MANAGEMENT

TABLE 3-13. SCROTAL MASSES: ETIOLOGIES AND CLINICAL MANAGEMENT
LESION	LOCATION	ETIOLOGY	SYMPTOMS	PHYSICAL EXAM	WORKUP	TREATMENT	COMMENTS
I. Congenital
A. Scrotal dermoid	Scrotal raphe	Embryologic	Mass at scrotal raphe	Mass at scrotal raphe	Ultrasound	Surgery	Can develop calculi/infection
B. Polyorchism	Intrascrotal	Embryologic	Scrotal mass	Duplicated testes—smaller than normal	Nuclear scan if Dx doubtful	Orchiectomy if no ductus deferens	Torsion risk
C. Scrotal rests (splenic, adrenocortical)	Upper pole Spermatic cord Tunica vaginalis	Embryologic	Scrotal mass	Scrotal mass	Liver-spleen scan	Surgery for associated cryptorchidism, hernia	Other congenital abnormalities are associated
II. Acquired
A. Hydrocele (noncommunicating)	Fluid in tunica vaginalis	Idiopathic, or secondary to infection, torsion, lymphatic blockage	Painless enlargement	Nontender, fluid-filled mass, transillumination (+)	Ultrasound if tumor suspected	Surgery or aspiration/ sclerotherapy	Rx reserved for large hydroceles or if painful
B. Spermatocele	Efferent ductal system	Painless cystic nodule	Nodule above and posterior to testes	No change with Valsalva, transillumination (+)	N/A	Surgery only if painful	Does not affect fertility
C. Varicocele	Pampiniform plexus	Idiopathic, or secondary to intraabdominal mass, hepatosplenomegaly, hydronephrosis	Usually none Pain rarely, if thrombosis present	"Bag of worms" appearance Usually left-sided ↓ Supine position ↑ Valsalva	N/A	Surgery if ipsilateral testes is hypotrophic	Depression of spermatogenesis with prolonged presence of lesion
D. Torsion of spermatic cord	Hemiscrotum	Associated with anomaly of suspension of testes	Acute onset of pain, swelling in testis, inguinal area, lower abdomen Nausea and vomiting	Diffusely swollen and tender testicle Cremasteric reflex absent	Radionuclide scan: scrotal imaging (↓ uptake except late, or large hydrocele) Doppler (no flow)	Attempt manual detorsion Emergent surgery: orchiectomy if necrotic; orchiopexy Analgesics	Emergency: salvage rate related to time torsion present
E. Torsion of testicular appendage	Hemiscrotum	Torsion of vestigial structure (appendix testis or appendix epididymis)	Sudden or gradual pain onset: upper pole of testis	Tender, pea-sized swelling at upper pole "Blue dot" sign	Doppler: normal to increased flow Radionuclide scan: normal to increased uptake	Analgesics Anti-inflammatories	Resolves spontaneously in 2-12 days
F. Trauma/hematocele	Blood in tunica vaginalis	Trauma	Pain +/- swelling	Fluid-filled mass if hematocele present	Ultrasound if expanding hematocele suspected	Analgesia, ice, scrotal elevation Expanding hematocele requires drainage
G. Neoplasms	Testicle or paratesticular structures	Unknown	Painless swelling Pain present if hemorrhage/necrosis Back pain with retroperitoneal lymph node involvement	Firm irregular mass Transillumination Hydrocele/varicocele may be present	Physical examination, CBC, LFTs, electrolytes, BUN, Ca, renal function tests, sperm analysis, hCG, AFP, testicular ultrasound, CT of chest and abdomen	Surgery (orchiectomy and peritoneal lymph node dissection) Radiation Chemotherapy Presurgery sperm banking	May be the most common malignancy in young men
III. Infectious
A. Epididymitis	Epididymis	C. trachomatis N. gonorrhoeae Coliforms Pseudomonas Gram (+) cocci	Acute onset of pain and swelling Frequency, dysuria, urethral discharge, fever	Swollen and tender epididymis Testicle may be tender Cremasteric reflex (+/-)	U/A, Gram stain of discharge, Urethral culture Dx epididymitis from torsion: Radionuclide scan: ↓ uptake = torsion ↑ uptake = epididymitis Doppler ultrasound: ↓ absent flow = torsion ↑ flow = epididymitis	Antibiotics See Table 3-17	Must R/O torsion Can result in azoospermia
B. Orchitis	Testicle (unilateral or bilateral)	Usually secondary to epididymitis (viral mumps)	Swollen and tender testicle Fever Parotitis history	Swollen and tender testicle Fever	None if mumps orchitis probable	Analgesia, bed rest, scrotal support	If bilateral atrophy, infertility likely Any atrophy-cancer risk 60×↑

TABLE 3-13. SCROTAL MASSES: ETIOLOGIES AND CLINICAL MANAGEMENT
LESION	LOCATION	ETIOLOGY	SYMPTOMS	PHYSICAL EXAM	WORKUP	TREATMENT	COMMENTS
I. Congenital
A. Scrotal dermoid	Scrotal raphe	Embryologic	Mass at scrotal raphe	Mass at scrotal raphe	Ultrasound	Surgery	Can develop calculi/infection
B. Polyorchism	Intrascrotal	Embryologic	Scrotal mass	Duplicated testes—smaller than normal	Nuclear scan if Dx doubtful	Orchiectomy if no ductus deferens	Torsion risk
C. Scrotal rests (splenic, adrenocortical)	Upper pole Spermatic cord Tunica vaginalis	Embryologic	Scrotal mass	Scrotal mass	Liver-spleen scan	Surgery for associated cryptorchidism, hernia	Other congenital abnormalities are associated
II. Acquired
A. Hydrocele (noncommunicating)	Fluid in tunica vaginalis	Idiopathic, or secondary to infection, torsion, lymphatic blockage	Painless enlargement	Nontender, fluid-filled mass, transillumination (+)	Ultrasound if tumor suspected	Surgery or aspiration/ sclerotherapy	Rx reserved for large hydroceles or if painful
B. Spermatocele	Efferent ductal system	Painless cystic nodule	Nodule above and posterior to testes	No change with Valsalva, transillumination (+)	N/A	Surgery only if painful	Does not affect fertility
C. Varicocele	Pampiniform plexus	Idiopathic, or secondary to intraabdominal mass, hepatosplenomegaly, hydronephrosis	Usually none Pain rarely, if thrombosis present	"Bag of worms" appearance Usually left-sided ↓ Supine position ↑ Valsalva	N/A	Surgery if ipsilateral testes is hypotrophic	Depression of spermatogenesis with prolonged presence of lesion
D. Torsion of spermatic cord	Hemiscrotum	Associated with anomaly of suspension of testes	Acute onset of pain, swelling in testis, inguinal area, lower abdomen Nausea and vomiting	Diffusely swollen and tender testicle Cremasteric reflex absent	Radionuclide scan: scrotal imaging (↓ uptake except late, or large hydrocele) Doppler (no flow)	Attempt manual detorsion Emergent surgery: orchiectomy if necrotic; orchiopexy Analgesics	Emergency: salvage rate related to time torsion present
E. Torsion of testicular appendage	Hemiscrotum	Torsion of vestigial structure (appendix testis or appendix epididymis)	Sudden or gradual pain onset: upper pole of testis	Tender, pea-sized swelling at upper pole "Blue dot" sign	Doppler: normal to increased flow Radionuclide scan: normal to increased uptake	Analgesics Anti-inflammatories	Resolves spontaneously in 2-12 days
F. Trauma/hematocele	Blood in tunica vaginalis	Trauma	Pain +/- swelling	Fluid-filled mass if hematocele present	Ultrasound if expanding hematocele suspected	Analgesia, ice, scrotal elevation Expanding hematocele requires drainage
G. Neoplasms	Testicle or paratesticular structures	Unknown	Painless swelling Pain present if hemorrhage/necrosis Back pain with retroperitoneal lymph node involvement	Firm irregular mass Transillumination Hydrocele/varicocele may be present	Physical examination, CBC, LFTs, electrolytes, BUN, Ca, renal function tests, sperm analysis, hCG, AFP, testicular ultrasound, CT of chest and abdomen	Surgery (orchiectomy and peritoneal lymph node dissection) Radiation Chemotherapy Presurgery sperm banking	May be the most common malignancy in young men
III. Infectious
A. Epididymitis	Epididymis	C. trachomatis N. gonorrhoeae Coliforms Pseudomonas Gram (+) cocci	Acute onset of pain and swelling Frequency, dysuria, urethral discharge, fever	Swollen and tender epididymis Testicle may be tender Cremasteric reflex (+/-)	U/A, Gram stain of discharge, Urethral culture Dx epididymitis from torsion: Radionuclide scan: ↓ uptake = torsion ↑ uptake = epididymitis Doppler ultrasound: ↓ absent flow = torsion ↑ flow = epididymitis	Antibiotics See Table 3-17	Must R/O torsion Can result in azoospermia
B. Orchitis	Testicle (unilateral or bilateral)	Usually secondary to epididymitis (viral mumps)	Swollen and tender testicle Fever Parotitis history	Swollen and tender testicle Fever	None if mumps orchitis probable	Analgesia, bed rest, scrotal support	If bilateral atrophy, infertility likely Any atrophy-cancer risk 60×↑