Scrotal Pain/Swelling

Differential Overview

Pain Predominant

❑ Epididymitis

❑ Testicular torsion

❑ Prostatitis

❑ Referred pain

❑ Trauma

❑ Orchitis

❑ Torsion of the appendix testis

❑ Inguinal hernia/incarcerated

Swelling Predominant

❑ Varicocele

❑ Inguinal hernia

❑ Hydrocele

❑ Spermatocele

❑ Sebaceous cyst

❑ Testicular cancer

Diagnostic Approach

Testicular torsion, a medical emergency, should be the primary consideration in a patient with an acutely painful scrotum; however, epididymitis is a more common cause than torsion by 10:1. Reduction in pain by manual elevation of the testicle (Phren sign) helps to distinguish epididymitis from testicular torsion. A cremasteric reflex is absent in testicular torsion but present in torsion of the appendix testis.

Testicular cancer must be definitively ruled out whenever a firm induration or mass is found to be contiguous with the testicle.

Referred pain can be differentiated from scrotal pathology by a normal testicular examination.

Clinical Findings

Epididymitis  Gradual in onset, it is often associated with dysuria and fever. The epididymis, located posterior to the testicle, is cord-like, swollen and exquisitely tender. In men younger than age 35, it is usually caused by a sexually transmitted organism; in those older than age 35, by urinary coliforms. Tuberculous epididymitis adheres to the scrotum.

Testicular torsion  Sudden in onset, testicular torsion causes the retracted testicle to lie high in the scrotum. It is recognized by an anterior or horizontal position of the testicle, a nontender epididymis palpable anteriorly, and an absent cremasteric reflex. Usually occurring before age 30, there may be a history of recurrent attacks.

Prostatitis  Perineal and testicular aching coincides with urinary urgency and frequency. The posterior scrotal nerve refers pain to the scrotum.

Referred pain  Pain in the inguinal region, testicle, and upper medial thigh may be caused by disease along the genitofemoral nerve in the retroperitoneum (e.g., abdominal aortic aneurysm, ureterolithiasis, or retrocecal appendicitis) or by superficial entrapment after an appendectomy or hernia repair.

Trauma  History is key, for example, an acute blow, or bicycle riding. The scrotum may be swollen and tender, resembling torsion. Trauma can cause a contusion, hematoma (or hematoceole), or rupture of the testis.

Orchitis  Usually caused by mumps, occurring 7 to 10 days after the parotitis, it is unilateral or bilateral (30%) and associated with high fever and swelling and erythema of the scrotum.

Torsion of the appendix testis  Onset of pain is gradual over days. There will be a small, tender nodule at the anterosuperior testis, and often a reactive hydroceole. A “blue dot sign” of infarction and necrosis, seen through the skin at the tender point in 20% of cases, is pathognomonic.

Inguinal hernia/incarcerated  A hernia appears as a pliant mass extending through the inguinal ring and increasing with Valsalva. The examining finger is unable to get above a direct hernia, and the hernia usually can be reduced through a patent inguinal ring. Bowel sounds are present over the hernia. With incarceration, the hernia will be increasingly painful, tender, and irreducible.

Varicocele  The scrotum feels like a “bag of worms,” and is bluish, nontender, and increases in size when standing. It usually occurs on the left (the left spermatic vein empties directly into the renal vein, and may be anatomically compressed). Isolated right varicocele or the acute appearance of a varicocele in an elderly man suggests a renal cell carcinoma or renal vein thrombosis with involvement of the inferior vena cava.

Hydrocele  It is appreciated as a large, pear-shaped mass anterior to and above the testicle. The skin is stretched shiny red and transilluminates. The testis is usually obscured. About 10% of testicular tumors present with a hydrocele.

Spermatocele  It is a cystic structure superior to the testicle, usually smaller than 2 cm in size, which also transilluminates.

Sebaceous cyst  It is spherical, marble-sized, firm, yellow, and superficial within the scrotal skin.

Testicular cancer  Cancer appears as a firm, heavy, nontender mass in the testicle that does not transilluminate, although a reactive hydrocele may transilluminate. It retains the testicular shape until it penetrates the tunica albuginea with soft projections, adhering to the scrotum. With metastasis, there may be an associated enlarged left supraclavicular node. If it produces hCG or estrogen, there may be gynecomastia. One-third present with pain, tenderness, and swelling, and 95% occur in men aged 20 to 45 years.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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