A painless scrotal mass is often noticed by the patient but may be an incidental finding on routine physical examination.
Scrotal pain and painful scrotal masses or swelling can be caused by testicular torsion, appendiceal torsion, epididymitis, , epididymo-orchitis, scrotal abscess, trauma, strangulated inguinal hernias, orchitis, and Fournier gangrene.
Etiology of Painless Scrotal Mass
There are several causes (see table Some Causes of a Painless Scrotal Mass) of a painless scrotal mass but the most common include the following:
Hydrocele
Nonincarcerated inguinal hernia
Varicocele (present in up to 20% of adult men)
Less common causes include spermatocele, hematocele, fluid overload, and occasionally testicular cancer. Testicular cancer is the most concerning cause of a painless scrotal mass. Although it is rare compared with the other listed causes, it is the most common solid cancer in men aged < 40 years; because it responds well to treatment, prompt recognition is important.
Some Causes of a Painless Scrotal Mass
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Hydrocele (communicating) usually in patients with inguinal hernias | Cystic swelling Increase in size when upright or when intra-abdominal pressure increases Usually congenital Transilluminates | Clinical evaluation Ultrasonography if diagnosis is uncertain |
Hydrocele (noncommunicating) | Cystic swelling Does not change in size with changes in position of intra-abdominal pressure Often a simultaneous scrotal abnormality (eg, tumor, epididymitis) Transilluminates | Clinical evaluation Usually ultrasonography |
Spermatocele | Cystic mass at the upper pole of the testis, adjacent to epididymis Transilluminates | Clinical evaluation Ultrasonography if diagnosis is uncertain |
Inguinal hernia | Increases in size when upright or when intra-abdominal pressure increases May disappear when recumbent or be reducible or compressible Possibly bowel sounds Absence of normal spermatic cord structures above the mass Possibly palpable in the inguinal canal | Clinical evaluation |
Varicocele | Palpable when standing (enhanced with Valsalva), feeling like a bag of worms Usually on left side Possibly pain and fullness when standing Possibly testicular atrophy | Clinical evaluation |
Hematocele | Tender swelling Risk factors (eg, trauma, surgery, bleeding disorder or use of anticoagulants) | Usually ultrasonography |
Fluid overload | Diffuse, bilateral enlargement of scrotal sac Often pitting edema of lower extremities Often causative disorder evident (eg, heart failure, ascites, nephrotic syndrome) Transilluminates | Clinical evaluation Ultrasonography if diagnosis is uncertain |
Lymphedema (eg, from filariasis, congenital, idiopathic, after pelvic radiation or cancer [eg, prostate, bladder, testicular]) | Diffuse scrotal swelling Often nonpitting | Clinical evaluation Imaging (CT/ultrasonography) if diagnosis is uncertain |
Testicular cancer and other malignancies such as lymphoma | Mass attached to or part of testis Is solid or does not transilluminate Possibly dull, aching pain or acute pain due to hemorrhage | Ultrasonography of scrotum Alpha-fetoprotein Beta-human chorionic gonadotropin Lactic dehydrogenase CT of the abdomen |
Evaluation of Painless Scrotal Mass
History
History of present illness should address duration of symptoms, the effect of upright position and increase in intra-abdominal pressure, and presence and characteristics of associated symptoms such as pain.
Review of systems should seek symptoms suggesting possible causes, including abdominal pain, anorexia, or vomiting (inguinal hernia with intermittent strangulation); dyspnea and leg swelling (right heart failure); abdominal distention (ascites); and decreased libido, feminization, and infertility (testicular atrophy with bilateral varicoceles).
Past medical history should identify existing disorders that can cause masses (eg, right heart failure, ascites causing bilateral lymphedema); known scrotal disorders (eg, testicular tumor or epididymitis causing hydrocele); past history of pelvic surgery or radiation, and inguinal hernia.
Physical examination
Physical examination includes evaluation for systemic disorders that can cause edema (eg, heart failure, ascites) and detailed inguinal and genital examination.
Inguinal and genital examination should be done with patients standing and recumbent. The inguinal area is inspected and palpated, particularly for reducible masses. The testes, epididymides, and spermatic cords should be palpated for swelling, masses, and tenderness. Careful palpation can usually localize a discrete mass to one of these structures. Nonreducible masses should be transilluminated to help determine whether they are cystic or solid.
Red flags
The following findings are of particular concern:
Nonreducible mass that obscures normal spermatic cord structures
Mass that is part of or attached to the testis and does not transilluminate
Interpretation of findings
A nonreducible mass that obscures normal spermatic cord structures suggests an incarcerated inguinal hernia. If a mass is part of or attached to the testis and does not transilluminate, testicular cancer is possible.
Other clinical characteristics can provide important clues (see table Some Causes of a Painless Scrotal Mass). For example, a mass that transilluminates is probably cystic (eg, hydrocele, spermatocele). A mass that disappears or becomes smaller when recumbent suggests varicocele, inguinal hernia, or communicating hydrocele. The presence of a hydrocele makes assessment for other scrotal masses by examination difficult. Rarely, a varicocele persists when the patient is recumbent or is present on the right side; either finding suggests inferior vena caval obstruction.
Testing
Clinical evaluation may be diagnostic (eg, in varicocele, lymphedema, inguinal hernia); otherwise, testing is typically done. Ultrasonography with Doppler imaging is done when:
The diagnosis is uncertain
Usually when hydrocele is present (to diagnose causative scrotal lesions)
The mass does not transilluminate
If ultrasonography confirms a solid testicular mass, further testing is done for testicular cancer (see Testicular Cancer: Diagnosis), including the following:
Beta-human chorionic gonadotropin level (hCG)
Alpha-fetoprotein level
Lactic dehydrogenase level
CT of the abdomen
Treatment of Painless Scrotal Mass
Treatment is directed at the cause. Not all masses require treatment. If inguinal hernia is suspected, reduction can be attempted (see Hernias of the Abdominal Wall).
Key Points
A nonreducible mass that obscures normal spermatic cord structures suggests an incarcerated inguinal hernia.
A solid mass, one that does not transilluminate, or the presence of both mandates evaluation for testicular cancer.
The cause of a hydrocele must be determined.
