32 CHAPTER 1 Preliminary investigation

Lumps in the scrotum

Differential diagnosis

•Testicle: Testicular malignancy (germ cell tumor such as seminoma, embryonal, choriocarcinoma, yolk sac tumor), lymphoma, benign testicular tumor (adenomatoid tumor, Leydig or Sertoli cell tumor), torsion of testicle or appendix, trauma with testicular rupture, benign cysts, granulomatous orchitis, syphilitic gumma

•Epididymis: epididymitis/epididmo-orchitis, epididymal cyst, cystadenoma, adenomatoid tumor

•Paratesticular masses: hydrocele, spermatocele, varicocele,

hematocele, hydrocele of the cord, cord lipoma, rhabdomyosarcoma of the cord

• Others: inguinal hernia, lesions of the scrotal wall (cysts, carcinoma)

Determining the diagnosis

Determination of the duration of the mass and whether it is painful can help establish the diagnosis. Painful masses include those from trauma, epididymitis, torsion, and hernia. Painless masses include tumors, hydrocele, spermatocele, varicocele, and epididymal masses.

Inguinal hernia

An indirect inguinal hernia often extends into the scrotum. It usually has a cough impulse (i.e., it expands on coughing) and usually reduces with direct pressure or on lying down. It is not possible to get above the lump.

Hydrocele

A hydrocele is an abnormal quantity of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis, the double layer of peritoneum surrounding the testis and which was the processus vaginalis in the fetus. It is usually painless, unless the underlying testicular disease is painful.

A hydrocele has a smooth surface, and it is difficult or impossible to feel the testis, which is surrounded by the tense, fluid collection (unless, rarely, the hydrocele is very lax). The superior margin can be palpated (i.e., you can get above the lump). It is possible to transilluminate a hydrocele (i.e., the light from a flashlight applied on one side can be seen on the other side of the hydrocele). Ultrasound is most reliable to evaluate for underlying testicular pathology in this setting.

Hydroceles may be primary (idiopathic) or secondary. Primary hydroceles develop slowly (over the course of years, usually) and there is no precipitating event such as epididymo-orchitis or trauma, and the underlying testis appears normal on ultrasound (no testicular tumor). Secondary hydroceles (infection, tumor, trauma) represent an effusion between the layers of the tunica vaginalis (the visceral and parietal layers), analogous to a pleural or peritoneal effusion.

In filariasis (infection with the filarial worm Wuchereria bancrofti), obstruction of the lymphatics of the spermatic cord gives rise to the hydrocele.

LUMPS IN THE SCROTUM 33

Epididymal cyst

This is also known as a spermatocele if there are spermatozoa in the contained fluid. Cysts derive from the collecting tubules of the epididymis and contain clear fluid. They develop slowly over years, lie within the scrotum (you can get examining finders above them), and usually lie above and behind the testis. They are often multiple or multiloculated.

Orchitis

This occurs in the absence of involvement of the epididymitis and is due to a viral infection, e.g., mumps. Orchitis often occurs with enlargement of the salivary glands.

Epididymitis

This is often difficult to differentiate from testicular torsion. Typically, it is caused by an ascending infection. Common agents include coliform bacteria, Pseudomonas, Chlamydia, and gonorrhea.

Acute epididymitis can be accompanied by pain, frequency, and dysuria. Early the epididymis can be palpated and is very tender. Later the testicle can become involved secondarily.

Tuberculous epididymo-orchitis

Infection of the epididymis (principally) by tuberculosis (TB) spreads from the blood or urinary tract. The absence of pain and tenderness is noticeable. The epididymis is hard and has an irregular surface. The spermatic cord is thickened and the vas deferens also feels hard and irregular (a “string of beads”).

Testicular tumor (seminoma, embryonal cell, yolk sac tumor, teratoma)

This is a solid mass on the testicle which, and if very large, may extend up into the spermatic cord. The typical malignant tumor in the testicle is painless and discovered incidentally, often after a minor trauma that probable calls attention to the area. Very rarely it can present with pain and tenderness in the testis and with fever.

The lump is usually firm or hard and may have a smooth or irregular surface. Examine the contralateral testicle and for abdominal and supraclavicular lymph nodes.

Gumma of the testis

This condition is rare. Syphilis of the testis results in a round, hard, insensitive mass involving the testis (a so-called billiard ball). It is difficult to distinguish from a tumor.

Varicocele

A variocele is dilatation of the pampiniform plexus—the collection of veins surrounding the testis and extending up into the spermatic cord (essentially varicose veins of the testis and spermatic cord). Small, symptomless varicoceles occur in approximately 20% of normal men and are more common on the left side.

They may cause a dragging sensation or ache in the scrotum; they are said to feel like a “bag of worms.” The varicocele disappears when the patient lies down.