Hospital Medicine

Scrotal/testicular nodules or masses

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I. What every physician needs to know.

Scrotal/testicular nodules and masses are a common complaint of male patients, and every physician should have basic knowledge of the possible etiologies and the appropriate initial steps in their management. There is a relatively limited list of common causes for scrotal/testicular nodules and masses, and even fewer causes that are considered serious or emergent. Identifying masses that need emergent evaluation and/or intervention is the first and most important step in the diagnostic process.

If a process requiring emergent surgical intervention is identified or cannot be excluded, appropriate and timely referral is critical. On the other hand, if a scrotal/testicular mass has been deemed non-emergent, a determination should be made as to whether the mass is benign or malignant. In doing so, one should keep in mind that in addition to all solid intratesticular lesions (which are considered malignant and should be removed), a benign lesion may also require elective surgery if it causes the patient significant distress or places the patient at risk of future morbidity.

Testicular masses should be regarded as neoplasm until proven otherwise (only 1% of testis tumors in adults are benign). Approximately 90-95% of testicular tumors are derived from the germ cells. Of these, the most common is seminoma which has a very different treatment algorithm than the non-seminomatous germ cell tumors (embryonal carcinoma, yolk sac tumor, choriocarcinoma, teratoma). The other 5-10% of tumors are stromal in origin (leydig cell, sertoli cell, granulosa cell). The most common bilateral testis tumor and most common metastatic tumor of the testicles is lymphoma. ALL of the aforementioned pathologies require prompt radical orchiectomy for tissue diagnosis, and staging.

II. Diagnostic Confirmation: Are you sure your patient has scrotal/testicular nodules or masses?

Evaluation of the patient with a scrotal/testicular nodule/mass should not be delayed, but there are some things to briefly consider before seeing the patient. It is important to keep in the forefront of your mind the most serious conditions in the differential: testicular torsion and malignancy. Testicular torsion is a true urologic emergency, and as such, should be ruled out first. Torsion is usually, but not always, accompanied by the acute onset of severe pain, and the absence of the cremasteric reflex is the most useful physical exam finding.

If there is considerable delay (on the scale of hours) from the time of onset to accurate diagnosis and subsequent surgery, testicular viability may be lost. On the other hand, testicular (or scrotal) malignancy is not an emergency, but still requires definitive intervention and long-term follow-up. In this case, a missed or delayed diagnosis (on the scale of weeks to months) can result in significant morbidity and even mortality.

Testicular torsion and malignancy can often be diagnosed accurately based on history and physical. However, when either one of these conditions cannot be excluded based on history and physical alone, other diagnostic studies may be required. Scrotal ultrasonography almost always serves this purpose, but in the case of possible testicular torsion, should not delay surgical exploration.

Before evaluating the patient, review the important contents and anatomy of the scrotum. The scrotum may be conveniently divided into four separate compartments for illustrative purposes: testicular, paratesticular, spermatic cord, scrotal wall/skin. The testis is the only structure within the testicular compartment; tumor (almost always malignant), torsion of the testis or its appendage, and orchitis are the testicular conditions that may present as "scrotal masses/nodules".

The most notable paratesticular structure is the epididymis. Tumor (almost always benign), cysts, spermatocele, epididymitis, and torsion of the epididymal appendix all affect the epididymis and may present as a mass or nodule. The spermatic cord carries the vas deferens, lymphatics, arteries and pampiniform venous plexus from the testis and epididymis to the external inguinal ring. Hydroceles, hernias, varicoceles, and tumors (usually benign) all affect the spermatic cord and may present as a scrotal mass. Finally, scrotal wall cysts, sexually transmitted diseases and various skin conditions (including tumor rarely) may present as scrotal masses/nodules.

In short, once acute scrotal process has been ruled out, a scrotal mass should be regarded as cancer until proven otherwise by ultrasound or urologic examination.

A. History Part I: Pattern Recognition:

Important aspects of the history and physical examination are described below, followed by the conditions likely to present with that sign/symptom.When evaluating the patient, it is important to inquire about pain and the acuity of onset. Non-traumatic solid intratesticular masses are usually painless and likely represent malignancy. In contrast, traumatic injury, epididymo-orchitis and testicular torsion present with significant pain.

The onset of pain in torsion is more acute than that associated with epididymo-orchitis.The location of pain and any tenderness or edema is also important. Testicular torsion is likely if the entire testis is enlarged and tender to palpation, though epididymo-orchitis may have a similar presentation. In contrast, infection limited to the epididymis (epididymitis) and torsion of the testicular and epididymal appendages are likely to cause localized pain in the area of the epididymis or the superior aspect of the testis.

The presence or absence of urinary symptoms should be elicited. The presence of urinary symptoms increases the likelihood of an infectious etiology. The examiner should also evaluate the position of the testes themselves. An abnormal testicular lie may be seen with testicular torsion, while hernias and hydroceles may displace the testis or make the testis difficult to locate or non-palpable.

B. History Part 2: Prevalence:

Although young adults are most often affected, additional generalization regarding the prevalence of scrotal/testicular masses/nodules is difficult due to the heterogeneity of the various underlying conditions. Testicular torsion occurs most often in adolescents and young adults and is considerably less common in prepubertal males. Torsion of the testicular appendices can occur at any age, but is most common in children and is rare in adults. It occurs most commonly in prepubertal children and is the leading cause of acute scrotum in this age group.

Testicular or extratesticular (but intra-scrotal) malignancy can occur at any age, but is most common in men in their 20's and 30's. Epididymitis has a similar incidence in all ages between age 25 and 65 years, although the likely causative agents differ between younger and older men (see discussion on epididymitis). Hydroceles occur most often in infants and young boys, many times in association with an inguinal hernia. Hydroceles are more common in premature infants. Hydroceles also occur in adult males, where they are rarely indicative of malignancy or the result of previous varicocelectomy. Varicoceles are reported in approximately 10% to 15% of adolescents and men, though the true prevalence may be greater due to under-reporting.

C. History Part 3: Competing diagnoses that can mimic scrotal/testicular nodules or masses.

A focal scrotal abscess can feel like a scrotal mass. However, the typically obvious constellation of pain, swelling and induration with focal fluctuance will almost always elicit this process from other etiologies. In a diabetic, scrotal infection must be regarded with caution as it can evolve into necrotizing fasciitis (Fournier's gangrene) which is a life-threatening condition requiring emergent surgical intervention.

D. Physical Examination Findings.

An abnormal testicular position or lie should alert the examiner to the possibility of testicular torsion. On the other hand, the presence of an ipsilateral cremasteric reflex (drawing up of the testis and scrotum in response to stroking the superior and medial aspect of the thigh) almost always indicates the absence of testicular torsion and is the most valuable physical exam finding in ruling out this entity.

A blue dot visible near the superior pole of the testis likely represents underlying ischemic tissue and indicates torsion of one of the appendices.

Transillumination may be used in an attempt to differentiate solid from cystic scrotal masses. A penlight held against the scrotal skin will transilluminate the scrotum in cases of cystic masses but not in cases of solid masses. Therefore, transillumination may be indicative of a hydrocele or less likely a hernia, while the lack of transillumination makes a solid mass more likely.

Notably, 5-10% of testicular tumors present with an ipsilateral hydrocele which can obscure the tumor. Therefore, a thorough physical examination of a hydrocele is important. If the testis cannot be palpated through the hydrocele, scrotal ultrasound can clearly evaluate the testicular parenchyma.

E. What diagnostic tests should be performed?

Scrotal ultrasound with doppler flow studies. The threshold for ordering this study should be incredibly low as it is low cost, does not use ionizing radiation, and is able to rule out emergent processes in addition to diagnosing solid testicular/epididymal masses.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Urinalysis, urine culture and complete blood count help to differentiate infectious etiologies from non-infectious etiologies. Furthermore, in the case of infectious etiologies, urine culture results guide antimicrobrial selection. In some cases, a metabolic profile and coagulation studies may be useful. Renal function may be important in selecting an antibiotic and the appropriate dosing. Coagulation studies may be useful if hemorrhage or hematoma is suspected, if the patient is on anticoagulant therapy or if operative intervention is planned.

If a testicular mass is appreciated on clinical exam or scrotal ultrasound immediate urologic consultation should be rendered. If in-house urology is not available, prompt clinic follow-up for urologic evaluation is a must as expeditious surgical intervention is required. If urologic consultation is not immediately available and a testicular mass has been confirmed three tumor markers should be sent immediately (beta HCG, Alpha-feto protein and LDH) as this will aid the urologist upon initial consultation. In this scenario, a plain film of the chest should be obtained as well.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Please see discussion on ultrasonography above.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

As discussed above, ultrasound is a valuable tool in the diagnosis of scrotal/testicular masses. However, in many cases it is not necessary as the diagnosis can often be made by physical examination. Furthermore, when testicular torsion cannot be excluded by history and physical, the use of ultrasound should not delay surgical exploration, since testicular viability is at risk.

III. Default Management.

N/A

A. Immediate management.

Occasionally, a testicular mass can be mistaken for normal scrotal anatomy in a pathologic state. These conditions can collectively be considered the "acute scrotum" and typically refer to testicular torsion, torsion of the appendix testis or epididymo-orchitis (covered elsewhere).

Testicular torsion can occur at any age, but most commonly occurs in men under the age of 25. All new scrotal masses whose onset was sudden in nature should be considered torsion until proven otherwise. Torsion occurs spontaneously and often the anatomic anomaly found during exploration is an atypical insertion of the tunica vaginalis which can lead to a hyper-mobile testis. The classic physical exam finding is a high riding painful testicle in a lateral lie. Presence of an ipsilateral cremasteric reflex rules out torsion, however, the most accurate way to confirm presence of a torsion is a scrotal ultrasound with doppler flow study to evaluate for absence of arterial flow.

The gold standard treatment for testicular torsion is immediate scrotal exploration with detorsion and testicular fixation (almost always performed bilaterally). However, if a urologist is not readily available or there may be delay in getting to the operating room a manual trans-scrotal detorsion can be attempted. This should be done by grasping the testicle and rotating the anterior aspect laterally. Detorsion can be confirmed with doppler ultrasound. It should be noted that this maneuver is typically more forceful than the provider expects and in all likelihood will require significant pre-medication of the patient with pain medications.

The appendix testis is an embryologic remnant of the Mullerian duct that persists on the superior aspect of the testicle. While it has no functional purpose, it can spontaneously torse (much like a testicle). If testicular torsion can be ruled out, torsion of the appendix does not warrant exploration. The classic physical exam finding in young children is a "blue dot" sign, which as the name indicates, appears to be a blue dot at the top of the testicle from the ischemic appendix.

Epididymo-orchitis is discussed in depth in another chapter, however, it bears mention here as it can often present as a scrotal mass. The mainstay of treatment is medical/supportive in nature (antibiotics and symptom management). However, on rare occasion the acute scrotum can initially appear with what appears to be epididymitis and very rapidly degrade into a form of necrotizing fasciitis of the scrotum/perineum (Fournier's gangrene). Typified by rapidly progressive cellulitis, and often subcutaneous emphysema, with a strong predispostion to appearance in diabetis, Fournier's gangrene is a life-threatening surgical emergency that requires immediate and aggressive surgical debridement. This debridement is typically performed by a general surgeon, a trauma surgeon or a urologist. From a medical perspective, these patients need immediate broad spectrum antibiotics, large bore IV access, preparation for volume and pressure support, and anticipation for impending intubation. The morbidity and very high risk of mortality of this condition should not be underestimated.

B. Physical Examination Tips to Guide Management.

When performing a scrotal examination, the patient can be either supine or standing. The testicle is cupped in three fingers with the middle and index fingers posterior and the thumb anterior on the testicle. Once fixed, the thumb and contralateral hand can be used to palpate the entire surface of the testicle as well as gently grasp the epididymal head on the top of the testicle posteriorly. In order to feel the tail of the epidiymis it can be tracked down from the head OR the vas deferens can be palpated (it is the most posterior structure in the spermatic cord) and followed back down to the tail of the epididymis.

When an infectious etiology is identified, the patient's clinical examination should improve with antibiotic therapy, though improvement may take some time (e.g. epididymitis treatment is typically 10 days). If there is no improvement within several days, consider an alternate diagnosis or the presence of a resistant microorganism.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

Once again, when an infectious etiology is identified, systemic findings of infection (e.g. an elevated white blood count) should normalize with appropriate antibiotic therapy. However routine monitoring of such parameters is usually not necessary, especially in the context of clinical improvement.

D. Long-term management.

All scrotal masses require urologic evaluation and should not be managed on a "long-term" basis unless otherwise instructed by the consulting urologist.

E. Common Pitfalls and Side-Effects of Management

Pitfalls in the management of scrotal masses are rare, however, three in particular can have catastrophic consequences:

  • Failure to detect an infectious process: This scenario would be quite rare as untreated infection (whether it be an abscess or a case of epididymo-orchitis), will typically drive a patient back to care on the basis of clinical presentation alone.

  • Delay in referral: Cancer of the testicle and associated appendages can be quite aggressive and rapidly progressive in nature. Fortunately, we have highly effective multi-disciplinary treatment algorithms involving surgery, radiation and chemotherapy. Unfortunately, the nature of the organ system involved combined with the most commonly presenting age group (young and healthy men) lends itself to poor compliance with prompt follow-up. For this reason, although not emergent by nature, many clinicians will admit a patient with a newly diagnosed scrotal mass simply to obtain prompt urologic evaluation.

  • Transscrotal biopsy: This is absolutely contra-indicated under all circumstances. On rare occasion, a urologist may perform this procedure for very unique circumstances. In general transscrotal biopsy of a mass is associated with an increased rate of tumor seeding and should be regarded as an absolute contra-indication.

A. Renal Insufficiency.

Use caution when administering non-steroidal anti-inflammatory (NSAID) agents for pain control in patients with renal insufficiency.

B. Liver Insufficiency.

Not applicable.

V. Transitions of Care

A. Sign-out considerations While Hospitalized.

1. Completion of any work-up required to rule out acute processes such as vascular compromise (torsion) or infection (abscess).

2. Absolute confirmation that prompt urologic follow-up is confirmed if patient is not seen by urologist as an inpatient.

B. Anticipated Length of Stay.

In the event of infectious etiology, the patient can be discharged once only appropriate antibiotic therapy is performed, and if necessary surgical incision and drainage of any abscesses.

In the event of an actual solid mass, there is no absolute medical indication for admission, but prompt urologic evaluation and surgical resection are needed. For this reason, patients are often admitted for an expedited work-up.

C. When is the Patient Ready for Discharge.

The patient with a scrotal mass is ready for discharge once all causes of acute scrotum have been ruled out and once coordination of urologic care has been established.

D. Arranging for Clinic Follow-up

Prompt urologic clinic follow-up imperative for all scrotal/testicular nodules/masses.

1. When should clinic follow up be arranged and with whom.

As soon as possible with a urologist.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

Scrotal ultrasound should have already been performed on any patient being referred for a scrotal/testicular nodule/mass. Tumor markers (AFP, beta-HCG and LDH) in addition to a chest X-ray would be helpful to the urologist in the event of referral for a testicular mass.

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

Scrotal ultrasound should have already been performed on any patient being referred for a scrotal/testicular nodule/mass. Tumor markers (AFP,beta-HCG and LDH) in addition to a chest X-ray would be helpful to the urologist in the event of referral for a testicular mass.

E. Placement Considerations.

N/A

F. Prognosis and Patient Counseling.

Prognosis is highly dependent on pathology and staging of radical orchiectomy specimen. Overall, the modern multidisciplinary approach (surgery, chemotherapy and radiation therapy when appropriate) is highly effective in long-term cure of MOST testicular cancers. Patients with Stage I seminoma as well as non-seminoma both have greater than 98% 5-year survival. The figures drop to greater than 95% survival for stage IIA or IIB. Survival of stage IIC or III becomes dependent on risk status stratification, but remains high.

VI. Patient Safety and Quality Measures

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

In the event of scrotal masses that are found to be infectious in origin, focused antibiotic treatment (epididymo-orchitis) or surgical drainage (scrotal abscess) with good follow-up hygiene should prevent prior relapse. In a diabetic, good glycemic control will also yield lower rates of infection.

While there is no known prophylaxis for prevention of testicular masses, self examination will aid in early detection. Cryptorchidism (undescended testicle) does confer a higher incidence of testicular neoplasm. In the pediatric population, these patients should be referred for orchidopexy (may need to be staged). While this does not reduce the incidence of neoplasm, it does afford the patient the ability to perform self surveillance. In the adult male with a newly discovered cryptorchid testicle, radical orchiectomy is recommended for a testis that is not easily brought into the scrotum.

What's the evidence?

Richie, JP, Steele, GS. "Neoplasms of the Testis. In:". Campbell-Walsh Urology. Saunders Elsevier, Philadelphia. 2007. pp. 893-935.

Nickel, JC. "Inflammatory Conditions of the Male Genitourinary Tract: Prostatitis and Related Conditions, Orchitis, Epididymitis.". Campbell-Walsh Urology. Saunders Elsevier. 2007. pp. 304-329.

Weiss, JP, Kohn, IJ. "Urologic Emergencies.". Penn Clinical Manual of Urology.

Wieder, JA. "Testicular Tumors.". Pocket Guide to Urology.

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