Evaluation of Scrotal Masses



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Scrotal masses are caused by a variety of disorders, ranging from benign conditions to those requiring emergent surgical intervention. Painful scrotal masses require urgent evaluation. Characteristics that suggest testicular torsion include rapid symptom onset, nausea and vomiting, high position of the testicle, and abnormal cremasteric reflex. Doppler ultrasonography or surgical exploration is required to confirm the diagnosis. Surgical repair must occur within six hours of symptom onset to reliably salvage the testicle. Epididymitis/orchitis have a slower onset and are associated with a C-reactive protein level greater than 24 mg per L (228.6 nmol per L) and increased blood flow on ultrasonography. Acute onset of pain with near normal physical examination and ultrasound findings is consistent with torsion of the testicular appendage. Testicular malignancies cause pain in 15% of cases. If ultrasonography shows an intratesticular mass, timely urology referral is indicated. Inguinal hernias are palpated separate to the testicle and can cause pain. Emergent surgery is indicated for a strangulated hernia. Hydrocele, varicocele, and scrotal skin lesions may be managed in nonurgent settings. A biopsy should be performed to rule out cancer in patients with scrotal skin lesions that are erosive, vascular, hyperkeratotic, or nonhealing, or that change color or have irregular borders.

Scrotal masses are a common presentation in primary care, and a painful scrotum accounts for 1% of emergency department visits.1 Some causes of scrotal masses require rapid diagnosis and treatment to avoid loss of fertility or other complications.16  Table 1 summarizes the causes of scrotal masses.1,2,4,68

Normal testes are firm but not hard, nearly equal in size, smooth, and ovoid. Normal testicular length ranges from 1.5 to 2 cm before puberty and from 4 to 5 cm after puberty. The epididymis is posterolateral to the testicle; the epididymis and testicle are separated but attached. The vas deferens emanates from the tail of the epididymis and joins the vascular pedicle of the testicle to form the spermatic cord. The spermatic cord travels superiorly to the inguinal canal.3 Figure 1 illustrates the anatomy of the scrotum.9

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Epididymitis/orchitis should be suspected in patients with testicular pain and a C-reactive protein level of more than 24 mg per L (228.6 nmol per L).

C

7

Any patient presenting with acute scrotal pain and a mass or swelling should be evaluated for testicular torsion by scrotal ultrasonography or surgical exploration within six hours of symptom onset.

C

1, 12

Testicular torsion should be suspected in patients with rapid onset of acute unilateral scrotal pain and swelling, nausea or vomiting, high position of the testicle, and an abnormal cremasteric reflex.

C

1, 12


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Epididymitis/orchitis should be suspected in patients with testicular pain and a C-reactive protein level of more than 24 mg per L (228.6 nmol per L).

C

7

Any patient presenting with acute scrotal pain and a mass or swelling should be evaluated for testicular torsion by scrotal ultrasonography or surgical exploration within six hours of symptom onset.

C

1, 12

Testicular torsion should be suspected in patients with rapid onset of acute unilateral scrotal pain and swelling, nausea or vomiting, high position of the testicle, and an abnormal cremasteric reflex.

C

1, 12


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1.

Overview of the Causes of Scrotal Masses

CauseClinical presentationDiagnosisTreatment

Testicular torsion

Acute unilateral pain and swelling

Abnormal cremasteric reflex

High position of the testicle

Nausea/vomiting

See Table 2

Clinical, with or without ultrasonography

Surgery

Epididymitis/orchitis

Acute unilateral pain and swelling

Dysuria

Erythema of the scrotal skin

Fever

Clinical, with or without ultrasonography

Ceftriaxone (Rocephin) and doxycycline

Torsion of the testicular appendage

Acute unilateral pain

Blue dot sign (i.e., bluish discoloration of the scrotum over the superior pole)

Ultrasonography

Pain control

Hematocele or testicular rupture

History of trauma

Pain and swelling

The Authors

PAUL CRAWFORD, MD, is program director of the Nellis Family Medicine Residency in Las Vegas, Nev. He is an associate professor at the Uniformed Services University of the Health Sciences in Bethesda, Md.

JUSTIN A. CROP, DO, is a faculty member at the Nellis Family Medicine Residency. He is an assistant professor at the Uniformed Services University of the Health Sciences.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, Navy, or Air Force Medical Departments or the U.S. Army, Navy, Air Force, or Public Health Service.

Address correspondence to Paul Crawford, MD, Nellis Family Medicine Residency, 4700 Las Vegas Blvd. N, Nellis AFB, NV 89191 (e-mail: paul.crawford@us.af.mil). Reprints are not available from the authors.

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