Scrotal and testicular masses can be broadly categorized into painful and painless presentations. Although this classification is useful, any condition discussed may cause discomfort, and the presence or absence of pain alone is insufficient to confirm or exclude a diagnosis. Family physicians should be familiar with the different types of scrotal masses to differentiate among conditions requiring emergent intervention, non-urgent treatment, and those that may be safely monitored. The anatomy of the scrotum is depicted in Figure 1.¹

Approach To Evaluation

In addition to the presence or absence of pain, patients should be asked about exacerbating and remitting factors, chronicity of symptoms, constitutional symptoms, abdominal pain, dysuria, and hematuria. The physical examination should include visual inspection and palpation of the testicles and spermatic cords for nodules or masses. An intact cremasteric reflex is present when pinching or stroking the inner thigh causes contraction of the cremaster muscle, pulling the ipsilateral testicle toward the inguinal canal; its absence may be associated with testicular torsion. If testicular pain improves with elevation of the testicle, this is a positive Prehn sign, which is associated with an increased risk of acute epididymitis. The inguinal canal should be palpated for evidence of a hernia. Fluid-containing masses such as hydroceles will transilluminate with a penlight.

Ultrasonography is the imaging test of choice for any suspected scrotal mass, and simultaneous Doppler imaging is used to confirm the presence or absence of adequate perfusion.² Laboratory testing is generally restricted to cases of suspected infection or malignancy.

Figure 2 provides a suggested approach to evaluate scrotal masses.³

Painful Masses

Painful masses include testicular torsion, torsion of the testicular appendage, and epididymitis.

TESTICULAR TORSION

Testicular torsion is defined as a twisting of the spermatic cord around its longitudinal axis, causing venous congestion, reduced arterial blood flow, and eventual ischemia of the testicle. Torsion accounts for about 20% of childhood emergency department visits for acute scrotal pain.⁴ The incidence in males younger than 25 years is approximately one in 4,000, but torsion occurs most frequently in adolescence.⁵ Risk factors include a family history of torsion, a hyperactive cremasteric reflex in the setting of cold weather, antecedent trauma, and the bell-clapper deformity (excessive mobility of the testicle due to abnormal anchoring).⁶

Patients with torsion typically present with severe, acute, unilateral scrotal pain of less than 24 hours' duration accompanied by nausea, vomiting, and scrotal swelling.⁴ The affected testicle is usually high-riding and in transverse lie.⁴ Absence of the ipsilateral cremasteric reflex had an odds ratio of 47.6 for diagnosing torsion in one study.⁷ The Testicular Workup for Ischemia and Suspected Torsion score should be used during the initial evaluation of an acute scrotum to predict the risk of torsion (Table 1).⁸

Urgent urologic consultation is recommended before imaging in cases with a high clinical suspicion of torsion.⁴ In intermediate-risk cases, high-resolution color Doppler ultrasonography is the test of choice to evaluate testicular blood flow, with an estimated sensitivity of 100% and specificity of 97.9% for detecting torsion.⁹

If the affected testicle is not necrotic and does not require removal, surgical detorsion and orchiopexy are the treatments of choice. Surgery should be done within six hours of presentation when the testicular salvage rate is approximately 90%.¹⁰ The salvage rate decreases significantly at 12 hours (50%) and 24 hours (10%).¹¹ Bilateral orchiopexy is typically done to prevent torsion of the contralateral testicle in the future.⁶ Although manual detorsion can be attempted, it is not considered definitive treatment, and any attempt should not delay surgical evaluation and treatment.⁵