10 - Scrotal Mass

Authors: Macfarlane, Michael T.

Title: Urology, 4th Edition

Copyright 2006 Lippincott Williams & Wilkins

> Table of Contents > Part One - Chief Presentations > Chapter 10 - Scrotal Mass

Chapter 10

Scrotal Mass

Scrotal pathology is a common cause of referral to the urologist. Patients will either present with a mass in the scrotum, with or without pain, or with an empty scrotum (cryptorchidism), which is covered in the next chapter. When evaluating a scrotal mass, always work through the complete differential diagnosis. This helps avoid the significant consequences of misdiagnosing testicular torsion or tumor. A thorough understanding of each pathologic condition is the best tool for correct diagnosis.

Review of Pathology

Testicular Torsion

Torsion refers to a twisting of the testis and spermatic cord around a vertical axis, resulting in venous obstruction, progressive swelling, arterial compromise, and eventually testicular infarction. Torsion must be considered in the initial diagnosis of any scrotal pathology because without immediate detorsion, the testis will be lost. Two types of torsion occur: extravaginal and intravaginal.

Extravaginal Torsion

Extravaginal torsion occurs in neonates (and occasionally in utero) because of incomplete attachment of the gubernaculum and testicular tunics to the scrotal wall. This incomplete attachment leaves the testis, epididymis, and tunica vaginalis free to twist within the scrotum. Extravaginal torsion accounts for fewer than 10% of all cases of testicular torsion. Infants typically present in minimal distress with a firm, painless scrotal mass that does not transilluminate. Most of these testes will be gangrenous at exploration, and the salvage rate is poor. Early recognition of postnatal torsion is a clear indication for surgery because of the increased chance for testicular salvage. However, intrauterine torsion rarely results in testicular salvage, so the indications for surgery are less clear. Removal of the infarcted testis has been recommended by

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some authors because of the theoretic concern for autoimmune damage to the contralateral testis, with resultant fertility problems in the adult.

Intravaginal Torsion

This condition can occur at any age but is most common among adolescents. It is the result of an abnormally narrowed testicular mesentery, with the tunica vaginalis almost completely surrounding the entire testis and epididymis. This narrowed mesentery facilitates twisting of the testis within the tunica vaginalis about its vascular pedicle and gives an appearance termed the bell-clapper deformity.

Diagnosis

The typical patient presents with sudden onset of pain and swelling, occasionally associated with some minor trauma. The testis will be tender, is often high in the scrotum because of shortening by the twisted cord, and may have a transverse lie or an anteriorly positioned epididymis. Urinalysis is usually negative. Elevation of the scrotum will not relieve the pain (negative Prehn's sign). Color-flow Doppler ultrasonography should be obtained without hesitation and has become the test of choice. A radionuclide testicular scan may be useful in equivocal cases if performed early after the onset of symptoms and before significant reactive hyperemia of the scrotal skin occurs. Surgical exploration is the best diagnostic test and should not be delayed if this diagnosis is seriously considered.

Treatment

Treatment consists of immediate detorsion. Correction within 6 hours of onset of pain usually results in a normal testis. Delay for more than 12 hours results in poor testicular salvage (~20%). Manual detorsion can be attempted by either lifting the scrotum or rotating the testis about its vascular pedicle. Successful manual detorsion must still be followed by surgical orchiopexy. An unsuccessful attempt at manual detorsion requires immediate surgical exploration. The clearly infarcted testis should be removed; however, if viability is in doubt, it should be left in situ because Leydig cell function may be preserved. After detorsion, the testis should be fixed to the scrotal wall with two to

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three nonabsorbable sutures to prevent repeated torsion. The contralateral testis must also be fixed because of the high incidence of its subsequent torsion.

Testicular Appendages

The five potential testicular appendages are as follows: (a) appendix testis, (b) appendix epididymis, (c) paradidymis organ of Giraldes, (d) superior Haller's vas aberrans, and (e) inferior Haller's vas aberrans. Only the appendix testis and the appendix epididymis are regularly found. Their only importance is that they also can undergo torsion and mimic testicular torsion. Torsion of the appendix testis is by far the most common and typically occurs as acute onset of scrotal pain in an adolescent. Generally, a tender, pea-sized nodule can be palpated near the upper pole of the testis. An infarcted appendage can often be seen as a small blue-black dot through the scrotal skin (blue dot sign). Color-flow Doppler ultrasound should be performed to confirm blood flow to the testis. If the diagnosis is doubtful, surgical exploration should be performed to rule out testicular torsion; otherwise, conservative management may be considered. If surgery is performed, the infarcted appendage should simply be excised.

Testicular Tumors

Testicular cancers (see Chapter 26) usually are discovered as an incidental finding of a painless lump or nodule in the scrotum of a male aged 20 to 40 years. The lump or nodule may be accompanied by a heavy sensation or dull ache in the lower abdomen. Occasionally, testis cancers present with acute pain secondary to rapid growth, with hemorrhage and necrosis. More commonly, however, they are hard, nontender nodules localized to the testis. They do not transilluminate, yet an associated hydrocele may occur. Up to 10% of testis cancers will present initially with epididymitis. Benign testicular tumors are rare (<1%) and include teratoma of childhood, epidermoid cyst, dermoid cyst, simple testicular cyst, cyst of tunica albuginea, and adenomatoid tumor. Testicular ultrasound should be performed. The pathologic diagnosis is made by radical inguinal orchiectomy. Consider all testicular masses malignant until proven otherwise.

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Inguinal Hernia

An inguinal hernia often is first seen as a scrotal mass secondary to loops of bowel within the scrotum. Indirect inguinal hernias may be secondary to a patent processus vaginalis or protrusion of a new peritoneal process following the same path along the cord into the scrotum. Direct inguinal hernias result from weakness of the transversalis fascia at Hesselbach's triangle, with peritoneal outpouching into the area of the external ring only, rarely descending into the scrotum. An inguinal hernia that cannot be reduced is said to be incarcerated. If the vascular supply of the herniated organ (usually bowel) is compromised, it is said to be strangulated a surgical emergency.

Epididymitis

Acute epididymitis may present in any age group as sudden onset of pain and swelling in the scrotum (refer to Chapter 17). Urinalysis is usually positive for inflammatory cells, and temperature is often elevated. A urethral discharge or irritative voiding symptoms are common. Elevation of the scrotum may decrease the patient's pain (positive Prehn's sign). Early, the swelling and tenderness can often be localized to the tail of the epididymis; however, this distinction blurs as the infection progresses. An inflammatory hydrocele may develop within a few days. Fixation of the testicle to the scrotal wall suggests abscess formation. Color-flow Doppler testicular ultrasound can help make the diagnosis by demonstrating increased blood flow.

Hydrocele

A hydrocele is a fluid collection within the tunica vaginalis surrounding the testis. It presents as a painless swelling of the scrotum that transilluminates. It often makes testicular palpation difficult and can conceal an underlying testicular tumor.

Congenital or Infant Hydroceles

Congenital or infant hydroceles are usually the result of peritoneal fluid accumulation within the scrotum via a patent processus vaginalis and occur in 6% of full-term boys. Their size often changes from day to day or with recumbency. Treatment should be delayed during the first year of life because normal

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spontaneous closure of the processus vaginalis may occur. After 1 year, surgical ligation of the processus vaginalis should be undertaken.

Acquired or Adult Hydroceles

Acquired or adult hydroceles are usually idiopathic but may be secondary to tumor, infection, or systemic disease. An imbalance in fluid secretion and absorption by the tunica vaginalis has been suggested as a possible cause. Treatment is generally indicated to allow easy palpation of the testis or because of symptomatic discomfort or disfigurement. Simple needle aspiration is an effective temporary treatment; however, the hydrocele will often recur. Injection of a sclerosing solution after aspiration can be successful in coapting the visceral and parietal layers of the tunica vaginalis and preventing reaccumulation of fluid. A mixture of 250 mg tetracycline diluted in 5 mL 0.5% bupivacaine (Marcaine) is often effective and minimizes the pain that accompanies injection. Sclerosing therapy is contraindicated with a patent processus vaginalis or an associated hernia. Definitive therapy is surgical drainage and excision of tunica vaginalis.

Spermatocele

A spermatocele is an epididymal retention cyst that arises from the efferent ductules and holds a cloudy fluid containing spermatozoa. It presents as a painless, cystic mass that lies above and anterior to the testis. Ultrasound can confirm the diagnosis if doubt exists. Treatment consists of spermatocelectomy and epididymectomy for extensive involvement. Aspiration or sclerosing therapy may result in epididymitis. Therapy should be avoided in young male patients concerned with fertility.

Varicocele

A varicocele is an abnormal dilatation of the veins of the pampiniform plexus and internal spermatic vein of the spermatic cord. Left-sided varicoceles are most common, occurring in approximately 15% of normal adult men. Unilateral right-sided varico-celes are rare (noted in only 2% of cases) and should suggest the possibility of compression or obstruction of the inferior vena cava (e.g., tumor or thrombus). Physical examination makes the diagnosis. Dilated veins are best palpated with the patient standing and aided by a Valsalva maneuver. Varicoceles have been

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described as feeling like a bag of worms. The significance of a varicocele is its association with infertility. Indications for varicocelectomy include oligospermia, decreased sperm motility, and a painful symptomatic varicocele.

Trauma

Patients may have pain and swelling after blunt trauma to the scrotum. Differentiating a simple scrotal contusion from a fracture of the testicle can be difficult. Ultrasound can be helpful. Testicular fracture is almost always associated with a hematocele and should undergo surgical exploration. Simple contusions can be treated conservatively. Testicular torsion should always be suspected in the patient who has pain after minor scrotal trauma.

Paratesticular Tumors

Paratesticular tumors account for fewer than 10% of all intrascrotal tumors and can generally be differentiated from intratesticular masses by palpation and ultrasound. The adenomatoid tumor and lipoma of the cord are most common. Malignant tumors include rhabdomyosarcoma, fibrosarcoma, liposarcoma, and leiomyosarcoma.

Scrotal Edema

Lymphedema of the scrotum can present as markedly enlarged bilateral scrotal sacs. Potential causes include obstruction secondary to inflammation (filariasis, lymphogranuloma, tuberculosis, or syphilis), neoplasia, surgical procedures, or radiation.

Diagnosis

The basic workup of a patient with scrotal pathology follows:

• History

• Physical examination with transillumination of the scrotum (use high-intensity light source if available)

• Urinalysis

• Color-flow Doppler ultrasound

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The single most helpful piece of information is whether the patient has pain. A history of recent significant trauma also will narrow the diagnosis. Color-flow Doppler ultrasound is the best test to aid in the diagnosis of scrotal pathology.

Differential Diagnosis

Painful Scrotal Mass			Painless Scrotal Mass
Testicular torsion			Testicular tumor
Epididymitis			Hydrocele
Inguinal hernia			Inguinal hernia
Testicular tumor (rapidly growing)			Spermatocele
Trauma (testicular rupture)			Varicocele
			Paratesticular tumors
Pathology	Pain	Trans- illumination	Urinalysis	Ultrasound	Blood Flow
Testicular torsion	Yes	No		Solid	Negative
Testicular tumor	No	No	Negative	Solid	Normal
Testicular rupture	Yes	No	Negative	Complex
Epididymitis	Yes	No	Positive	Complex	Increased
Hydrocele	No	Yes	Negative	Cyst	Normal
Spermatocele	No		Negative	Cyst	Normal
Inguinal hernia			Negative	Complex	Normal