Assessment of a Testicular Mass

Dr. Saifulla Syed

 Introduction

• Scrotal swellings – common presentation in clinical practice

• Varied etiology
• Must not miss conditions – Testicular torsion, acute epididymo-
orchitis and testicular malignancy
 History

• Age
• Onset and duration
• Painful / painless
• Predisposing factors
• Urinary symptoms
• Systemic symptoms
• Masses anywhere else
 Examination

• Scrotal skin
• To get above the swelling – differentiate scrotal from inguino-
scrotal swelling
• Testis/epididymis/cord
• Is the testis palpable separate from the swelling
• Tenderness
• Fluctuation
• Transillumination
• Testicular sensation
• Any other masses – ab / supraclavicular
 Differential Diagnosis

• Hydrocele
• Hematocele
• Pyocele
• Epididymal cyst
• Spermatocele
• Epididymo-orchitis
• Testicular torsion
• Testicular malignancy
• Varicocele
 Investigations

• Baseline bloods ± Tumor markers (AFP, ß HCG, LHD)

• Urinalysis
• Scrotal U/S
• Chest x-ray
• CT scan
 Hydrocele

• Age gp – middle age and later life, gradual onset, long duration
• Clinical features –
• Loss of rugosity, otherwise normal scrotal skin
• Tense swelling – discomfort/pain
• Fluctuation +
• Transillumination +
• Cannot feel testis apart from the swelling
• Testicular sensation +
• Management
• Surgical – Excision and eversion of the sac
Lord’s plication
• Tapping
 Hematocele

• Age gp – middle age, sudden onset, short duration

• Clinical features –
• Loss of rugosity ±
• Painful swelling
• Fluctuation ±
• Transillumination –
• Cannot feel testis apart from the swelling
• Testicular sensation +
• Management
• Surgical – Evacuation of hematocele/hematoma
 Pyocele

• Age gp, sudden onset, short duration, systemic symptoms ±

• Clinical features –
• Loss of rugosity ±, erythematous and odematous scrotal skin
• Painful swelling
• Fluctuation +
• Transillumination –
• Cannot feel testis apart from the swelling
• Testicular sensation +
• Management
• Surgical – Drainage
 Epididymal Cyst

• Age gp – middle age, gradual onset, long duration

• Clinical features –
• Loss of rugosity, otherwise normal appearing scrotal skin
• Tense swelling – discomfort/pain
• Fluctuation +
• Transillumination ++
• Can feel testis apart from the swelling
• Testicular sensation +
• Management
• Surgical – Excision
 Spermatocele

• Age gp – middle age, gradual onset, long duration

• Clinical features –
• Loss of rugosity, otherwise normal appearing scrotal skin
• Tense swelling – discomfort/pain
• Fluctuation +
• Transillumination – poor
• Can feel testis apart from the swelling
• Testicular sensation +
• Management
• Surgical – Excision
 Epididymo-orchitis

• Age gp – young men, middle and elderly, sudden onset, short

duration, urinary/systemic symptoms
• Clinical features –
• Erythematous scrotal skin with normal rugosity
• Painful swelling
• Fluctuation –
• Transillumination –
• Tender swollen epididymis ± testis
• Testicular sensation +
• Elevation of testicle releaves pain
• Management
• Conservative – Anti-inflammatory/analgesics, antibiotics, scrotal
elevation
 Testicular Torsion

• Age gp – 10 to 25 yrs, acute onset, short duration

• Clinical features –
• Normal appearing scrotal skin
• Acutely painful scrotal swelling; ab pain (misleading presentation)
• Fluctuation and Transillumination –
• Tender swollen high lying testis, difficult to differentiate cord
structures
• Testicular sensation +
• Elevation of testicle worsens pain
• Management
• Urgent exploration, untwist the torsion and bilateral orchidopexy (±
orchidectomy if the testis is non viable)
 Testicular Malignancy

• Age gp – 20 to 45 yrs, gradual onset, long duration

• Clinical features –
• Normal appearing scrotal skin
• Painless swelling
• Fluctuation –
• Transillumination –
• Firm/hard irregular enlarged testis
• Testicular sensation –
• Ab mass ± neck mass
• Management
• High orchidectomy, CT/RT, RPLND
 Varicocele

• Age gp – adolesence or early adulthood, gradual onset, long duration

• Clinical features –
• Normal appearing scrotal skin
• Swelling +, discomfort/pain
• Fluctuation –
• Transillumination –
• Can feel testis apart from the swelling
• Testicular sensation +
• “Bag of worms” feel
• Management
• Ligation of testicular vein (inguinal canal / retroperitoneal)
Thank you