What Are Scrotal Swellings?
A scrotal swelling refers to any abnormal enlargement or mass in the scrotum, which may involve the testicles, epididymis, or surrounding structures. Swellings may be painful or painless, hard or soft, and may or may not extend above the scrotum into the groin.
Because some causes—like testicular torsion or tumors—require urgent medical attention, understanding the nature and cause of scrotal swelling is essential for prompt and accurate treatment.
Categorizing Scrotal Swellings
Based on Location
- On the scrotum: Usually cutaneous or subcutaneous in origin (e.g., sebaceous cyst).
- In the scrotum: May involve the testis or epididymis.
- Extending above the scrotum: Suggests inguinoscrotal hernia.
Painful Scrotal Swellings
1. Torsion of Testis
A urological emergency mostly seen in adolescents. The testis twists on the spermatic cord, cutting off blood supply. Presents with:
- Sudden, severe scrotal pain
- Swelling and redness
- Testis lying transversely
- Absent cremasteric reflex
2. Torsion of Hydatid of Morgagni
Mimics testicular torsion but less severe. Affects prepubertal boys. A small, blue spot may be seen on the upper pole of the testis.
3. Epididymitis
Infection of the epididymis, usually in sexually active males or post-UTI. Features include:
- Gradual onset of pain
- Fever, scrotal erythema
- Relief on elevation (Prehn's sign)
- Bacterial causes: Coliforms, NSU (non-specific)
4. Orchitis
Inflammation of the testis, often due to viral infections like mumps or EBV. Can be bilateral. Bacterial causes: Coliform, Chlamydial.
Hard and Painless Scrotal Swellings
1. Testicular Tumour
Most common in men aged 20–50 years. Features include:
- Painless, hard mass
- May be associated with secondary hydrocele
- Possible lymphadenopathy
2. Syphilis and Tuberculosis
Chronic granulomatous infections causing firm, rubbery swelling. Rare in modern practice but still seen in endemic regions.
3. Haematoma
Post-trauma accumulation of blood, leading to firm, non-transilluminant swelling.
Soft Scrotal Swellings
1. Hydrocele
A collection of fluid around the testis, common in older men. Classic findings:
- Soft, cystic swelling
- Transilluminates brightly
- Testis may be difficult to palpate
2. Varicocele
Dilated veins of the pampiniform plexus. More common on the left side. Features:
- "Bag of worms" feel
- Worse with standing, better when lying down
- May cause infertility or discomfort
3. Epididymal Cyst
Fluid-filled cyst behind the testis. Features:
- Transilluminant
- Separate from testis
- Painless and smooth
Swellings Extending Above the Scrotum
Inguinoscrotal Hernia
Part of the bowel herniates into the scrotum. Clues include:
- Swelling that extends above and into the groin
- May be reducible
- Increases on coughing or straining
Scrotal Swellings in Specific Age Groups
| Age Group | Common Causes |
|---|---|
| Children | Torsion of testis, hydrocele, hernia |
| Adolescents | Torsion of testis, epididymitis |
| Young Adults | Tumors, trauma, infections |
| Elderly | Hydrocele, hernia, testicular cancer |
Key Physical Exam Findings
| Condition | Tenderness | Transillumination | Distinct Mass | Remarks |
|---|---|---|---|---|
| Torsion | Yes | No | Yes | Testis elevated, horizontal |
| Epididymitis | Yes | No | Yes | Pain relieved by elevation |
| Hydrocele | No | Yes | No | Testis not easily palpable |
| Varicocele | No | No | Yes | Bag of worms feel |
| Tumor | No | No | Yes | Hard, irregular, firm mass |
| Epididymal Cyst | No | Yes | Yes | Behind the testis |
Important Red Flags in Scrotal Swellings
- Sudden onset of severe pain (→ suspect torsion)
- Firm, non-tender swelling (→ possible tumor)
- Persistent swelling despite antibiotics
- Recurrent hydrocele in adults
- Signs of systemic infection or fever
Investigations for Scrotal Swelling
1. Blood Tests
- FBC: Detect infection or inflammation
- Tumor markers: AFP, β-hCG, LDH (for suspected testicular tumors)
2. Imaging
- Ultrasound with Doppler: Best non-invasive test for differentiating cystic vs solid, vascularity (torsion vs tumor)
- CT Scan: For tumor staging
- MRI (rare): Detailed soft tissue evaluation
3. Surgical Exploration
When torsion is strongly suspected, do not delay surgery for imaging. Time is testis.
Treatment Options
For Torsion
- Emergency surgical detorsion and fixation (orchidopexy)
- If necrotic: orchiectomy
For Infections (Epididymitis/Orchitis)
- Antibiotics: Based on suspected organisms (e.g., ceftriaxone + doxycycline)
- Supportive care: Rest, scrotal elevation, NSAIDs
For Hydrocele
- Observation (if asymptomatic)
- Surgery (hydrocelectomy) if large or painful
For Tumors
- Radical orchidectomy via inguinal route
- Further treatment depends on histology (chemo/radiotherapy)
For Varicocele
- Observation if asymptomatic
- Varicocelectomy if painful or causing infertility
FAQs on Scrotal Swellings
Q. Is every scrotal swelling an emergency?
A. No, but testicular torsion is. Always evaluate sudden painful swellings urgently.
Q. Can a scrotal swelling be cancerous?
A. Yes. Testicular tumors often present as painless, hard swellings.
Q. What does it mean if a swelling transilluminates?
A. Likely a fluid-filled structure, such as hydrocele or epididymal cyst.
Q. Can infections cause scrotal swelling?
A. Yes. Orchitis and epididymitis are common, especially in young sexually active men.
Q. What is the best test for scrotal swelling?
A. Scrotal ultrasound with Doppler is the investigation of choice.
