Painless Scrotal Mass

History of present illness should address duration of symptoms, the effect of upright position and increase in intra-abdominal pressure, and presence and characteristics of associated symptoms such as pain.

Review of systems should seek symptoms suggesting possible causes, including abdominal pain, anorexia, or vomiting (inguinal hernia Hernias of the Abdominal Wall A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more with intermittent strangulation); dyspnea and leg swelling (right heart failure); abdominal distention (ascites Ascites Ascites is free fluid in the peritoneal cavity. The most common cause is portal hypertension. Symptoms usually result from abdominal distention. Diagnosis is based on physical examination and... read more ); and decreased libido, feminization, and infertility (testicular atrophy with bilateral varicoceles).

Past medical history should identify existing disorders that can cause masses (eg, right heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more , ascites causing bilateral lymphedema); known scrotal disorders (eg, testicular tumor Testicular Cancer Testicular cancer begins as a scrotal mass, which is usually not painful. Diagnosis is by ultrasonography. Treatment is with orchiectomy and sometimes lymph node dissection, radiation therapy... read more or epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more causing hydrocele); past history of pelvic surgery or radiation, and inguinal hernia.

Physical examination includes evaluation for systemic disorders that can cause edema (eg, heart failure, ascites) and detailed inguinal and genital examination.

Inguinal and genital examination should be done with patients standing and recumbent. The inguinal area is inspected and palpated, particularly for reducible masses. The testes, epididymides, and spermatic cords should be palpated for swelling, masses, and tenderness. Careful palpation can usually localize a discrete mass to one of these structures. Nonreducible masses should be transilluminated to help determine whether they are cystic or solid.

The following findings are of particular concern:

A nonreducible mass that obscures normal spermatic cord structures suggests an incarcerated inguinal hernia. If a mass is part of or attached to the testis and does not transilluminate, testicular cancer Testicular Cancer Testicular cancer begins as a scrotal mass, which is usually not painful. Diagnosis is by ultrasonography. Treatment is with orchiectomy and sometimes lymph node dissection, radiation therapy... read more is possible.

Other clinical characteristics can provide important clues (see table Some Causes of a Painless Scrotal Mass) Some Causes of a Painless Scrotal Mass . For example, a mass that transilluminates is probably cystic (eg, hydrocele, spermatocele). A mass that disappears or becomes smaller when recumbent suggests varicocele, inguinal hernia, or communicating hydrocele. The presence of a hydrocele makes assessment for other scrotal masses by examination difficult. Rarely, a varicocele persists when the patient is recumbent or is present on the right side; either finding suggests inferior vena caval obstruction.

Clinical evaluation may be diagnostic (eg, in varicocele, lymphedema Lymphedema Lymphedema is edema of a limb due to lymphatic hypoplasia (primary) or to obstruction or disruption (secondary) of lymphatic vessels. Symptoms and signs are brawny, fibrous, nonpitting edema... read more , inguinal hernia Hernias of the Abdominal Wall A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more ); otherwise, testing is typically done. Ultrasonography with Doppler imaging is done when:

If ultrasonography confirms a solid testicular mass, further testing is done for testicular cancer (see Testicular Cancer: Diagnosis Diagnosis Testicular cancer begins as a scrotal mass, which is usually not painful. Diagnosis is by ultrasonography. Treatment is with orchiectomy and sometimes lymph node dissection, radiation therapy... read more ), including the following: