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Lumps in the groin and scrotum can occur at any age. Clinical assessment is needed to detect those which need urgent investigation or treatment. Usually a working diagnosis can be made clinically, and ultrasound is often helpful.
- Skin swellings, eg epidermal (sebaceous) cyst, contact dermatitis.
- Nontender nodes.
- Femoral hernia.
- Undescended, maldescended or ectopic testis.
- Femoral artery aneurysm.
- Saphena varix (varicosity of saphenous vein at the junction with the femoral vein).
- Torsion of testis.
- Torsion of a testicular or epididymal appendage.
- Epididymo-orchitis or orchitis.
- Strangulated inguinal hernia.
- Inguinal hernia (may sometimes be painful).
- Epididymal cyst.
- Spermatocele (feels similar to epididymal cyst).
- Testicular tumour.
- Haematoma (may also be painful).
- Skin swellings (as for groin lumps).
Less common causes of scrotal swelling include:
- Idiopathic scrotal oedema (mainly children).
- Squamous cell carcinoma of scrotum.
- Henoch-Schönlein purpura.
- Kawasaki's disease.
- Pancreatitis (fluid may track down the retroperitoneal compartment into the inguinal canal and scrotal sac).
- Complications of peritoneal dialysis and ventriculoperitoneal shunts.
- Crohn's disease manifestations: erythema nodosum and pyoderma gangrenosum.
- Familial Mediterranean fever.
- Metastases (mainly from penile lesions).
- Hidradenitis suppurativa.
- Congenital abnormalities of lymphatic vessels (Milroy's disease).
- Generalised oedema.
Anatomy of structures in the groin and scrotum
- Duration and speed of onset
- Change in size
- Does it reduce (eg on lying down)?
- Associated symptoms:
Examine the patient standing and supine - hernias, varicoceles and saphena varix are more prominent when the patient is standing.
Check the normal structures and landmarks, which are:
- Inguinal ligament
- Femoral artery
- Pubic tubercle
- Spermatic cord
When examining the lump, note:
- Tenderness: suggests infection or ischaemia, so think of testicular torsion, a strangulated hernia, epididymo-orchitis or psoas abscess.
- Location relative to landmarks. Femoral hernias are below and lateral to the pubic tubercle but, in practice, it is not always possible to distinguish inguinal and femoral hernias.
- Can you 'get above' the swelling (ie feel the upper border of it)? You cannot 'get above' a hernia.
- Is the lump separate from it?
- Testicular lie (may be transverse or high-riding in testicular torsion).
- Cremasteric reflex (if there is acute scrotal pain or swelling, suspect testicular torsion if the cremasteric reflex is absent).
- A cough impulse suggests hernia or saphena varix.
- Transillumination: cystic swellings such as hydroceles transilluminate well; solid tumours and most hernias don't; inguinal hernias in infants may transilluminate.
- Skin changes - a raised papule, plaque, or ulcer suggests scrotal cancer (rare).
- It is not necessary to distinguish between direct and indirect inguinal hernias.
- Varicoceles typically feel like a 'bag of worms' and are more often left-sided.
Scrotal swellings - urgent problems not to miss
Testicular torsionRequires a low threshold of suspicion and immediate referral:
- May be difficult to exclude on clinical grounds; may mimic epididymo-orchitis.
- Common in teenagers, rare >30 years of age.
- Sudden or gradual onset; may have had previous self-limiting pain episodes.
- Painful; usually severe pain, which may radiate to the abdomen; may have vomiting.
- Cremasteric reflex is almost always absent.
- Testis is often elevated or lying transversely.
- Neonates - testis is hard, nontender, and usually haemorrhagic.
- Most common in men aged 20-40 years; can occur in older men (usually lymphoma).
- Usually presents with testicular enlargement.
- Often painless and nontender; there may be a dragging sensation.
- May have back or flank pain, dyspnoea, supraclavicular lymphadenopathy, abdominal mass (enlarged para-aortic lymph nodes), weight loss, gynaecomastia, epididymo-orchitis, or hydrocele.
- On palpation, solid/firm swelling involving all or part of the testis.
Inguinal hernias in infants, or if strangulated/obstructed
- May enlarge with Valsalva-type manoeuvres, and disappear on lying down (if reducible).
- Positive cough impulse; bowel sounds on auscultation.
- May be features of strangulation or obstruction (abdominal pain and/or intestinal obstruction symptoms).
- Cannot get above the swelling.
Squamous cell carcinoma of the scrotum
- Extremely rare; usually only in men aged >50 years.
- Raised papule, plaque, or ulcer on the scrotal wall; often purulent.
- Inguinal lymphadenopathy may be present (due to metastases or infection).
- Clinically suspected testicular cancer - do not wait for investigations, but refer urgently to be seen within 2 weeks by an urologist.
- Where diagnosis is unclear, request urgent ultrasound of the scrotum and/or groin (almost 100% sensitive for testicular tumours). This is useful, for example, where the body of the testis cannot be distinguished or where it is not clear whether the swelling is testicular or extratesticular, and for hydroceles in adults (to exclude testicular cancer).
- Alpha-fetoprotein (AFP) and beta-hCG are tumour markers for testicular cancer - can arrange a blood test while awaiting appointment.
- Acute lymphadenopathy may need investigation for limb or genital/sexually transmitted infection.
- Persistent unexplained lymphadenopathy needs biopsy.
- Inguinal hernias in baby girls probably merit investigation for androgen insensitivity syndrome.
This depends on the diagnosis, but note that:
- Immediate referral is necessary for:
- Suspected torsion of the testis.
- Strangulated or obstructed hernia.
- Urgent referral/investigation is needed for:
- Femoral hernias:
- These are more likely to strangulate than inguinal hernias; if suspected, they should be referred to consider surgery.
- In infants, these usually resolve spontaneously.
- Hydroceles occurring in adults may be secondary to testicular tumour or infection and should be investigated - request urgent ultrasound for hydrocele in men aged 20-40 years.
Testicular cancer may present as a painless testicular swelling, and is often curable if treated early. Testicular self-examination may have a role in the early detection of testicular cancer. As for any lump, early consultation for testicular swellings should be encouraged.
Further reading & references
- Nicks BA et al; Hernias, Medscape, Jun 2012
- Tiemstra JD, Kapoor S; Evaluation of scrotal masses. Am Fam Physician. 2008 Nov 15;78(10):1165-70.
- Muttarak M, Chaiwun B; Painless scrotal swelling: ultrasonographical features with pathological correlation. Singapore Med J. 2005 Apr;46(4):196-201; quiz 202.
- Henry & Thompson, Clinical Surgery: second edition. Elsevier Saunders, 2005. ISBN 0702027197
- Scrotal swellings, Clinical Knowledge Summaries (February 2010)
- Viswaroop BS, Kekre N, Gopalakrishnan G; Isolated tuberculous epididymitis: a review of forty cases. J Postgrad Med. 2005 Apr-Jun;51(2):109-11, discussion 111.
- Dayanir YO, Akdilli A, Karaman CZ, et al; Epididymoorchitis mimicking testicular torsion in Henoch-Schonlein purpura. Eur Radiol. 2001;11(11):2267-9.
- Majeed HA, Rawashdeh M, el-Shanti H, et al; Familial Mediterranean fever in children: the expanded clinical profile. QJM. 1999 Jun;92(6):309-18.
- Jenkins JT, O'Dwyer PJ; Inguinal hernias. BMJ. 2008 Feb 2;336(7638):269-72.
- Essential paediatrics, fourth edition. Churchill Livingstone 2000
- Deeb A, Hughes IA; Inguinal hernia in female infants: a cue to check the sex chromosomes? BJU Int. 2005 Aug;96(3):401-3.
- Ortenberg J et al; Pediatric Hydrocele and Hernia Surgery, Jan 2012
- Dawson C, Whitfield H; ABC of urology. Urological malignancy--III: Renal and testicular carcinoma. BMJ. 1996 May 4;312(7039):1146-8.
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Dr Naomi Hartree
Dr Naomi Hartree