Lumps in the Groin and Scrotum

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.

Groin lumps

Painful lumps:

• Tender lymph nodes
• Strangulated femoral hernia
• Psoas abscess

Painless lumps:

• Skin lumps e.g. epidermal (sebaceous) cyst
• Non-tender nodes
• Femoral hernia
• Undescended, maldescended or ectopic testis
• Vascular:
  • Femoral artery aneurism
  • Saphena varix (varicosity of saphenous vein at junction with femoral vein)

Scrotal lumps

Painful lumps:

• Torsion of testis
• Epididymo-orchitis or orchitis
• Strangulated inguinal hernia

Painless lumps:

• Inguinal hernia (may sometimes be painful)
• Hydrocoele
• Epididymal cyst
• Spermatocoele (feels similar to epididymal cyst)
• Varicocele
• Testicular tumour
• Haematoma (may also be painful)

History

• Duration
• Change in size
• Pain
• Does it reduce (e.g. on lying down)?
• Any abdominal symptoms - e.g. torsion of testis may have pain referred to abdomen; intestinal obstruction symptoms likely with strangulated hernia.
• For adults with hernias: occupation, hobbies, how bothersome are the symptoms, any illness affecting fitness for surgery?

Examination¹

Examine patient standing and supine - accentuates varicocoeles and saphena varix, which are more prominent standing.

Check the normal structures and landmarks, which are:

• Inguinal ligament
• Femoral artery
• Pubic tubercle
• Testis
• Epididymis
• 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 the testis?
• A cough impulse suggests hernia or saphena varix.
• Transillumination: cystic swellings such as hydrocoeles transilluminates well; solid tumours and most hernias don't. However, inguinal hernias in infants may transilluminate.²
• It is not necessary to distinguish between direct and indirect inguinal hernias.
• Varicocoeles typically feel like a 'bag of worms' and are more often left-sided.

If appropriate, first-line investigations are:

• Ultrasound of scrotum and/or groin
• If testicular tumour suspected, blood for AFP (alfa-fetoprotein) and β-HCG. These are tumour markers for testicular cancer.

Note that:

• Acute lymphadenopathy may need investigation for limb or genital infection.
• Persistent unexplained lymphadenopathy needs biopsy.
• Inguinal hernias in baby girls probably merit investigation for androgen insensitivity syndrome.⁴

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:
  • Scrotal swellings unless diagnosis known, to exclude testicular cancer
  • Inguinal hernias in infants (need urgent elective repair as high risk of strangulation)²
• Femoral hernias:
  • These are more likely to strangulate than inguinal hernias; if suspected they should be referred to consider surgery.
• Hydroceles:⁵
  • In infants, these usually resolve spontaneously.
  • Hydrocoeles occurring in adults may be secondary to testicular tumour or infection and should be investigated (ultrasound is useful).

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.