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.

Aetiology

Groin lumps

Painful lumps:

• Tender lymph nodes.
• Strangulated femoral hernia.
• Psoas abscess.

Painless lumps:

• Skin swellings, e.g. epidermal (sebaceous) cyst, contact dermatitis.
• Nontender nodes.
• Femoral hernia.
• Undescended, maldescended or ectopic testis.
• Vascular:
  • Femoral artery aneurysm.
  • Saphena varix (varicosity of saphenous vein at the junction with the femoral vein).

Scrotal lumps¹

Painful lumps:

• Torsion of testis.
• Torsion of a testicular or epididymal appendage.
• Epididymo-orchitis or orchitis.
• Strangulated inguinal hernia.

Painless lumps:

• Inguinal hernia (may sometimes be painful).
• Hydrocele.
• Epididymal cyst.
• Spermatocele (feels similar to epididymal cyst).
• Varicocele.
• 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.
• Infections:
  • Syphilitic gumma of the testis (round, hard, insensitive mass, indistinguishable from a tumour).
  • Tuberculous epididymitis.²
  • Filariasis.
• Henoch-Schönlein purpura.³
• 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.
• Sarcoidosis.
• Familial Mediterranean fever.⁴
• 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

Assessment¹

History

• Pain
• Duration and speed of onset
• Change in size
• Does it reduce (e.g. on lying down)?
• Associated symptoms:
  • Urethral discharge or dysuria (suggests epididymo-orchitis).
  • Abdominal pain, nausea and vomiting (can occur with testicular torsion).
  • Back pain, weight loss, dyspnoea (can occur with metastatic testicular cancer).
  • Parotid swelling (mumps orchitis).

Examination⁵

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
• 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 (i.e. feel the upper border of it)? You cannot 'get above' a hernia.
• Testis:
  • 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.⁶
• 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.

Investigations

• Clinically suspected testicular cancer - do not wait for investigations, but refer urgently to be seen within 2 weeks by an urologist.¹
• 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).¹
• Alpha-fetoprotein (AFP) and beta-hCG are tumour markers for testicular cancer - can arrange a blood test while awaiting appointment.¹
• 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.⁷

Management

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 the diagnosis is known, to exclude testicular cancer:¹
  • Inguinal hernias in infants (need urgent elective repair as there is high risk of strangulation).⁸
• Femoral hernias:
  • These are more likely to strangulate than inguinal hernias; if suspected, they should be referred to consider surgery.
• Hydroceles:⁸
  • 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.¹

Prevention⁹

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.

Document references

1. Scrotal swellings, Clinical Knowledge Summaries (February 2010)
2. 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. [abstract]
3. Dayanir YO, Akdilli A, Karaman CZ, et al; Epididymoorchitis mimicking testicular torsion in Henoch-Schonlein purpura. Eur Radiol. 2001;11(11):2267-9. [abstract]
4. 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. [abstract]
5. Jenkins JT, O'Dwyer PJ; Inguinal hernias. BMJ. 2008 Feb 2;336(7638):269-72.
6. Essential paediatrics, fourth edition. Churchill Livingstone 2000
7. Deeb A, Hughes IA; Inguinal hernia in female infants: a cue to check the sex chromosomes? BJU Int. 2005 Aug;96(3):401-3. [abstract]
8. Ortenberg J, Collins S, Roth CC, Hydrocele and Hernia in Children, eMedicine, Sep 2009
9. Dawson C, Whitfield H; ABC of urology. Urological malignancy--III: Renal and testicular carcinoma. BMJ. 1996 May 4;312(7039):1146-8.

Internet and further reading

• Tiemstra JD, Kapoor S; Evaluation of scrotal masses. Am Fam Physician. 2008 Nov 15;78(10):1165-70. [abstract]
• Muttarak M, Chaiwun B; Painless scrotal swelling: ultrasonographical features with pathological correlation. Singapore Med J. 2005 Apr;46(4):196-201; quiz 202. [abstract]
• Nicks BA, Askew K; Hernias, eMedicine, Jan 2010
• Henry & Thompson, Clinical Surgery: second edition. Elsevier Saunders, 2005. ISBN 0702027197

Acknowledgements