scrotal lump post pic

Doc, I’ve felt a lump…

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Introduction

You are a junior doctor working in urology. A 27-year-old man has been referred to your clinic with concerns regarding a scrotal lump. Work through the clinical case scenario, considering what would be most appropriate at each stage.


History

Presenting Complaint

The patient is worried because he noticed a swelling in the left side of his scrotum.

“Doc, I’ve felt this lump…”

History of Presenting Complaint

Onset: When did he first notice the swelling?

Size: Has the swelling grown?

Pain: Is it painful or painless? It may be useful to use the SOCRATES framework for inquiring about pain.

  • Site
  • Onset of pain (e.g. sudden, gradual)
  • Character (e.g. sharp, dull)
  • Radiation
  • Associated symptoms with pain (e.g. nausea, vomiting)
  • Timing (e.g. is the pain related to anything?)
  • Exacerbating & relieving factors (i.e. things that make the pain worse/better)
  • Severity (e.g. scale of 1-10)

Was there any preceding trauma?

Associated symptoms: Infective symptoms such as fever or dysuria, systemic symptoms such as weight loss or night sweats.

Patient response: “I noticed it in the shower a few weeks ago – I didn’t think much at first because it doesn’t hurt, but now I think it’s getting bigger. I feel fine though.”

Other Components of History

Sexual history

See the Geeky Medics guide to taking a sexual history here.

Past medical history

  • Other medical diagnoses (e.g. patients with Klinefelter’s and Kallman’s syndrome have a greater risk of testicular cancer)
  • Previous hospitalisations
  • Previous abdominal, pelvic or perineal surgeries
  • Specifically, ask about a history of childhood cryptorchidism (higher risk of testicular cancer)

Medications/allergies

Family history

Specifically, ask about a family history of testicular cancer.

Social history

  • Smoking history
  • Alcohol history
  • Illicit drug use
  • Occupation
  • Relationships/family
  • Fertility status

Patient response: “I’ve never had to come to the hospital before. I’m really worried because my Dad had one of his testicles removed, he had cancer when he was about my age.  My wife and I want a baby- I don’t want to lose mine.”


Examination

General examination of the patient: Do they look well? Have they got signs of infection? Do they look cachexic? Are they in pain?

Examination of scrotum

  • Site of swelling
  • Size of swelling
  • Shape of swelling
  • Colour: Are there overlying skin changes?
  • Consistency: Is the lump firm or fluctuant?
  • Tenderness: Is it painful to examine?
  • Temperature: Is it hot to touch? (may indicate infection)
  • Scars: signs of previous surgery.
  • Cremasteric reflex/ Prehn’s sign

*See the Geeky Medics guide to comprehensive testicular examination, here

Chest and Abdominal Examination: Specifically examine for palpable lymph nodes or signs of lung metastasis (both signs of testicular cancer).

Findings:

  • Testicular examination reveals a painless, firm, irregular, intratesticular swelling on the left hemiscrotum
  • There are no overlying skin changes
  • Abdominal and respiratory examination are unremarkable

Investigations

  • Urinalysis (may show infection/blood which may point to diagnosis)
  • Bloods: FBC, U&E, CRP, (can consider tumour markers if concerned – bHCG, LDH, AFP)
  • Ultrasound scan of the scrotum: this is the recommended first-line investigation for any scrotal lumps
  • Chest X-ray/CT Chest Abdomen & Pelvis (if concerned about malignancy and metastasis)

Findings:

  • Urinalysis is negative
  • FBC, U&E and CRP are unremarkable

Diagnosis

Benign:

  • Epididymo-orchitis
  • Hydrocele
  • Varicocele
  • Hernia
  • Epididymal cyst
  • Spermatocele
  • Testicular torsion

Malignant:

  • Germ cell tumour
  • Stromal tumour
  • Lymphoma
  • Secondary malignancy

The most likely diagnosis is a testicular tumour.

See Table 1 for help with distinguishing clinical features of scrotal masses.

Table 1. Distinguishing scrotal masses by key clinical and investigative features

Age Painful? Urine dip Separate from testis on physical examination?

 

Transillumination Consistency Other features
Epididymo-orchitis Adult Yes +ve No No Tense Fever, erythema, hot to touch
Hydrocele

 

Any No -ve Yes Yes Fluctuant May be very large
Varicocele

 

Adult No -ve No No “bag of worms”
Epididymal cyst Any No -ve Yes Yes Fluctuant
Torsion

 

Teen Yes -ve No No Vomiting, high riding testis
Cancer

 

20-40

 

No -ve No No Firm, irregular Weight loss, lymph nodes
Hernia

 

Any Either -ve Can’t get above No Depends if incarcerated or not May be reducible

Management

MANAGEMENT DEPENDS ON THE SUSPECTED DIAGNOSIS

In most cases, SCROTAL ULTRASOUND is a useful investigation (NOT IN SUSPECTED TESTICULAR TORSION – in this case, immediate scrotal exploration is indicated).

If testicular cancer is suspected, the patient will require a multidisciplinary team (MDT) discussion, subsequent orchidectomy (via groin approach) and counselling about sperm banking.

Infective causes may be managed with antibiotics, or incision and drainage if an abscess is present.

Benign cysts and hydroceles may be left alone unless causing discomfort.

An inguinoscrotal hernia should be surgically repaired to prevent complications.


References

  1. European Association of Urology. Oncology Guidelines. Published in 2020. [LINK]
  2. British Association of Urological Surgeons. Testicular Lumps.  Published in 2019. [LINK]

Reviewer

Mr Sachin Malde

Consultant Urologist


Editor

Hannah Thomas


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