Scrotal abnormalities

Scrotal abnormalities include various conditions such as varicoceles, hydroceles, and malpositioning of the testicles (e.g., cryptorchidism, retractile testes). The differential diagnosis is broad and encompasses both painless (e.g., testicular tumors, scrotal hernia) and painful conditions (e.g., testicular torsion, epididymitis). A varicocele is the abnormal dilation of the pampiniform vessels within the scrotum. Patients may present with a dull, aching, and swollen scrotum (typically on the left). A bag of worms sensation may be palpable at the apex of the scrotum. Management may include active monitoring or surgical treatment in selected cases (e.g., infertility, pain, testicular atrophy). A hydrocele is a fluid-filled sac derived from the tunica vaginalis or processus vaginalis (infantile hydrocele), which causes a painless swelling of the scrotum that occurs at birth or later in life. Typical clinical findings and transillumination confirm the diagnosis. Hydroceles usually resolve spontaneously, but treatment may be indicated for symptomatic or communicating hydroceles. The most common congenital anomaly is cryptorchidism, which involves the incomplete descent of one or both testicles into the scrotum. The testicle may be located within the abdominal cavity, inguinal canal, or at the external inguinal ring. Cryptorchidism is associated with an increased risk of infertility and/or testicular cancer; therefore, early diagnosis and treatment are essential. Retractile testes usually do not require surgical intervention.

Scrotal abnormalities

Etiology of scrotal abnormalities [1][12]

Scrotal pain

Some causes of scrotal pain may also manifest with a palpable abnormality.

• Testicular torsion
• Epididymitis
• Complicated inguinal hernia
• Trauma (e.g., testicular rupture, scrotal hematocele)
• Hydatid of Morgagni torsion
• Nephrolithiasis
• Orchitis
• Fournier gangrene

Painless scrotal mass or swelling

Although these conditions do not typically cause acute or severe pain, all causes of scrotal mass or swelling can cause discomfort or a dull, aching sensation.

• Varicocele
• Hydrocele
• Spermatocele
• Uncomplicated inguinal hernia
• Testicular tumor
• Scrotal edema (e.g., in heart failure)

Empty scrotum [11]

Empty scrotum is a condition in which a testicle is not palpable in the scrotal sac unilaterally or bilaterally.

• Cryptorchidism
• Retractile testis
• Ectopic testis
• Differences of sex development
• Iatrogenic (e.g., surgical removal)

Approach to scrotal abnormalities [1][12]

• Perform a clinical evaluation.
  • Focused history: presence of pain, duration of symptoms, constitutional symptoms, urinary symptoms, abdominal pain
  • Testicular exam to evaluate for:
    • Palpable masses
    • Prehn sign
    • Transillumination
    • Cremasteric reflex
  • Examination for inguinal hernia
• Provide analgesia as needed.
• If testicular torsion suspected (e.g., based on TWIST score):
  • Attempt manual testicular detorsion.
  • Consult urology immediately.
• Obtain diagnostics as indicated, e.g.,
  • Scrotal swelling and/or mass: ultrasound
  • Suspected infection:
    • Laboratory studies
    • Urinalysis
    • STI testing
• Start condition-specific treatment as indicated and refer patients to urology.

Definition [12]

• Abnormal enlargement and tortuosity of the pampiniform plexus in the scrotum
• Due to proximal obstruction or valvular dysfunction of the spermatic vein

Epidemiology [12]

• Found in 15% of male individuals
• More prevalent in male individuals with infertility

Varicocele is the most common cause of scrotal enlargement.

Etiology

• Idiopathic/primary
  • The cause of primary varicocele is not fully understood.
  • The left testicle is most commonly affected (85% of cases)
    • The longer course of the left spermatic vein and its insertion at a 90° angle into the left renal vein predisposes to slower drainage and increased hydrostatic pressure.
    • Left renal vein passes between the aorta and superior mesenteric artery → ↑ susceptibility of the renal vein to compression (nutcracker phenomenon) → ↑ intravascular pressure in the left spermatic vein → varicocele formation
• Symptomatic/secondary
  • Caused by a mass in the retroperitoneal space (Ormond disease, lymphoma, renal cell carcinoma) obstructing venous drainage into inferior vena cava (right-sided varicocele) or left renal vein (left-sided varicocele) or a thrombotic event (e.g., pampiniform plexus obstruction in renal cell carcinoma)
  • Persist in the supine position due to a physical obstruction to blood flow within the spermatic vein

A unilateral right-sided varicocele is uncommon and may be associated with a mass in the retroperitoneal space (e.g., Ormond disease, lymphoma, renal cell carcinoma) blocking the spermatic vein.

Clinical features

Signs and symptoms [1][12]

• Painless scrotal enlargement (typically left-sided)
• Dull, aching pain may be present
• Scrotal heaviness

Physical examination findings [1][12]

• Soft bands or strands palpable in the upper pole of the affected scrotum (may feel like a bag of worms)
• Increases in size with Valsalva maneuver or standing
• Negative transillumination

Diagnosis [1][12]

Varicocele is a clinical diagnosis that can be confirmed with scrotal ultrasound.

Scrotal ultrasound

• Indications
  • Scrotal discomfort with suspected varicocele
  • Inconclusive physical examination
• Findings
  • Dilated (> 2 mm) hypoechoic pampiniform vessels
  • Doppler ultrasound may be be used to assess vein dilation and reflux during Valsalva maneuver.

Ultrasound is not recommended to assess for nonpalpable varicoceles as they do not require treatment. [13]

Abdominal imaging [13]

• Indication: Consider for suspected secondary varicocele (e.g., new-onset or nonreducible varicocele).
• Modalities: CT, MRI, ultrasound

Treatment [1][12]

Conservative treatment [14]

• Many varicoceles resolve spontaneously and do not require surgery.
• Patients who do not meet criteria for surgery should undergo active monitoring in consultation with urology, e.g.:
  • Annual physical examination
  • Serial scrotal ultrasound
  • Semen analysis
• Consider symptomatic treatment (e.g., scrotal support). [15]

Surgery [14][16]

• Indications
  • Infertility (e.g., persistently abnormal semen analysis)
  • Pain
  • Significant testicular volume discrepancy or delayed growth in adolescents
• Procedures
  • Varicocelectomy: surgical ligation of dilated testicular veins (pampiniform plexus) to relieve venous congestion and redirect blood flow
  • Percutaneous embolization

Complications

• Testicular atrophy and infertility
  • Sperm is produced in the testicles 2.0°C below the average body temperature.
  • In a varicocele, blood stasis within the scrotum increases local temperature, resulting in a suboptimal environment for spermatogenesis.

Definition [12]

A painless fluid-filled sac within the tunica vaginalis

Etiology

• Idiopathic (most common)
• Congenital hydrocele
  • Communicating hydrocele
    • Occurs due to the failed closure of the processus vaginalis during development
    • Usually discovered in infancy
  • Noncommunicating hydrocele: no connection to the peritoneal cavity present
• Acquired hydrocele
  • Secondary to underlying pathology (e.g., trauma, tumor, torsion, infection)
  • Wuchereria bancrofti infection is the most common cause worldwide, but virtually nonexistent in the US (see “Lymphatic filariasis”).

Clinical features [1][12]

• Painless swelling of affected scrotum
• Physical examination
  • Palpation: smooth, nontender, fluctuant mass confined to the scrotum
  • Positive transillumination

Diagnosis [12][17]

• Primarily a clinical diagnosis
• Consider ultrasound to confirm the diagnosis or evaluate for alternative or concurrent conditions (e.g., testicular tumors, testicular torsion, hernia).

Differential diagnosis

• Testicular tumor (negative transillumination test)
• Inguinal hernia

Treatment [12][17]

• Congenital hydroceles often resolve spontaneously within the first year of life.
• Referral to urology is indicated for:
  • Symptomatic hydroceles
  • Communicating hydroceles
  • Large, persistent hydroceles
• Treatment options include:
  • Aspiration and/or sclerotherapy
  • Hydrocelectomy: resection of the hydrocele sac

Definition [11]

A common congenital anomaly characterized by a failure of one or both testicles to descend into the scrotum

Epidemiology [11]

• Most common congenital anomaly of the genitourinary tract
• Typically identified at birth

Etiology [11]

• Unknown, possibly multifactorial
• Risk factors
  • Prematurity
  • Low birth weight

Classification [11][18]

• Palpability
  • Palpable (70–80% of patients): The testicle can be felt and in some cases manipulated into the upper scrotum with tension.
  • Nonpalpable: may be intra-abdominal or absent
• Laterality
  • Unilateral
  • Bilateral
• Onset
  • Congenital: Testis has remained undescended since birth.
  • Acquired (ascending testis) [19]
    • Testis previously descended but has since ascended
    • The testicle can be manually retracted into the scrotal pouch but immediately retracts into the groin if tension is not maintained.
• Location
  • Inguinal testis: The testicle is located between the external and internal inguinal ring, preventing adequate mobilization (90% of patients).
  • Intra-abdominal testis: The testicle is located proximal to the internal inguinal ring.
  • Suprascrotal testis: The testicle is located distal to the internal inguinal ring and above the scrotum.
  • Ectopic testis (rare): The testicle is located outside the embryological path of descent (e.g., superficial inguinal pouch, suprapubic region, perineum, femoral canal).

Diagnosis [11][18]

Cryptorchidism is primarily a clinical diagnosis.

• Obtain a gestational history if cryptorchidism is suspected.
• Evaluate for cryptorchidism during the newborn and routine well-child examinations.
  • Position the infant supine.
  • Palpate the scrotum for the presence of testes (typically oval and mobile).
  • Gently palpate along the inguinal canal and path of descent.
• Imaging is not routinely recommended and should be guided by a specialist.

Do not obtain imaging studies without consulting a specialist as these studies rarely affect management. [11]

Hormonal studies may show ↑ FSH, ↑ LH, ↓ inhibin B, and decreased testosterone levels (in bilateral cryptorchidism) or normal testosterone levels (in unilateral cryptorchidism; due to normal Leydig cell function). [11]

Treatment

Approach [11][18]

• < 6 months corrected gestational age
  • Unilateral undescended testis
    • Serial testicular examinations at every well-child visit
    • Spontaneous testicular descent is still possible; no immediate intervention is required.
  • Bilateral nonpalpable testes: Consult pediatric endocrinology and urology to evaluate and treat disorders of sex development.
• ≥ 6 months corrected gestational age: Consult urology for surgical treatment.

Hormonal therapy for testicular descent is not recommended due to limited efficacy and risk of recurrence.

Orchiopexy [11][18]

• Definition: mobilization and fixation of a testicle to the scrotal wall; typically performed for cryptorchidism or to prevent recurrence of testicular torsion
• Indication: undescended testis at ≥ 6 months corrected gestational age
• Timing: should be performed within the first 18 months of life, with optimal timing between 6 and 12 months

For nonpalpable testes, laparoscopic or open exploration may be necessary and can be combined with immediate or staged orchiopexy.

Monitoring [11][18]

Postsurgical monitoring is guided by shared decision-making. Follow-up often includes:

• Annual clinical examinations
• Serial ultrasound and evaluation for testicular atrophy
• Annual laboratory testing
  • Hormonal testing (e.g., FSH, LH, testosterone)
  • Semen analysis as indicated
• Testicular biopsy as indicated

Complications [11][18]

• Infertility
  • Successful orchiopexy may reduce the risk of infertility but does not prevent it.
  • Bilateral cryptorchidism is associated with a sixfold reduction in fertility compared to the general population. [18]
• Testicular cancer (germ cell tumors)
  • Patients with a history of cryptorchidism have a 5–10 times greater risk for testicular cancer. [18]
  • The risk for testicular cancer decreases with early surgical intervention.
• Testicular torsion
• Inguinal hernia

• Definition
  • Temporary displacement of the testicle in the inguinal canal by the cremasteric reflex
  • The testis may be easily repositioned back into the scrotal pouch.
• Treatment: No treatment is necessary.