Scrotal mass differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sujit Routray, M.D. [2]
Overview
Differential Diagnosis
| Disease Name | History & Symptoms | Physical Exam | Lab Findings | Imaging Findings | Gross and Histologic Findings | Genetic Studies / Immunohistochemistry | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Germs Cell Tumors | |||||||||||||||||||||||||
| Seminoma | • Most common• 30-50 year-old with painless unilateral testicular mass or mild discomfort | • Palpable, nontender unilateral testicular mass• Usually homogeneous enlargement | • Elevated serum placental ALP (PALP) | • Hypoechogenic intratesticular well-defined mass on ultrasound with internal blood flow on Doppler ultrasound• Cysts and calcificications are uncommon• Hypointense lesion with inhomogeneous enhancement on MRI• Homogeneous when small and heterogeneous when large | • Grey-white homogeneous mass with a lobular appearance• Fried egg appearance on histopathology (large cells and clear cytoplasm)• Prominent lymphocytic infiltration and less commonly, granulomatous formation | • Stains positively for ALP, c-KIT, CD30, EMA, and glycogen | |||||||||||||||||||
| Embryonal cell carcinoma | • Young adults• Painful testicular mass• Manifests with early mestastasis (bone, lung, CNS) | • Often unremarkable (small primary tumor) | • Elevated serum hCG• Elevated serum AFP when mixed | • Variable echogenicity (usually hypoechoic ono ultrasound)• No differentiating features on imaging• Commonly invade the surrounding structures (tunica albuginea)• Irregular calcifications | • Pale-grey mass with areas of hemorrhagic and necrosis• Often mixed histopathological features (solid, papillary, tubular, pseudoglandular) | • Stains positively for CD30 and hCG stain• May stain positively for AFP when mixed | |||||||||||||||||||
| Yolk salk tumor(endodermal sinus tumor, infantila embryonal carcinoma, or orchidoblastoma) | • Most common testicular cancer in children less than 3 years of age• Rapidly growing unilateral mass in an infant or a young child | • Palpable, nontender unilateral testicular mass• Usually heterogeneous enlargement | • Elevated serum AFP | • Diffuse enlargement of the testis with a heterogeneous appearance on ultrasound• Areas of hemorrhage and necrosis on MRI | • Yellow, mucinous, non-encapsulated, heterogeneous mass with areas of necrosis and hemorrhagePatterns that resemble embryonal structures (yolk sac, allantois) with reticular, papillary, or elongated forms• Schiller-Duval bodies (perivascular structures) | • Stains positively for AFP, alpha-1-antitrypsin, PAS diastase | |||||||||||||||||||
| Teratoma | • Bimodal distribution of age (infants and middle aged adults)• Painless tumor• History of congenital disease (Down syndrome, klinefelter, spina bifida) | • Palpable, nontender unilateral testicular mass• Usually heterogeneous enlargement | • Elevated serum hCG• Elevated serum AFP | • Heterogeneous, cystic appearance with mucinous or sebaceous depositions• Variable echogenicity on ultrasound• Calcifications usually irregular | • Large, heterogeneous appearance with solid, cystic, mucoid, and/or cartilageanous components• Presence of at least 2 germ layers | • Chromosome 12p mutations• Stains positively for cytokeratin. hCG, and AFP | |||||||||||||||||||
| Teratocarcinoma | • Middle aged adult with painless testicular mass of mild discomfort• May manifest with features of metastasis | • Palpable, nontender unilateral testicular mass• Usually heterogeneous enlargement | • Elevated serum hCG• Elevated serum AFP | • Variable echogenicity on ultrasound | • Features of both teratoma and embryonal carcinoma (more common) or both teratoma and choriocarcinoma (less common)• Solid and cystic components with mucoid, cartilagenous, sebaceous gland, myxoid stroma components• Additional features of underlying embryonal carcinoma or choriocarcinoma | • Stains positively for cytokeratin. hCG, AFP, and CD30 | |||||||||||||||||||
| Choriocarcinoma | • Adolescent or young adult with extratesticular symptoms• Mass is small and locally asymptomatic• Manifests with early metastasis and signs of hemorrhage (hemorrhagic stroke, hyperthyroidism, cannon-ball metastasis in lung, liver involvement, neurological deficits) | • Often unremarkable (small primary tumor) | • Elevated serum hCG | • Variable echogenicity• No differentiating features on imaging• Commonly invade the surrounding structures (tunica albuginea) | • Prominent areas of hemorrhage and necrosis • Nest and sheet pattern that simultaneously includes both cytotrophoblast and syncytiotrophoblast (rarely pure)• Paucity of intermediate trophoblasts (unlike placental site trophoblastic tumor) | • Stains positively for hCG | |||||||||||||||||||
| Diffuse embryoma | • 20-25 yo man with painful testicular mass | • Tender testicular mass | • Elevated serum hCG• Elevated serum AFP | • Poorly-defined, heterogeneous hyperechoic mass on ultrasound | • Non-encapsulated mass• Intermingled (lace-like) embryonal carcinoma and yolk sac components in equal proportions, but no discrete embyoid bodies• Scattered trophoblastic components• Necklace-like arrangement of cells | • Stains positively for cytokeratin, AFP (yolk sac component), and CD30 (embyonal component) | |||||||||||||||||||
| Polyembryoma | • 20-25 yo man with painful testicular mass | • Tender testicular mass | • Elevated serum AFP• Elevated serum hCG | • Poorly-defined, heterogeneous hyperechoic mass on ultrasound | • Multiple discrete embyoid bodies (combination of both embyonal carcinoma and yolk sac components) | • Stains positively for cytokeratin, AFP (yolk sac component), and CD30 (embyonal component) | |||||||||||||||||||
| Placental site trophoblastic tumor | • Infant or young adult • Painful small testicular mass | • Small nontender or minimally painful testicular mass | • Elevated serum hCG | • Variable echogenicity• No differentiating features on imaging• May have vascular flow | • Solid yellowish mass that resembles uterine tissue• Less prominent foci of hemorrhage and ncerosis• Predominance of intermediate trophoblast cells (implantation-site type) that invade surrounding blood vessels• Paucity of cytotrophoblast and syncytiotrophoblast cells (unlike choriocarcinoma) | • Stains positively for hPL (diffuse), p63, cytokeratin, AFP, and hCG (patchy)• Negative p63 staining | |||||||||||||||||||
| Epithelioid trophoblastic tumor | • Infant or young adult• Painful small testicular mass | • Small nontender or minimally painful testicular mass | • Elevated serum hCG | • Variable echogenicity• No differentiating features on imaging• May have vascular flow | • Solid yellowish mass that resembles uterine tissue• Less prominent foci of hemorrhage and ncerosis• Predominance of intermediate trophoblast cells (chorionic type) that invade surrounding blood vessels• Paucity of cytotrophoblast and syncytiotrophoblast cells (unlike choriocarcinoma) | • Stain positively for p63 (diffuse), cytokeratin, AFP, and hCG (patchy)• Negative hPL staining | |||||||||||||||||||
| Mixed germ cell tumor | • Typical age at diagnosis and other clinical features based on underlying components | • Physical exam findings based on underlying components | • Elevated serum hCG, AFP, and/or PALP dependeing on the underlying compoenents | • Imaging findings based on underlying components | • Histopathological findings based on underlying components• Variable proportion of choriocarcinoma, embryonal cell carcinoma, yolk sac tumor, seminoma, and/or teratoma tissue | • May stain positively for any of CD30, hCG, AFP, ALP, c-KIT, CD30, EMA, alpha-1-antitrypsin, PAS diastase, and glycogen depending on underlying compoenents | |||||||||||||||||||
| Carcinoid (pure neuroendocrine neplasm) | • Middle-aged and elderly adult• Manifests as a minimally painful, rapidly growing mass• May manifest as carcinoid syndrome | • Tender testicular mass• Hydrocele or cryptorchidism | • Elevated serum and urine 5-HIAA if carcinoid syndrome present | • Unilateral, well-circumscribed mass without vascular invasion• Solid and cystic appearance• Mixed echogenicity on ultrasound• Irregular calcifications | • Well-circumscribed, yellowish solid mass• Occasional cystic masses• Small acini, cord-forming rosettes, prominent cytoplasmic granularity• Salt and pepper chromatic pattern• Absent features of atypia• Neurosecretory granules on electron microscopy | • Stains positively for cytokeratin, serotonin, chromogranin, synaptophysin, and CD56 | |||||||||||||||||||
| PNET (Ewing's tumor of the testes) | • 30-50 yo man with rapidly enlarging mass• Often metastatic at presentation | • Palpable, nontender unilateral testicular mass | • Unremarkable | • No differentiating features on imaging• Vascular flow on Dopper | • Greyish necrotic mass of immature neural tissue• Sheet-like / rosette distribution of small round blue tumor cells• Neurosecretory granules on electron microscopy | • Stains positively for synaptophysin, NSE, chromogranin, CD99, GFAP, FLI1• Split of EWS gene on chromosome 22 | |||||||||||||||||||
| Sex-Chord Stromal Tumors | |||||||||||||||||||||||||
| Fibroma | • Middle-aged adult (range 20-70 years) with slowly-growing, painless testicular mass• History of nevoid basal cell carcinoma (Gorlin syndrome) | • Palpable, nontender unilateral testicular mass | • Unremarkable | • Isoechoic mass on ultrasound with prominent acoustic shadowing (fibrous component)• May be homogeneous or heterogeneous• Margins often blended with the tunica albuginea• No vascular flow on Dopper | • Well-circumscribed, often non-encapsulated solid pale yellow mass• No hemorrhage, no necrosis• Pure fibromatous features of collagenized plaques and spindle cells that synthesize collagen.• Low cellularity | • Mutation in PTCH gene• Positive staining for calretinin, inhibin, CD56, CD34, actin, vimectin• Usually (but not always) negative staining for S-100, keratin, CD99/MIC-2, and desmin | |||||||||||||||||||
| Granulosa cell tumor | • Young or middle-aged adult (adult-type) or infant/child (juvenile-type) patient with slowly-enlarging painless testicular mass• May manifest with symptoms of metastasis or hormonal secretion (e.g. gynecomastia in estrogen-secreting tumors) | • Palpable, nontender unilateral testicular mass | • Unremarkable | • Hypoechoic mass with solid and cystic appearance on ultrasound (swiss-cheese appearance) | • Well-circumscribed tumor between the seminiferous tubules• May be solid, cystic, of lobular• Pseudo-capsule• No hemorrhage, no necrosis• Elongated grooved nuclei (coffee-bean appearance)• Call-Exner bodies• Variable atypia | • Stains positively for calretinin, inhibin, vimentin, actin, and MIC2 | |||||||||||||||||||
| Leydig (interstitial) cell tumor | • Bimodal age distribution• Slowly enlarging painless unilateral mass | • Palpable, nontender unilateral testicular mass• Signs of excess estradiol (e.g. gynecomastia) | • Unremarkable | • Well-defined, hypoechoic solid mass on ultrasound• May have cystic component• Irregular calcifications | • Well-circumscribed, unencapsulated solid mass• Yellowish-brown tumor• May have cystic, hemorrhagic, or necrotic areas• Often dffuse growth of large polygonal Leydig cells, but may have unique patterns of growth• Vacuolated cells with marked atypia• Reinke crystals• Psammoma bodies | • Mutation in fumarate hydratase• Stains positively for inhibin, cytokeratin, calretinin, synaptophysin, vimentin, Melan-A | |||||||||||||||||||
| Sertoli hyperplasia (Sertoli adenoma, Pick's adenoma) | • Child or young adult with history of Peutz-Jegher syndrome, androgen insensitivity syndrome, or McCune Albright syndrome• Slowly enlarging painless bilateral masses | • Palpable, nontender bilateral testicular masses• Signs of excess estradiol (e.g. gynecomastia) | • Elevated serum estradiol • Elevated anti-Mullerian hormone and inhibin B• Reduced androgen concentration | • Hyperechogenic nodules on ultrasound | • Well-demarcated yellowish nodules in the testis• Unencapsulated nodules composed of Sertoli cells | • Stains positively for anti-Mullerian hormone, inhibin A, CK8, and CK18• Negative staining for AFP, hCG, and p53• | |||||||||||||||||||
| Large cell calcifying Sertoli cell tumor | • Young patient with history of Carney syndrome, Peutz-Jeghers syndrome, or tuberous sclerosis• Slowly enlarging painless unilateral/bilateral mass(es) | • Palpable, nontender unilateral or bilateral testicular mass• Signs of excess estradiol (e.g. gynecomastia) | • Elevated serum estradiol | • Diffuse and regular (smooth, rounded, large) calcifications• Variable appearance on ultrasound• Often multiple hyperechogenic regions with strong shadowing • Possible increased blood flow | • Multifocal, well-circumscribed yellowish-grey nodules• Absent hemorrhage or necrosis• Patterrns (sheet or trabeculae) of large cells and formation of solid tubules• Psammoma bodies• Charcot Bottcher crystals on electron microscopy | • Stains positively for inhibin, vimentin, calretinin, S100, and cytokeratin• Negative staining for laminin, PALP, AFP, and hCG | |||||||||||||||||||
| Sclerosing Sertoli cell tumor | • Variable age at presentation (adolescence to elderly)• Slowly enlarging painless unilateral mass | • Palpable, nontender unilateral testicular mass | • Unremarkable | • Well-circumscribed hypoechogenic lesion on ultrasound | • Well-circumscribed, yellowish-grey nodule• Absent hemorrhage or necrosis• Tubuules and cords of Sertoli cells surrounded by hypocellular collagenous strome (sclerosis) | • Stains positively for calretinin, inhibin, and vimentin• Negative staining for cytokeratin, AFP, and hCG | |||||||||||||||||||
| Sertoli tumor, non-specific | • Bimodal age districution: either 40-50 year old man or infants with history of Carney syndrome or Peutz-Jegher syndrome• Slowly enlarging testicular mass | • Palpable, nontender unilateral testicular mass• Signs of excess estradiol (e.g. gynecomastia) | • Often unremarkable• Elevated serum estradiol may be present, less common | • Well-circumscribed mass with variable echogenicity | • Well-circumscribed, yellowish-grey nodule• Hemorrhage and necrosis may be present, but uncommon• Features of fetal, prepubertal, and adult Sertoli cells present simultaneously• Charcot Bottcher crystals on electron microscopy | • Stains positively for vimentin, cytokeratin, inhibin, S100, chromogranin, synaptophysin, and CD99• Negative staining for hCG, AFP, and PLAP | |||||||||||||||||||
| Sertoli-Leydig cell tumor (SLCT) | • Young adult or phenotypic female with history of androgen insensitivity• Slowly enlarging painless unilateral mass• | • Palpable, nontender unilateral testicular mass• Signs of excess estradiol (e.g. gynecomastia) | • Often unremarkable• Elevated serum estradiol may be present, less common• Abrnomally elevated testosterone among pts with androgen insensitivity | • Well-circumscribed mass with variable echogenicity• Solid mass with intratumoral cysts may be present | • Heterogeneous, lobulated, encapsulated yellowish solid mass• Mass contains combination of Sertoli cells and Leydig cells • Poorly differentiated cells (immature tubules of Sertoli cells, large Leydig cells) | • Stains positively for inhibin, melanA, and CD99• Negative staining for EMA, PLAP, and S100 | |||||||||||||||||||
| Testicular tumor of andrenogenital syndrome (testicular adrenal rest tumor) | • Post-pubertal patient with history of congenital adrenal hyperplasia (CAH)• Often asymptomatic, detected during screening in patients with CAH | • Unremarkable testicular exam• Other signs of congenital adrenal hyperplasia | • Elevated 11-beta-hydroxylase activity• Reduced concentrations of AFP, LDH, and hCG | • Uniform hypoechogenicity on ultrasound• Usually multifocal and bilateral lesions | • Hyperplasia, bilateral lesions in testicular hilum• Yellowish nodules• Cells resemble adrenocortical cells, no mitoses• Normal surrounding tissue• Absent Reinke crystals | • Stains positively for CD56, synaptophysin, and inhibin• Negative staining for androgen receptor protein• | |||||||||||||||||||
| Other tumors | |||||||||||||||||||||||||
| Lymphoma | • Elderly patient (>60 years) with history of lymphoma (commonly diffuse large B cell lymphoma)• Unilateral or bilateral painless testicular mass | • Palpable, nontender unilateral or bilateral testicular mass | • Depends on lymphoma subtype | • Diffuse infiltration• Hypoechoic solid masses on ultrasound• Hypervascularity on Doppler ultrasound | • Whitish-tan colored mass• Large, pleomorphic malignant cells• Seminiferous tubules may be spared or undergo sclerosis• Vascular invasion | • Stains positively for CD45• Depends mainly on lymphoma subtype• Usually negative staining for PLAP and SALL4 | |||||||||||||||||||
| Angiosarcoma | • Bimodal age distribution• Young man with history of teratoma or elderly man with history of radiation or chronic hydrocele• Painless/painful testicular mass | • Tender or non-tender testicular mass• Low-grade fever• Scrotal swelling• Flank pain• Hydrocele | • Often unremarkable | • Hypervascularity on Doppler ultrasound | • Solid vascular lesion• Classical pattern of proliferating anastomosing blood-filled channels• 2 patterns: solid (sheet proliferation without lumen) and primitive (small lumina filled withblood) | • Stains positively for CD31, CD34, lectin, and factor VIII-related antigen• Negative staining for pancytokeratin, PLAP, CD45, CD68, CAM5.2, and AE1/AE3 | |||||||||||||||||||
| Chondrosarcoma | • Young or middle-aged adult with history of teratoma• Painless testicular mass | • Palpable, non-tender, heterogeneous mass | • Often unremarkable | • Lobulated mass | • Firm, grey mass with irregular lobulations• Cartilaginous (chondroid) matrix surrounded by fibrovascular bands• Most have non-cartilagenous components (rarely pure) | • Stains positively for S100 | |||||||||||||||||||
| Hemangioma | • Painless testicular mass among pts of any age | • Palpable, non-tender, homogeneous mass | • Often unremarkable | • Homogeneous hypoechoic mass• Hypervascularity on Doppler ultrasound | • Well-defined hemorrhagic mass• Red blood cells in tubules | • Stains positively for CD31, CD34, FLI1, and factor VIII-related antigen• Negative staining for pancytokeratin, AE, keratin, PLAP, and EMA | |||||||||||||||||||
| Mesothelioma | • Middle aged man with painless testicular mass and history of hydrocele or exposure to asbestos | • Palpable, non-tender testicular mass• Scrotal swelling | • Often unremarkable | • Thickening of tunica vaginais• Solid paratesticular mass• Hydrocele | • May be benign or malignant• Papillary patterns of uniform epithelioid cells with fibrovacular core• Polygonal cells with microvilli on electron microscopy• Psammoma bodies | • Benign: stains positively for p53 (focal) and CEA• Malignant: Stains positively for calretinin, WT1, EMA, thrombomodulin, CK5, CK6, CK7 and negative staining for CEA and CK20 | |||||||||||||||||||
| Plasmacytoma | • Adult (of any age) with concurrent or history of plasma cell neoplasia (commonly multiple myeloma)• Symptoms of multiple myeloma (e.g. fatigue, back pain) | • Testicular exam unremarkable | • Lab findings of plasmacytosis (e.g. anemia, elevated creatinine, hypercalcemia)• No specific lab finding for testicular involvement | • Poorly circumscribed hypoechoic lesions on ultrasound• Hypervascularity on Doppler ultrasound | • Large, tan-yellow mass• Areas of hemorrahgeAtypical plasma cellsTubule effacement in the center and tubule sparing in the periphery | • Positive staining for EMA, CD45, CD79am CD138, kappa or lambda light chains, and other plasma cell markers | |||||||||||||||||||
| Non-neoplasic lesions | |||||||||||||||||||||||||
| Adrenal cortical rest | • Usually asymptomatic (incidental finding)• Young man with scrotal swelling and dull pain• History of congenital adrenal hyperplasia (hydroxylase deficiency) | • Scrotal swelling | • May be unremarkable• If secretory, elevated concentration of adrenal hormone | • Heterogeneous, well-circumscribed hypoechoic mass on ultrasound• No or minimal vascularity on Doppler• No distinguishing features | • Well-circumscribed, small, round, orange-yellow nodule• Adrenal cortical tissue with absence of adrenal medullary tissue | • Positive staining for markers of cortical adrenal tissue | |||||||||||||||||||
| Chylocele | • Scrotal swelling in a man with history of filariasis / elephantiasis | • Scrotal swelling• Negative trans-illumination test | • Unremarkable | • Fluid collection surrounding the testes | • Milky chylous fluid (not waterry) on aspiration• Usually no evidence of microfliariae in chylous fluid• Abundant leukocytes | N/A | |||||||||||||||||||
| Cystic dysplasia | • Young child with history of renal agenesis / dysplasia• May be unilateral or bilateral, painless testicular mass• | • Palpable, non-tender testicular mass | • Unremarkable | • Irregular cystic spaces witht varying sizes• Absence of solid or vascular components• | • Varying cystic spaces• Formation of incomplete connective tissue septa• Cells resembling the normal adult rete testes | N/A | |||||||||||||||||||
| Dermoid cyst | • Young or middle aged adult with slowly growing painless mass• Ruptured cyst may manifest with scrotal swelling, erythema, and pain | • Palpable, nontender unilateral testicular mass• Usually heterogeneous enlargement | • Unremarkable | • Onioin-skin appearance on ultrasound• Target-shape lesions with halo of hypoechonicity and central hyperechogenicity on ultrasound• No vacular flow on Doppler | • Mature epithelial tissue• May have hair (similar to teratoma)• Keratin filled cyst• Epidermal epithelium surrounded by pilosebaceious units• Formation of lipogranulomas and microcalcifications• Absence of atypia | • Absence of any mutation (normal 12p)• Stains positively for cytokeratin | |||||||||||||||||||
| Epidermoid cyst (keratocyst) | • 10-40 yo • Painless slowly growing testicular mass• Ruptured cyst may manifest with scrotal swelling, erythema, and pain | • Palpable, non-tender testicular mass• Usually heterogeneous enlargement | • Unremarkable | • Onioin-skin appearance on ultrasound• Target-shape lesions with halo of hypoechonicity and central hyperechogenicity on ultrasound• No vacular flow on Doppler | • Absence of dermal structures, such as hair, sebaceous glands etc. (found in dermoid cyst)• Cyst with white keratin debris• Lined by squamous epithelium• Laminated keratin• Granuloma when cyst ruptures | • Absence of any mutation (normal 12p) | |||||||||||||||||||
| Granulomatous orchitis | • 40-60 yo man with sudden-onset testicular tenderness and mass formation• History of infection, sarcoidosis, or testicular trauma | • Tender testicular mass• Fever | • Unremarkable | • Solid hypoechoic mass | • Solid nodule• Lymphocytic infiltration and formation of giant cells and macrophages • Not true granuloma | N/A | |||||||||||||||||||
| Hematocele | • Scrotal mass in patients with history of testicular trauma, torsion, or increased bleeding tendency | • Scrotal swelling• Negative trans-illumination test | • Unremarkable | • Fluid collection surrounding the testes | • Bloody fluid on aspiration | N/A | |||||||||||||||||||
| Hydrocele | • Scrotal mass in patients with history of testicular trauma or epidymitis | • Scrotal swelling• Positive trans-illumination test | • Unremarkable | • Fluid collection surrounding the testes | • Clear fluid on aspiration | N/A | |||||||||||||||||||
| Macroorchidism | • History of fragile X syndrome, FSH secreting adenoma | • Large testicle (the testicle itself is large)• Signs of underlying disease• | • May have elevated hormone concentration (e.g. FSH) if secretory adenoma | • Large testicle, but normal architecture | Normal testicular findings | N/A | |||||||||||||||||||
| Malakoplakia | • Young man with long-standing symptoms of orchi-epididymitis (pain, scrotal swelling) • History of immunosuppression | • Palpable, tender testicular mass• Scrotal swelling• Erythema | • Positive culture results for bacterial infection (chronic inflammation) | • Hypoechogenic mass on ultrasound• Increased vascularity on Doppler | plakos=plaques)• Von Hansemann cells (large cells with abundant eosinophilic cytoplasm) and Michaelis-Gutmann bodies (intracytoplasmic inclusion bodies with owl eyes appearance) | N/A | |||||||||||||||||||
| Meconium periorchitis | • Neonate or infant (delayed diagnosis) with history of meconium peritonitis (leakage from patent processus vaginalis to scrotum) | • Palpable, non-tender testicular mass | • Unremarkable | • Hypoechogenic mass with shadowing calcifications• Normal testicle with normal blood flow | • Greenish-yellowish masss with dystrophic calcifications (meconium converts to fibrous solid mass)• Calcifications either fibroadhesive or cystic• Hemosiderin laden macrophages• Lanugo hairs, bile pigments, cholesterol, mucin, and other components normally present in meconium• Myxoid stroma | N/A | |||||||||||||||||||
| Testicular Vasculitis | • Middle aged man with history of polyarteritis nodosa (less commonly granulomatosis with polyangiomatosis, Henoch-Schonlein purpura, or giant cell arteritis)• History of HBV or HIVPainful testicular mass with intra-testicular hemorrhage• Symptoms of underlying vasculitis | • Signs of underlying vasculitis• Palpable, tender testicular mass• Scrotal swelling if vasculitis includes extratesticular structures | • Unremarkable | • Heterogeneous, hypoechogenic lesion on ultrasound• Inreased intralesional vascularity on Doppler | • Soft, dark red lesion with areas of hemorrhage• Fibrinoid necrosis• Vascular wall fibrosis | N/A | |||||||||||||||||||
| Fibrous proliferation (paratesticular fibrous pseudotumor) | • Patients of all ages (peak during young adulthood)• Slowly growing painless unilateral scrotal masss• History of genitourinary infection or trauma | • Palpable, non-tender scrotal mass | • Unremarkable | • Paratesticular mass between tunica layers• Hypoechogenic solid mass on ultrasound• No vascularity on Doppler | • Whitish mass with multinoduular thickening• Collagen-rich fibrous tissue with increased fibroblasts• Dystrophic calcifications• No hemorrhage or necrosis | • Stains positiively for actin and keratin• Negative staining for ALK-1, beta-catenin | |||||||||||||||||||
| Polyorchism (supranumerary testes) | • Often asymptomatic (incidental finding)• Young patient with scrotal pain, swelling, hydrocele, varicocele • Patients may present with testicular torsion | • Palpable, non-tender scrotal mass• Scrotal swelling• Testicular torsion manifests with excruciating testicular or pelvic pain, erythema, and swelling | • Unremarkable | • Isoechogenic scrotal mass | • Normal testicular tissue | N/A | |||||||||||||||||||
| Spermatocele | • Young or middle aged adult with painless testicular or scrotal mass | • Homogeneous palpable non-tender testicular or scrotal mass | • Unremarkable | • Well-defined cystic dilation of the rete testis or head of the epididymis | • Cuboidal / flat and ciliated epithelium• Presence of numerous spermatozoa• | N/A | |||||||||||||||||||
| Splenogodal fusion syndrome (ectopic scrotal spleen) | • Child or adolescent with painless, left scrotal mass (not right) and history of perimelia (continuous subtype) or cardiac defect (discontinuous subtype) | • Homogeneous palpable non-tender scrotal mass | • Unremarkable | • Well-defined, homogeneous,, hypoechoic mass on ultrasound• Increased vascular flow on Doppler | • Splenic tissue (red with clear boundaries)• Occasional calcification, thrombi, or fibrosis | N/A | |||||||||||||||||||
| Varicocele | • Often asymptomatic• Dull or sharp testicular pain that increases with standing or physical activity and improves when lying down• History of infertility | • Scrotal mass and swelling• Often left-sided• Dilated, tortuous veins • "Bag of worms" sensation upon palpation | • Unremarkable | • On ultrasound, CT/MRI, and venography, apperance of dilated pampiniform plexus veins with serpentine appearance is diagnostic • Flow reversal (reflux) with Valsalva maneuver on Doppler• Enhancement following administration of gadolinium on MRI | • Testicular atrophy in advanced cases | N/A | |||||||||||||||||||
| Testicular torsion | • Excruciating, acute, sharp testicular pain that radiates to the pelvis and abdomen• Testicular swelling and pain | • Scrotal swelling and tenderness• • | • Unremarkable | • Focal/diffuse hypoechogenicity on ultrasound• No blood flow on Doppler (vs. increased flow in infections)• Scrotal wall thickening | • • • | N/A | |||||||||||||||||||
| Scrotal | |||||||||||||||||||||||||
| AIDS-related testicular tumor | • Commonly testicular lymphoma or germ cell tumor• Patient with history of AIDS presents with testicular swelling or pain• Systemic manifestations of underlying malignancy | • Palpable testicular mass that may be tender or non-tender | • Depends on underlying malignancy | • Depends on underlying malignancy | • Depends on underlying malignancy | • Depends on underlying malignancy | |||||||||||||||||||
| Brucellosis | • Patient with history of exposure to cattle/sheep/goat/swine or animal products (milk, meat, cheese) presents with acute scrotal pain and swelling• Undulant fever and night sweats (characteristic wet hay odor) • Relapses common with similar symptoms | • Tender testicular mass• Fever• Hydrocele | • Elevated WBC count• Positive serum STA test for brucellosis• Elevated Brucella IgM and IgG antibodies• Urine PCR positive for Brucella spp. | • Focal/diffuse heterogeneous, hypoechoic intratesticular mass on ultrasound• Focal/diffuse increased blood flow on Doppler• Scrotal wall thickening | • Abscess formation at diagnosis is common• Grey-white mass suggestive of testicular atrophy• Granulomatous inflammation with lymphocytic infiltration | N/A | |||||||||||||||||||
| Gonorrhea infection | • Patient with history of unprotected sexual intercourse presents with unilaterla testicular pain, swelling, and fever• May be either acute or chronic | • Tender testicular mass• Fever• Hydrocele | • Elevated WBC count• Gram-negative diplococci on urethral Gram stain• Urine PCR positive for Gonorrhea | • Focal/diffuse hypoechogenicity on ultrasound• Focal/diffusre increased blood flow on Doppler• Scrotal wall thickening | • Granulomatous inflammation with lymphocytic infiltration | • Urethral Gram stain demonstrates Gram-negative diplococci | |||||||||||||||||||
| Histoplasma infection | • Chronic testicular enlargement• Patients may have systemic manifestations of histoplasmosis• | • Tender/non-tender testicular mass | • Elevated WBC count and eosinophilia may be present (may be normal in chronic cases) | • Focal/diffuse hypoechogenicity on ultrasound• Focal/diffusre increased blood flow on Doppler• Scrotal wall thickening | • Caseating granuloma with giant cells | • Yeast observed on silver stain | |||||||||||||||||||
| Mumps | • Post-pubertal man with recent manifestations of mumps (e.g. parotiditis, pancreatitis, arthritis, myocarditis, meningoencephalitis) presents with acute, unilateral painful testicular mass | • Tender testicular mass• Hydrocele• Fever• Parotiditis• Rash | • Elevated WBC• Elevated paramyxovirus IgM and IgG• Urine PCR positive for paramyxovirus | • Focal/diffuse hypoechogenicity on ultrasound• Focal/diffusre increased blood flow on Doppler• Scrotal wall thickening | • Non-specific interstitial edema, degenerative changes, vascular dilation • Lymphocytic infiltration | N/A | |||||||||||||||||||
| Pyogenic epididymo-orchitis | • Patient with history of unprotected sexual intercourse presents with acute scrotal swelling and pain | • Tender testicular mass• Fever• Hydrocele | • Elevated WBC• Bacterial growth on urethral swab specimin (usually E. coli)• Urine PCR positive for offending bacterial agent | • Focal/diffuse hypoechogenicity on ultrasound• Focal/diffusre increased blood flow on Doppler• Scrotal wall thickening | • Abscess formation in advanced cases• Non-specific interstitial edema, degenerative changes, vascular dilation • Lymphocytic infiltration• Grey-white mass suggestive of testicular atrophy | N/A | |||||||||||||||||||
| Syphilis | • Patient with long history of unprotected sexual intercourse presents with painful testicular swelling (tertiary syphilis)• Often manifests as epidimo-orchitis that is resistant to conventional antibiotic therapy• May have other systemic symptoms of tertiary syphilis | • Irregular tender testicular mass• Thickened epididymis• Hydrocele | • Positive syphilis serology (suggest latent syphilis)• VDRL may be either positiive or negative • Positive dark field microscopy from lesion content | • Heterogeneous hypoechogenicity on ultrasound• Solid and cystic appearance with areas of necrosis• May have increased blood flow on Doppler | • Discrete gummas on gross pathology• Microscopic features of gumma (interstitial inflammation, lymphocytic and plasma cell infiltration, obliterative endorteritis (endoarteritis obliterans), perivascular cuffing)• Spirochetes may occasionally be observed | • May stain positively for silver-based methods (Warthin-Starry stain, Wright stain, Levaditi stain)• • | |||||||||||||||||||
| Tuberculosis | • Patient with history of tuberculosis presents with painless mass or chronically dull testicular discomfort• Positive constitutional symptoms (weight loss, malaise)• May be isolated or may be associated with other systemic symptoms of tuberculosis (e.g. lymphadenopathy, pulmonary lesions, renal involvement)• May have concomitant involvement of other GU organs (e.g. prostate, seminal vesicles) | • Irregular testicular mass• May be tender or non-tender• Thickened scrotal skin• Hydrocele | • Ejaculum may demonstrate positive acid fast bacilli (AFB) staining | • Heterogeneous hypoechogenicity on ultrasound• No/minimal blood flow on Doppler• Hypointense lesion on T1WI MRI and hyperintense on T2WI MRI | • Possible abscess formation • Caseating necrosis• Epithelioid cells and lymphocytic infiltration with presence of multinucleated giant cells | • Positive acid fast bacilli staining |