Scrotal mass evaluation

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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]

Evaluation of Scrotal Mass

• If there is an acutely painful scrotum,there should be a strong suspicion for testicular torsion, which is an emergency condition, and emergent surgical referral should be strongly considered. Sonography may be performed if testicular torsion is not suspected to confirm the diagnosis.
• The evaluation of scrotal mass is as follows:

Evaluation of the scrotal mass

Painful

Nonpainful

High-riding or horizontal testicle; nausea/vomiting?

Transilluminates?

Yes

No

Yes

No

Presumed torsion Doppler ultrasonogram, urology consult

Blue dot sign?

Hydrocele

"Bag of worms" on palpation that increases on Valsalva maneuvers

Yes

No

Yes

No

Torsion of testicular appendage

Lack of blood flow on doppler sonogram, C-reactive protein level <24 mg per L

Varicocele

Reducible mass?

Yes

No

Yes

No

Testicular torsion; urgent surgery

Likely epididymitis/orchitis, possibly incarcerated inguinal hernia, or hemorrhagic testicular cancer

Hernia

Extratesticular and nontender

Yes

No

Likely benign, further workup as needed

Doppler sonography prior to urology evaluation

Unilateral mass

Evaluate for testicular cancer: AFP, B-HCG, and LDH levels; MRI or CT scans may be considered to look for possible metastases and cryopreservation of sperm while awaiting urology evaluation

Adapted from American academy of family physicians.