Scrotal mass differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[2]

Overview

Scrotal masses may be differentiated according to clinical features, laboratory findings, imaging features, histological features, and genetic studies from other diseases that cause testicular mass with discomfort, back pain, abdominal discomfort, or abdominal mass. Common differential diagnoses include yolk sac tumor, teratoma, choriocarcinoma, embryonal cell carcinoma, seminoma, and testicular lymphoma (usually non-Hodgkin lymphoma).

Differential Diagnosis

The table below summarizes the findings that differentiates scrotal mass according to the clinical features, laboratory findings, imaging features, histological features, and genetic studies.

Scrotal Swelling	Diseases	Clinical manifestations									Para-clinical findings				Gold standard	Associated
Painful		Symptoms				Physical examination
											Lab Findings		Past Medical History	Histopathology
		Unilateral /Bilateral swelling	Onset	Fever	Urinary symptoms	Tenderness	Erythema	Discharge	Inguinal Lymphadenopathy	Cremasteric Reflex	Blood/Urine Analysis	Doppler U/S
	Epididymitis	Unilateral	Gradual	±	Dysuria, frequency, and/or urgency	+	-	Pyuria Bacteriuria	Painful local lymphadenopathy	+	CBC-Leukocytosis Urine culture (pre-pubertal and elderly) NAAT Immunofluorescent antibody testing	Decreased epididymal blood flow	Enlarged (>17 mm) epididymis with a hypoechoic, hyperechoic, or heterogeneous echotexture, increased blood flow	Acute infection is characterized by infiltration of neutrophils. Chronic cases are characterized by granulomatous inflammation.	Ultrasound for diagnosis (Testicular massesor swollen testicles with hypoechoic and hypervascular areas)	Hydrocele Urinary tract infection Gonococcal infection chlamydia infection Phen sign +ve
	Orchitis (Mumps)	Bilateral	Abrupt	±	Dysuria	+	-	±	Painful local lymphadenopathy	+	CBC-Leukocytosis raised CRP Immunofluorescent antibody testing Urine analysis and culture - normal	Increased blood flow in affected side.	Mumps, coxsackievirus infection Concurrent epididymitis Congenital abnornmalities	Tubules are infiltration with neutrophiles, lymphocytes and cells resembling histiocytes Microscopic destruction of spermatogenic cells	RT‐PCR Serum immunofluorescence antibody testing.	Phen sign +ve Testicular atrophy Infertility
	Testicular Torsion	Unilateral	Sudden	-	-	+	+	Blood in semen may be present	Absent	-	Normal	Absent or decreased arterial perfusion of the testis	Previous history of testicular torsion Family history of testicular torsion Prematurity Undescended testes Low birth weight	In the first 4 hours: testicular parenchyma shows edema and and desquamation of the germ cells 4-8 hours partial necrosis of germ cells. >24 hrs: necrosis	Doppler ultrasound> CT scan	Phen sign +ve
	Hematocele	Unilateral or bilateral	Sudden	-		+	+	Blood in semen	Absent						Ultrasonography: to check for testicular rupture.
	Incarcerated Hernia	Unilateral	Sudden	+	Absent	+	+	-	Absent	+	Normal	Normal	-	-	Groin ultrasound or CT scan show presence of bowel and omentum.	Valsalva maneuvers performed while palpating the inguinal canal will push a hernia against the examiner's finger.
	Brucellosis	Unilateral or Bilateral	Sudden	±	Dysuria	-	-	±	Painful local lymphadenopathy	+	CBC-Leukocytosis raised CRP Immunofluorescent antibody testing Urine analysis and culture - normal	Increased blood flow in affected side	-	Acute infection is characterized by infiltration of neutrophils. Chronic cases are characterized by granulomatous inflammation.	Culture of the organism from blood.	Antibodies are detected using: Serum agglutination (standard tube agglutination) Enzyme-linked immunosorbent assay Rose Bengal agglutination Coombs test Immunocapture agglutination (Brucellacapt) 2-mercaptoethanol agglutination
	Torsion of the appendix testis	Unilateral or Bilateral	Sudden	-	Absent	+	-	-	Absent	+	Normal	Normal blood flow to the testis with an occasional increase on the affected side	-	In the first 4 hours: testicular appendages shows edema and and desquamation. 4-8 hours partial necrosis of appendix cells. >24 hrs: necrosis	scrotal ultrasound shows the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area.	Scrotal wall mayshow the classical "blue dot" sign, which is due to infarction and necrosis of the appendix testis
	Henoch-Schonlein purpura	Unilateral	Sudden	-	-	+	+	-	-	-	Serum IgA levels are elevated Elevated ESR	-	Sore throat 2-3 weeks back	Light microscopy shows leukocytoclastic vasculitis in postcapillary venules with IgA deposition	Biopsy	Palpable purpura Age at onset is less than 20 years Acute abdominal pain
	Fournier's gangrene	Bilateral	Sudden	+	-	+	+	-	-	+	Leukocytosis Acidosis Elevated ESR and CRP Blood cultures are positive in majority of patient for streptococcus.	-	-	-	Computed tomography (CT) scan shows most useful finding is presence of gas in soft tissues.	Patient show signs of tense edema outside the involved skin, blisters, bullae, crepitus, and subcutaneous gas.
Scrotal Swelling	Diseases	Unilateral /Bilateral swelling	Onset	Fever	Urinary symptoms	Tenderness	Erythema	Discharge	Inguinal Lymphadenopathy	Cremasteric Reflex	Blood/Urine Analysis	Doppler U/S	Past Medical History	Histopathology	Gold standard	Additional findings
Painless	Fragile X Macroorchidism	Bilateral	Gradual	-	Absent	--	-	+	Absent	+	Normal	-	-	Increased volume of testis	FMR1 DNA analysis	Long and narrow face with prominent forehead and chin (prognathism) Large ears Intellectual Disability
	Testicular Tumors	Unilateral or bilateral	Gradual	±		±		+	Present	+	Increased serum beta-hCG or alpha fetoprotien (AFP)	-	-	Seminoma shows findings such as: Large cells with watery cytoplasm Fried egg appearance	Biopsy	Pain in the back or abdomen Ascites Weight loss Gynecomastia Precocious Puberty Infertility
	Hydrocele	Bilateral	Gradual	-	Absent	-	-	-	Absent	+	-	Normal	-	-	Ultrasound: simple fluid collection	Transillumination test is positive
	Varicocele	Unilateral (Mainly left)	Gradual	Local warmth	Absent	-	±	-	Absent	+	Elevations in unstimulated luteinizing hormone and follicle stimulating hormone levels may be seen in when associated with infertility in adults	Thrombosis of Inferiror vena cava ●Thrombosis of Right renal vein ●Abdominal mass	Renal cancer Nephrectomy Nut-cracker syndrome	-	Ultrasonography: tortuous, tubular, anechoic structures adjacent to the testis corresponding to dilated veins of the pampiniform plexus with calibers of 2–3 mm during the Valsalva maneuver	Infertility
	Spermatocele	Unilateral	Gradual	-	-	-	-	-	Absent	+	-	Falling snow, resulting from internal echoes moving away from the transducer	Epididymitis Trauma	Epididymal scarring is seen	Ultrasonography: hypoechoic with posterior acoustic enhancement	Transillumination test is positive
	Inguino-scrotal hernia					-		-	Absent
	Scrotal edema	Bilateral and can extend to perineum	Gradual	-	-	-	-	-	Absent	+	Eosinophilia Hypoalbuminemia Hyperlipidemia. Proteinurea	Deep Vein Thrombosis	Nephrotic Syndrome Hepatic Cirrhosis Insect Bite	-	Kidney or Liver biopsy	Occurs between 4-12 years of age.
	Sebaceous cyst	Unilateral	Gradual	-	-	-	-	-	Absent	+	-	Normal	-	Fibrous tissues and fluids A fatty,(keratinous), substance that resembles cottage cheese,. A viscous, serosanguinous fluid (containing purulent and bloody material).	Histological examination	Freely movable on palpation.
	Carcinoma of the scrotum	-	Gradual	-	-	-	-	-	Absent	+	-	Normal	-	keratinocytic dysplasia involving the full thickness of the epidermis without infiltration of atypical cells into the dermis. The keratinocytes are pleomorphic with hyperchromatic nuclei Numerous mitoses are present.	Biopsy	Scaly patch or plaque is seen over the testis.
	Chylocele (Filariasis)	Unilateral or Bilateral	Gradually/Rapidly	+	-	-	-	-	Absent	+	Circulating filarial antigen (CFA) assays are positve	Lymphatics containing worms can be differentiated from the blood vessels by irregular movement	-	-	CFA assay	Ultrasound demonstrates living worms which has been described as "filarial dance" sign.
	Scrotoliths	Unilateral	Gradual	-	-	-	-	-	Absent	+	-	Normal	Trauma Torsion of appendix	-	Ultrasound	Ultrasound shows mobile hyperechoic extratesticular focus in the potential tunica space.