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

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	Painful local lymphadenopathy	+		Leukocytosis	Enlarged (>17 mm) epididymis with a hypoechoic, hyperechoic, or heterogeneous echotexture, increased blood flow	Hydrocele Urinary tract infection	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)	Phen sign +ve
	Orchitis (Mumps)	Bilateral	Abrupt	±	Dysuria	+	-	±	Painful local lymphadenopathy	+	Leukocytosis		Mumps, coxsackievirus infection Concurrent epididymitis Congenital abnornmalities		Ultrasound for diagnosis (Testicular massesor swollen testicles with hypoechoic and hypervascular areas)	Phen sign +ve
	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		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								-	Testicular Abcess					-												-	Brucellosis					-
	Histoplasma
	Gonorrhea
	Fournier's gangrene
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 XMacroorchidism	Bilateral				-		+
	Testicular Tumors					±		+
	Henoch-Schonlein purpura					-		-
	Hydrocele		Gradual	-	Absent	-	-	-	Absent	+					Ultrasound: simple fluid collection	Transillumination test +ve.
	Varicocele	Unilateral (Mainly left)	Gradual	Local warmth	Absent	-	±	-	Absent	+			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
	Spermatocele		Gradual			-	-	-	Absent	+		Falling snow, resulting from internal echoes moving away from the transducer			Ultrasonography: hypoechoic with posterior acoustic enhancement
	Inguino-scrotal hernia					-		-	Absent
	Scrotal edema	Bilateral and can extend to perineum				-	-	-			Eosinophilia					Occurs between 4-12 years of age.
	Epididymal cyst					±									Ultrasonography: posterior acoustic enhancement, well defined anechoic lesions, larger cysts may contain septations
	Scrotal oedema
	Sebaceous cyst
	Carcinoma of the scrotum
	Chylocele (Filariasis)		Gradually/Rapidly
	Cystic dysplasia
	Srotoliths