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[1][2]
[3][4][5][6][7][8] 		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
Orchitis

(Mumps)[9][10][11][12]
[13][8][7][14]

Bilateral Abrupt ± Dysuria + - ± Painful local lymphadenopathy +
  • CBC-Leukocytosis
  • raised CRP
  • Immunofluorescent antibody testing
  • Urine analysis and culture - normal
  • Increased blood flow in affected side.
  • 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[15][16][17][18][19][7] Unilateral Sudden - - + + Blood in semen may be present Absent - Normal
  • Absent or decreased arterial perfusion of the testis
  • 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
 Phen sign +ve
Hematocele[20][21]
[22][23][24] 		Unilateral or bilateral Sudden - + + Blood in semen Absent
  • Ultrasonography: to check for testicular rupture.
Incarcerated Hernia[25][26] 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[27][28][29][30] 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 -
  • 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[31][32][33][34] 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: Biopsy
Hydrocele[35] Bilateral Gradual - Absent - - - Absent + - Normal - - Ultrasound:

simple fluid collection

Transillumination test is positive
Varicocele[36] 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

- 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[37] 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[38][25] - - Absent
Scrotal edema Bilateral and can extend to perineum Gradual - - - - - Absent +
  • 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.

References

  1. ↑ Yu KJ, Wang TM, Chen HW, Wang HH (2012). "The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis". Chang Gung Med J. 35 (1): 38–45. PMID 22483426.
  2. ↑ Manavi K, Turner K, Scott GR, Stewart LH (May 2005). "Audit on the management of epididymo-orchitis by the Department of Urology in Edinburgh". Int J STD AIDS. 16 (5): 386–7. doi:10.1258/0956462053888853. PMID 15949072.
  3. ↑ Lee YS, Kim SW, Han SW (2018). "Different managements for prepubertal epididymitis based on a preexisting genitourinary anomaly diagnosis". PLoS ONE. 13 (4): e0194761. doi:10.1371/journal.pone.0194761. PMC 5905873. PMID 29668706.
  4. ↑ Ralls PW, Jensen MC, Lee KP, Mayekawa DS, Johnson MB, Halls JM (June 1990). "Color Doppler sonography in acute epididymitis and orchitis". J Clin Ultrasound. 18 (5): 383–6. PMID 2161009.
  5. ↑ Michel V, Pilatz A, Hedger MP, Meinhardt A (2015). "Epididymitis: revelations at the convergence of clinical and basic sciences". Asian J. Androl. 17 (5): 756–63. doi:10.4103/1008-682X.155770. PMC 4577585. PMID 26112484.
  6. ↑ Tracy CR, Costabile RA (April 2009). "The evaluation and treatment of acute epididymitis in a large university based population: are CDC guidelines being followed?". World J Urol. 27 (2): 259–63. doi:10.1007/s00345-008-0338-0. PMID 19002691.
  7. ↑ 7.0 7.1 7.2 Pepe P, Panella P, Pennisi M, Aragona F (October 2006). "Does color Doppler sonography improve the clinical assessment of patients with acute scrotum?". Eur J Radiol. 60 (1): 120–4. doi:10.1016/j.ejrad.2006.04.016. PMID 16730939.
  8. ↑ 8.0 8.1 Ludwig M (April 2008). "Diagnosis and therapy of acute prostatitis, epididymitis and orchitis". Andrologia. 40 (2): 76–80. doi:10.1111/j.1439-0272.2007.00823.x. PMID 18336454.
  9. ↑ Davis NF, McGuire BB, Mahon JA, Smyth AE, O'Malley KJ, Fitzpatrick JM (April 2010). "The increasing incidence of mumps orchitis: a comprehensive review". BJU Int. 105 (8): 1060–5. doi:10.1111/j.1464-410X.2009.09148.x. PMID 20070300.
  10. ↑ CHARNY CW, MERANZE DR (July 1948). "Pathology of mumps orchitis". J. Urol. 60 (1): 140–6. PMID 18873054.
  11. ↑ Bjorvatn B (1973). "Mumps virus recovered from testicles by fine-needle aspiration biopsy in cases of mumps orchitis". Scand. J. Infect. Dis. 5 (1): 3–5. PMID 4580293.
  12. ↑ Beard CM, Benson RC, Kelalis PP, Elveback LR, Kurland LT (January 1977). "The incidence and outcome of mumps orchitis in Rochester, Minnesota, 1935 to 1974". Mayo Clin. Proc. 52 (1): 3–7. PMID 609284.
  13. ↑ Gall EA (July 1947). "The Histopathology of Acute Mumps Orchitis". Am. J. Pathol. 23 (4): 637–51. PMC 1934294. PMID 19970951.
  14. ↑ Başekim CC, Kizilkaya E, Pekkafali Z, Baykal KV, Karsli AF (2000). "Mumps epididymo-orchitis: sonography and color Doppler sonographic findings". Abdom Imaging. 25 (3): 322–5. PMID 10823460.
  15. ↑ Hazeltine M, Panza A, Ellsworth P (2017). "Testicular Torsion: Current Evaluation and Management". Urol Nurs. 37 (2): 61–71, 93. PMID 29240370.
  16. ↑ Estremadoyro V, Meyrat BJ, Birraux J, Vidal I, Sanchez O (February 2017). "[Diagnosis and management of testicular torsion in children]". Rev Med Suisse (in French). 13 (550): 406–410. PMID 28714632.
  17. ↑ Sharp VJ, Kieran K, Arlen AM (December 2013). "Testicular torsion: diagnosis, evaluation, and management". Am Fam Physician. 88 (12): 835–40. PMID 24364548.
  18. ↑ Mikuz G (1985). "Testicular torsion: simple grading for histological evaluation of tissue damage". Appl Pathol. 3 (3): 134–9. PMID 3842075.
  19. ↑ Gunther P, Schenk JP, Wunsch R, Holland-Cunz S, Kessler U, Troger J, Waag KL (November 2006). "Acute testicular torsion in children: the role of sonography in the diagnostic workup". Eur Radiol. 16 (11): 2527–32. doi:10.1007/s00330-006-0287-1. PMID 16724203.
  20. ↑ Bowen DK, Gonzalez CM (2014). "Intratesticular hematoma after blunt scrotal trauma: a case series and algorithm-based approach to management". Cent European J Urol. 67 (4): 427–9. doi:10.5173/ceju.2014.04.art24. PMC 4310892. PMID 25667770.
  21. ↑ Askari R, Khouzam RN, Dishmon DA (2017). "Image Diagnosis: Rapidly Enlarging Scrotal Hematoma: A Complication of Femoral Access?". Perm J. 21. doi:10.7812/TPP/16-111. PMC 5469436. PMID 28609265.
  22. ↑ Mizutani Y, Miyakawa M (February 1991). "[A case of idiopathic chronic scrotal hematocele]". Hinyokika Kiyo (in Japanese). 37 (2): 199–201. PMID 2048502.
  23. ↑ Kratzik C, Hainz A, Kuber W, Donner G, Lunglmayr G, Frick J, Schmoller HJ (November 1989). "Has ultrasound influenced the therapy concept of blunt scrotal trauma?". J. Urol. 142 (5): 1243–6. PMID 2681835.
  24. ↑ Rao MS, Arjun K (October 2012). "Sonography of scrotal trauma". Indian J Radiol Imaging. 22 (4): 293–7. doi:10.4103/0971-3026.111482. PMC 3698892. PMID 23833421.
  25. ↑ 25.0 25.1 Jenkins JT, O'Dwyer PJ (2008). "Inguinal hernias". BMJ. 336 (7638): 269–72. doi:10.1136/bmj.39450.428275.AD. PMC 2223000. PMID 18244999.
  26. ↑ Berger D (2016). "Evidence-Based Hernia Treatment in Adults". Dtsch Arztebl Int. 113 (9): 150–7, quiz 158. doi:10.3238/arztebl.2016.0150. PMC 4802357. PMID 26987468.
  27. ↑ Kaya F, Kocyigit A, Kaya C, Turkcuer I, Serinken M, Karabulut N (March 2015). "Brucellar Testicular Abscess Presenting as a Testicular Mass: Can Color Doppler Sonography be used in Differentiation?". Turk J Emerg Med. 15 (1): 43–6. doi:10.5505/1304.7361.2014.82698. PMC 4909939. PMID 27331193.
  28. ↑ Navarro-Martínez A, Solera J, Corredoira J, Beato JL, Martínez-Alfaro E, Atiénzar M, Ariza J (December 2001). "Epididymoorchitis due to Brucella mellitensis: a retrospective study of 59 patients". Clin. Infect. Dis. 33 (12): 2017–22. doi:10.1086/324489. PMID 11698991.
  29. ↑ Colmenero JD, Muñoz-Roca NL, Bermudez P, Plata A, Villalobos A, Reguera JM (April 2007). "Clinical findings, diagnostic approach, and outcome of Brucella melitensis epididymo-orchitis". Diagn. Microbiol. Infect. Dis. 57 (4): 367–72. doi:10.1016/j.diagmicrobio.2006.09.008. PMID 17141451.
  30. ↑ Reisman EM, Colquitt LA, Childers J, Preminger GM (April 1990). "Brucella orchitis: a rare cause of testicular enlargement". J. Urol. 143 (4): 821–2. PMID 2313817.
  31. ↑ Choong CS, Liew KL, Liu PN, Kuo TU, Su CM (July 2000). "Acute scrotum in Henoch-Schönlein purpura". Zhonghua Yi Xue Za Zhi (Taipei). 63 (7): 577–80. PMID 10934812.
  32. ↑ Modi S, Mohan M, Jennings A (May 2016). "Acute Scrotal Swelling in Henoch-Schonlein Purpura: Case Report and Review of the Literature". Urol Case Rep. 6: 9–11. doi:10.1016/j.eucr.2016.01.004. PMC 4855902. PMID 27169017.
  33. ↑ Dayanir YO, Akdilli A, Karaman CZ, Sönmez F, Karaman G (2001). "Epididymoorchitis mimicking testicular torsion in Henoch-Schönlein purpura". Eur Radiol. 11 (11): 2267–9. doi:10.1007/s003300100843. PMID 11702171.
  34. ↑ Akgun C (2012). "A case of scrotal swelling mimicking testicular torsion preceding Henoch-Schönlein vasculitis". Bratisl Lek Listy. 113 (6): 382–3. PMID 22693978.
  35. ↑ Yang DM, Kim HC, Lim JW, Jin W, Ryu CW, Kim GY, Cho H (2007). "Sonographic findings of groin masses". J Ultrasound Med. 26 (5): 605–14. PMID 17460003.
  36. ↑ Yang DM, Kim HC, Lim JW, Jin W, Ryu CW, Kim GY, Cho H (2007). "Sonographic findings of groin masses". J Ultrasound Med. 26 (5): 605–14. PMID 17460003.
  37. ↑ Yang DM, Kim HC, Lim JW, Jin W, Ryu CW, Kim GY, Cho H (2007). "Sonographic findings of groin masses". J Ultrasound Med. 26 (5): 605–14. PMID 17460003.
  38. ↑ Berger D (2016). "Evidence-Based Hernia Treatment in Adults". Dtsch Arztebl Int. 113 (9): 150–7, quiz 158. doi:10.3238/arztebl.2016.0150. PMC 4802357. PMID 26987468.
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