Scrotal Swellings and Examination

Scrotal swellings are not an uncommon presentation, and it is crucial to be able to differentiate the cause of swelling, as some are a lot more serious than others.  Common and important causes include:

  • Testicular cancer
  • Testicular torsion
  • Torsion of a testicular/epididymal appendage
  • Varicocele
  • Hydrocele
  • Haematocele
  • Epididymal cyst (spermatocele)


  • Ask about pain- duration, severity etc
    • usually severe and acute onset in testicular torsion
    • more gradual pain/swelling in epididymo-orchitis
    • episodic pain can be an atypical feature of testicular torsion
  • Ask about any associated symptoms
    • e.g. features of UTI/STI (e.g. discharge, pyuria) which might suggest epididymo-orchitis
    • parotid swelling (mumps orchitis)
    • nausea/vomiting (torsion, rarely in epididymo-orchitis)
  • Any history of trauma (haematocele, rarely in torsion)
  • Also ask about any relevant past medical history: in particular- undescended testes

NB consider the age of the patient: torsion is generally more common in young men, whereas cancer may be more common in older men


  • If there is a normal side, always examine this first to a) make sure it is normal and b) compare to abnormal
  • Inspect for
    • Lie (is one testis higher than other?); appearance; scars; oedema; sebaceous cysts, ulcers or swellings; erythema
  • Palpate
    • Does the patient have 2 testes? If not, feel the inguinal canal and perineum for an undescended testis.
      • The scrotum should be freely mobile from the testes
    • Feeling the normal side first, palpate the body and poles of the testicle, checking the patient’s face for any pain/tenderness (ask this too)
      • Compare size, shape and consistency (they should be roughly equal, smooth, rubbery and firm)
      • Are there any lumps, changes in consistency, tenderness, swelling etc?
    • Palpate the epididymis along the posterolateral border of the testis, again noting any tenderness or abnormality
    • Palpate up each spermatic cord, whilst gently pulling the respective testis downwards
      • It should feel regular and smooth
  • Special tests
    • Cremasteric reflex
      • can be elicited by stroking the superficial aspect of the medial thigh near the testes and the testis should rise on the respective side.
        • may not do so in torsion
    • Prehn’s sign
      • If the patient has pain which is relieved by raising the testes- the pain is suggestive more of epididymitis.
  • Assessing scrotal swellings
    • scrotal swellings

Differential Diagnosis


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