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)

History

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

Examination

YOU SHOULD ALWAYS EXAMINE THE SCROTUM IN THE STANDING POSITION
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