Scrotal or Testicular Lump

Overview

Any new lump or swelling in the scrotum warrants prompt urological assessment. While the majority of scrotal lumps are caused by benign conditions, it is essential to exclude testicular cancer, which — though uncommon — is the most frequent solid tumour in men between the ages of 20 and 40.

The guiding principle is that a new scrotal lump should be assessed without unnecessary delay. This is not a reason for alarm, but it is a reason for action. Testicular cancer, when diagnosed at an early stage, has a very high cure rate with appropriate treatment — making prompt assessment genuinely important.

Common benign causes of scrotal lumps

• Epididymal cyst — a smooth, non-tender cyst attached to the epididymis (the coiled tube behind the testicle); very common and entirely benign
• Hydrocele — fluid around the testicle, producing smooth scrotal swelling that transilluminates
• Varicocele — dilated veins producing a characteristic “bag of worms” texture above the testicle
• Epididymo-orchitis — infection or inflammation of the epididymis and sometimes the testicle itself; typically presents with pain and swelling and systemic upset
• Inguinoscrotal hernia — bowel or omental tissue descending into the scrotum through a groin hernia

Symptoms

The presentation of a scrotal lump varies with the underlying cause:

• Painless testicular lump — most characteristic presentation of testicular cancer; should never be dismissed as trivial
• Smooth, separate swelling behind or above the testicle — suggests epididymal cyst; the testicle itself is normal
• Painful swelling with fever and dysuria — suggests epididymo-orchitis; but infection should not be assumed until a testicular cause has been excluded by ultrasound, particularly in younger men
• Soft, compressible swelling above the testicle, worse on standing — suggests varicocele
• Transilluminable swelling around the testicle — consistent with hydrocele

The most important clinical distinction is whether the lump originates within the testicle or separately from it — a distinction that can be confirmed by ultrasound.

Diagnosis

• Scrotal ultrasound — the cornerstone investigation; performed urgently when a testicular origin cannot be excluded clinically; highly accurate at characterising the nature of a scrotal lump and identifying whether it arises within the testicle
• Tumour markers — AFP (alpha-fetoprotein), bHCG (beta human chorionic gonadotrophin), and LDH (lactate dehydrogenase) are measured when testicular cancer is suspected; they are elevated in certain tumour types and are important for staging and monitoring after treatment
• Clinical examination — systematic examination of both testes, the epididymis, and the cord; a clearly separate, non-testicular lump on examination significantly reduces the probability of malignancy

If testicular cancer is confirmed, staging CT scans of the chest, abdomen, and pelvis are arranged, and the patient is referred to an oncology multidisciplinary team.

Treatment

Treatment depends entirely on the diagnosis:

• Epididymal cyst — observation if asymptomatic; surgical excision if causing significant discomfort
• Hydrocele — observation or surgical repair depending on size and symptoms
• Varicocele — treated if symptomatic or if associated with infertility
• Epididymo-orchitis — antibiotic treatment guided by culture; scrotal support and analgesia
• Testicular cancer — radical orchidectomy (surgical removal of the affected testicle) is the definitive diagnostic and initial therapeutic step; this is performed through a groin incision; subsequent treatment (surveillance, radiotherapy, or chemotherapy) depends on the tumour type and stage and is coordinated by an oncology MDT

Dr Hadjipavlou performs scrotal ultrasound assessment and initial evaluation of scrotal lumps. Men in whom testicular cancer is confirmed are referred to the relevant oncology multidisciplinary team for further management.