Testicular / Scrotal Swelling

Common Causes

Diagnosis

Clinical Assessment

• History: onset (acute vs. gradual), pain, fever, sexual history, trauma
• Examination: side, consistency, tenderness, position, transillumination, cremasteric reflex

Investigations

• Scrotal Ultrasound (Doppler): First-line imaging — assesses blood flow (rules out torsion), identifies hydrocele, varicocele, masses (STI Guidelines, p. 101)
  • Ultrasound is primarily used to rule out torsion in acute painful swelling
  • A negative ultrasound does not rule out epididymitis and should not override clinical judgment
• Urinalysis / Urine culture: For suspected infection
• STI swabs / NAAT (urine or urethral): If epididymo-orchitis suspected
• Tumour markers: AFP, β-hCG, LDH — if testicular cancer suspected
• Radionuclide scan: Most accurate for epididymitis but rarely available

Note: Bilateral testicular pain/swelling should raise suspicion for systemic causes (e.g., mumps orchitis, vasculitis, lymphoma).

Treatment by Condition

🔴 Testicular Torsion (Surgical Emergency)

• Immediate surgical exploration — do NOT wait for imaging if clinical suspicion is high
• Manual detorsion can be attempted while awaiting theatre (usually "open book" — rotate outward)
• Orchiopexy of both testes (bilateral fixation) once viability confirmed
• Orchidectomy if testicle non-viable (>6 hours ischemia — salvage rate drops significantly)
• Window of salvage: >90% if within 6 hrs, <10% after 24 hrs

🟠 Epididymo-Orchitis

• Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg BD × 10–14 days
• Treat sexual partners; abstain during treatment

• Ofloxacin 200 mg BD × 14 days OR Levofloxacin 500 mg OD × 10 days

• Scrotal support / elevation
• NSAIDs (e.g., ibuprofen 400 mg TDS) for pain/inflammation
• Rest and hydration

🟡 Hydrocele

Aspiration + sclerotherapy (e.g., with tetracycline, polidocanol) is an option in patients unfit for surgery.

🟡 Varicocele

• Indications for treatment: subfertility, chronic dull pain, testicular atrophy in adolescents
• Options:
  • Surgical ligation (subinguinal microsurgical approach — gold standard)
  • Laparoscopic ligation
  • Percutaneous embolization (radiological, less invasive)
• No treatment needed if asymptomatic and fertility is not a concern

🟡 Epididymal Cyst

• Usually no treatment needed if asymptomatic
• Surgical excision if large, symptomatic, or causing anxiety — though risk of epididymal damage exists

🔴 Testicular Cancer

• Urgent orchidectomy via inguinal approach (never scrotal) for diagnosis and primary treatment
• Further management depends on histology (seminoma vs. non-seminoma) and staging:
  • Stage I: Surveillance / adjuvant radiotherapy (seminoma) / BEP chemotherapy (NSGCT)
  • Advanced: BEP chemotherapy ± retroperitoneal lymph node dissection (RPLND)

🟡 Inguinal Hernia with Scrotal Extension

• Elective surgical repair (open or laparoscopic) for reducible hernias
• Emergency surgery for irreducible/strangulated hernia

Clinical Image — Massive Scrotal Swelling

Chronic massive left-sided scrotal swelling with tense, shiny overlying skin and loss of rugosities — differential includes giant hydrocele, pyocele, or testicular neoplasm.

Key Clinical Pearls

• Acute painful scrotal swelling = testicular torsion until proven otherwise — time is testicle
• Doppler ultrasound is the investigation of choice but should never delay surgical exploration when torsion is clinically suspected
• A hard, painless testicular lump in a young man = cancer until proven otherwise
• Transillumination differentiates fluid-filled (hydrocele/cyst) from solid lesions