Testicular/scrotal abnormalities

Signs and symptoms in the classic case
	Symptoms	Signs
Testicular torsion	Sudden onset Severe pain Associated nausea and vomiting Associated trauma Possible abdominal pain	Asymmetric, high-riding testis Negative Prehn’s sign Absent cremasteric reflex
Epididymitis	Insidious onset Fevers and rigors Lower urinary tract symptoms Relevant sexual history	Indurated testis Tender upper pole of testis Positive Prehn’s sign Intact cremasteric reflex
Torsion of the appendix testis	Gradual onset Moderate to severe pain Associated nausea and vomiting	Localised tenderness to anterior testis‘ Blue dot’ sign

Non-painful scrotal swelling   

	Hydrocele	Varicocele	Idiopathic scrotal oedema	Tumour/  leukaemia
Typical age group	Infants	Peri-pubertal	3-7 years	1-8 years
Fever	Unusual	Unusual	Unusual	Possible
Palpation	Soft Non-tender Fluctuant	“Bag of Worms” Occasionally tender	Non-tender May have low-grade discomfort	Hard Non-tender May be painful if rapidly growing
Swelling pattern	Scrotal	Predominantly left-sided	Can extend across midline and into perineum, groin, penis	Unilateral or bilateral
Discoloration	No	No	Bland, purplish	No
Transilluminable	Brightly	No	No	No
Reactive hydrocele	–	No	No	Possible

Scrotal pain +/- swelling 

	Testicular torsion	Irreducible hernia	Torsion of testicular appendage	Epididymo-orchitis	Trauma eg testicular or epididymal rupture
Typical age group	Pubertal (and rarely neonates)	Infants	Pre-pubertal (7-12 years)	<2 years and post-pubertal (rarely pre-pubertal)	–
Pain	Severe Usually sudden onsetMay radiate to iliac fossa or thigh	Irritable	Usually sudden onset Usually minimal at rest	Sudden or subacute onset May improve with elevation	May be delayed
Swelling	Yes	Yes May extend to scrotum	Yes	Yes	May be delayed
Fever	Unusual	Unusual	Unusual	Common	Unusual
Nausea and vomiting	Common (90%)	Common	Uncommon	Uncommon	Uncommon
Dysuria or discharge	No	No	No	Common	No
Gait	Impaired	–	–	–	–
Position of testis	High riding or horizontal	–	Normal	–	–
Palpation	Tender Thickened spermatic cord	Firm and tender Swelling not reducible	Focal tenderness of upper pole of testis	Tender postero-lateral testis	Tender
Oedema crosses midline	No	No	No	Possible	Possible
Discoloration	Red/blue Dark in neonate	–	Blue dot sign	Red	Bruising(consider causes, eg NAI)
Cremasteric reflex	Usually absent	Usually present	Usually present	Usually present	Usually present
Reactive hydrocele	Possible	No	No	Possible	Possible

Testicular lump differentials

• Average testicular weight 20 g, > 15mL (< 12mL is reduced) 

1. Intratesticular:
   • malignant testicular tumour
     • Painless, may have dull ache heaviness, firmness or swelling
   • benign intratest lesions: 
     • simple cyst
     • epidermoid cyst
     • benign teratoma (esp in prepubertal testis)

2. Inflammatory:
   • acute epidiymoorchitis
     • Most common cause painful swelling in post-pubertal males
     • Infection due to Chlamydia ro Gonorrhea < 35 years
     • E coli > 35
     • If severe can cause scrotal swelling, urethral discharge, pain, fevers, LUTS
     • Elevation of scrotum
   • viral orchitis
     • Swelling/pain in on or both testicles
     • Usually due to infection
     • Testis is enlarge, indurated, tender on palpation
     • Treatment – bed rest, ice, scrotal support, analgesia, treat infection
   • chronic tuberculous epididymoorchitis
   • schistosomal epididymitis
   • sperm granuloma

3. Traumatic:
   • scrotal haematoma
   • haematocele: haematoma w/in TV
   • testicular haematoma: haematoma w/in TA

4. Derangement of testicular, adnexal or cord anatomy:
   • epididymal cysts or spermatocele of the epididymis
     • Fluid filled cyst that develops at the head of the epididymis
     • Generally painless
     • Usually filled with mild fluid and may contain sperm
   • varicocele: varicosities of the pampiniform plexus
     • Tortuosity
     • Present in up to 20% of males
     • Often asymptomatic
     • Most common surgically correctable cause of infertility
   • inguinal hernia: patent processus vag in children (–> indirect)
   • hydrocele:
     • Painless scrotal swelling which tends to worsen throughout the day
     • Collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis
   • late (missed) or prenatal torsion of the spermatic cord
   • persistence of embryological vestigular structures:
     • Müllerian duct remnant (appendix testis)
     • Wolffian duct remnants (appendix epididymis, vas aberrans of Haller, paradidymis)

5. Miscellaneous:
   • acute idiopathic scrotal oedema
   • cutaneous lesions (e.g. sebaceous cysts)
   • Henoch-Schönlein purpura

• Testicular torsion
  • Sudden onset pain, ischaemia, assymetrical