A man, aged 35 years, presents with a “lump” in his testicle that he first noticed three weeks earlier. The lump is not painful unless bumped or touched. No voiding symptoms are reported, and he has had no fever or other systemic symptoms. The patient thinks his cousin had his testicle removed years ago because of cancer, but he does not know any details. The man tries to appear calm, but a certain level of anxiety is obvious.
Is the problem life-threatening or just causing discomfort? Does the patient need surgery, or can the problem be left alone? Should we treat it, monitor it or forget about it?
We ask these questions about every patient and condition we treat. When the patient’s worry and concern are added to the equation, not only are our clinical abilities put to the test but our compassion and communication skills as well. Even if we are completely confident in the diagnosis and treatment, does the patient feel the same confidence at the end of the encounter?
Problems involving the male genitalia seem to heighten these concerns. Getting a man to come to the clinic is difficult enough, so when he does show up, you can be sure there is significant anxiety and concern — either on the part of the patient or on the part of the loved one who scheduled the appointment. Problems originating in the scrotum can range from small benign cysts to life-threatening cancer. Between these two extremes are a number of conditions that leave the patient wondering how worried he should be.
Most scrotal-content lesions are benign, cystic and found in the paratesticular tissue. Unlike adult testicular lesions, which are malignant 95% of the time, extra-testicular lesions are almost always benign.1 The clinical challenge is determining which is which and helping the patient feel confident in the assessment and treatment plan.
In this review article, we will look at a number of the conditions that may elicit the complaint, “There is a lump in my scrotum.”
The biggest concern for most men is cancer, which should be at the top of our list of differentials as well. Nevertheless, the likelihood of developing testicular cancer is quite low. Only nine in 100,000 men will develop testicular cancer each year. For white Americans, the lifetime risk is 0.2%; for black Americans, it is even lower — 0.05%. There is significant variance between cultural groups and socioeconomic status and prevalence of testicular cancer as well (there is a higher incidence among men who come from homes with higher education and income).2
The statistics notwithstanding, fear of cancer is the reason most men seek evaluation of lumps in the scrotum. Pain is another motivating factor, although it actually pushes testicular cancer down on the differential list because it is present in only 10% of men with a testicular tumor.2
This article will review six of the most common scrotal content problems for which men seek treatment. In order, from least morbidity to greatest, we will review spermatoceles, hydroceles, varicoceles, epididymitis, torsion and testicular cancer.
Cystic lesions that develop in the head of the epididymis, spermatoceles grow out of the efferent tubules, where sperm are stored and mature after spermatogenesis in the testicle. On examination, the lesion is a soft, freely movable, transilluminating mass that is separate from and superior to the testicle.3 At ejaculation, sperm are propelled out of the epididymis and through the vas deferens to combine with the rest of the ejaculatory content, which is produced in the seminal vesicles and prostate.
When found by the patient or his partner, spermatoceles are alarming because of concern for testicular cancer. Clinically, spermatoceles, which are present in about 30% of men who undergo ultrasonographic evaluation of the scrotum,4 are extratesticular cystic lesions that are first palpable when they reach 1 cm to 2 cm in size. They can get to be as large as 15 cm, and some patients will present with concern that they “have a third testicle.”
The consistency of a large spermatocele is, in fact, similar to that of a normal testis. Spermatoceles rarely cause pain. If both scrotal pain and a spermatocele are present, the pain is likely a secondary issue. Another possible reason for a painful spermatocele is that once the patient finds the lesion, he keeps checking to see if it is still present or getting bigger. Constant palpation of a spermatocele can lead to discomfort.
The cause of spermatocele development is unknown. One theory is that spermatoceles arise from trauma, infection, or some other inflammatory process. Another hypothesis is the epididymal ducts become obstructed, causing proximal dilation; obstruction is secondary to epithelium continually shedding immature germ cells that deposit in the efferent ducts.5
The fluid within a spermatocele contains protein and dead sperm. Although aspiration and evaluation of the fluid is one way to verify the diagnosis, this is not usually done because of the risk of infection and discomfort for the patient.6 For the most part, diagnosis can be made on physical examination alone. The key to diagnosis is palpation of a well-demarcated cystic lesion that clearly lies outside the testicle. Spermatoceles transilluminate well. If there is any question, ultrasound (US) is an appropriate imaging modality.
Once the diagnosis is clear, the patient needs to know that he does not have cancer, nor does he have precancer. Spermatoceles do not affect fertility. Some men report spermatocele size change with ejaculation. The spermatocele may get smaller because the content is expelled or larger because the cyst fills, but for the most part, the lesion does not change size appreciably.
Over time, however, spermatoceles may get larger. While spermatoceles do not resolve on their own, surgical removal is not typically warranted because of their benign nature. Moreover, surgical intervention carries inherent risks, such as infertility on the ipsilateral side and chronic pain. If the lesion is large enough to cause problems, however, spermatocelectomy is available.
Hydroceles are the most common cause of painless scrotal swelling and occur when fluid accumulates between either the tunica albuginea and the tunica vaginalis or the parietal and visceral layers of the tunica vaginalis.1
A dense white membrane, the tunica albuginea is the outer covering of each testicle and the penis (in females, it covers the ovaries). The tunica vaginalis is a pouch of serous membrane that lines the peritoneum.
Embryologically, as the testicles descend from the abdomen through the inguinal ring into the scrotum at about week 29 of gestation, the tunica vaginalis encapsulates the testicle and forms a peritoneal diverticulum. By the time a boy is age 2 years, the tunica vaginalis between the proximal testicle and the inguinal ring is obliterated and communication between the abdominal cavity and testicle is closed. Because of its pathophysiology, a hydrocele in a child is quite different from that in an adult.
Hydroceles in children are congenital. Since the testicle has created a diverticulum from the process vaginalis of the peritoneum, communication between the testicular cradle and the peritoneum is open. A patent tunica vaginalis is present in about 80% of infant boys and is clinically observed in about 30% of them. Spontaneous resolution is expected by age 18 months to 2 years as the communicating tunica vaginalis is obliterated. Surgical repair is typically delayed until the child is age 2 years and, if required, is similar to a hernia repair.7
Hydroceles in adults are acquired and rarely present before the fourth decade of life. They are the most common cause of scrotal swelling in adults and are typically found on routine physical examination or incidentally on US. Hydroceles are present, clinically or subclinically, in up to 40% of men.
Unlike congenital hydroceles, fluid accumulation in an adult is the result of an insult to the tunica albuginea or the portion of the tunica vaginalis that remains and encapsulates the testicle. Insults that may lead to a hydrocele include trauma, surgery, infection, radiation to the pelvis, and testicular cancer, but in many cases, no offending factor is identified.6 Note that while hydroceles themselves are almost always benign, they can mask testicular cancer. A hydrocele is present in 10% of men with testicular tumors.2
The pathogenesis of hydroceles is simply that there is an imbalance between fluid secretion and reabsorption in the closed sac between the tunica albuginea and the tunica vaginalis. There is also significant evidence that a defect in lymphatic drainage plays a role as well.
Evidence for lymphatic involvement is substantiated by the finding that protein content of fluid aspirated from idiopathic hydroceles is similar to that found in lymphatic fluid. Lymphatic obstruction probably has an important role in the pathogenesis of hydroceles.8