Scrotal Masses: Symptoms, Types, Causes and Treatment

Scrotal masses are a common clinical concern affecting males of all ages, from infants to older adults. These masses can arise from a variety of underlying conditions—some benign and others potentially life-threatening. Rapid and accurate evaluation is critical, especially when symptoms are acute, to determine the appropriate management and ensure the best outcomes. In this comprehensive guide, we’ll explore the key symptoms, types, causes, and treatments for scrotal masses, drawing on the latest clinical evidence and imaging practices.

Symptoms of Scrotal Masses

Recognizing the symptoms associated with scrotal masses is vital for early diagnosis and intervention. While some masses are discovered incidentally and are painless, others present acutely and may signal a medical emergency.

Symptom	Description	Urgency	Source(s)
Pain	Sudden, severe, or gradual onset	Emergency if acute	1 2 3
Swelling	Enlargement of scrotum, may be unilateral	Varies	1 2 3 8
Redness	Red or warm scrotal skin	Often acute	1 2
Palpable Mass	Lump or firm area within scrotal sac	Varies	2 3 8
Nausea/Vomiting	Often accompanies torsion	Emergency	3
High/rising testicle	Abnormal testicular position	Emergency	3
Non-healing skin lesion	Persistent skin change or ulcer	Possible malignancy	3

Table 1: Key Symptoms of Scrotal Masses

Understanding Symptom Presentation

Symptoms of scrotal masses can range from subtle to dramatic. Here’s how to interpret them in clinical practice:

Acute vs. Chronic Symptoms

• Acute onset (minutes to hours) often indicates emergencies like testicular torsion or infection (epididymitis/orchitis). These require immediate attention to prevent irreversible damage 1 2 3.
• Chronic or gradual symptoms are more typical of benign conditions such as hydroceles and varicoceles, or slow-growing tumors 4 5 7.

Painful vs. Painless Masses

• Painful masses are usually inflammatory (e.g., epididymitis, abscess), traumatic, or vascular in origin (torsion) 2 3.
• Painless masses are concerning for neoplasms but can also be benign cysts or malformations, especially in children 6 8.

Additional Clues

• Nausea, vomiting, and an abnormally high-riding testicle are red flags for testicular torsion, which can compromise blood flow and must be treated within six hours for testicular salvage 3.
• Redness and warmth suggest infection, while a palpable, non-tender mass may indicate a tumor or cyst 1 3 8.
• Persistent or changing scrotal skin lesions should raise suspicion for malignancy and warrant biopsy 3.

Types of Scrotal Masses

Scrotal masses are broadly categorized according to their anatomical location and nature—extratesticular (outside the testicle) or intratesticular (within the testicle). This distinction is crucial because it guides diagnosis and treatment.

Type	Location	Nature	Source(s)
Hydrocele	Extratesticular	Benign, cystic	2 4 6
Varicocele	Extratesticular	Benign, vascular	2 4 6
Epididymal cyst	Extratesticular	Benign, cystic	4 6
Spermatocele	Extratesticular	Benign, cystic	2 4
Tumor (benign)	Extratesticular	Rare, solid	4 5 7
Tumor (malignant)	Intratesticular	Often malignant	2 3 6 8
Orchitis/Epididymitis	Both	Inflammatory	1 2 4
Abscess	Both	Infectious	2 4
Trauma (hematoma, rupture)	Both	Variable	1 2
Hernia	Extratesticular	Benign	2 3 4

Table 2: Types of Scrotal Masses

Major Categories of Scrotal Masses

Extratesticular Masses

These are mostly benign and include:

• Hydroceles: Fluid-filled sacs surrounding the testicle, often painless and transilluminate with light 2 4.
• Varicoceles: Dilated veins of the pampiniform plexus, commonly found on the left side, described as a "bag of worms" on palpation 2 4 6.
• Epididymal cysts and spermatoceles: Small, fluid-filled collections in the epididymis 2 4 6.
• Benign tumors: Lipomas and adenomatoid tumors are the most frequent; malignant extratesticular tumors are rare but include sarcomas and lymphomas 4 5 7.

Intratesticular Masses

• Testicular tumors: The majority of intratesticular masses are malignant in adults (e.g., germ cell tumors), while some benign tumors occur in children 3 6 8.
• Infections: Orchitis and epididymo-orchitis can cause testicular enlargement and mimic neoplasms 1 2 4.
• Cystic lesions and malformations: Such as cystic dysplasia or ectasia of the rete testis, especially in pediatric cases 9 10.

Other Masses

• Abscesses: Can develop from untreated infections, sometimes requiring drainage 2 4.
• Traumatic lesions: Hematomas, testicular rupture or fracture after injury 1 2.
• Hernias: Inguinal hernias may extend into the scrotum and can be differentiated by their separation from the testicle and reducibility 2 3 4.

Causes of Scrotal Masses

A scrotal mass can result from a variety of causes, including infection, trauma, neoplasia, congenital malformations, or vascular events.

Cause	Typical Presentation	Risk Group	Source(s)
Infection	Pain, swelling, erythema	All ages	1 2 4
Tumor (benign)	Painless lump	Adults, some children	4 5 7 8
Tumor (malignant)	Painless or painful lump	Young men, children	3 6 8
Trauma	Acute pain, swelling	Adolescents, adults	1 2
Hernia	Swelling, reducible mass	All ages	2 3 4
Congenital	Swelling, sometimes bilateral	Infants, children	8 9 10
Vascular (torsion)	Sudden pain, high-riding testicle	Adolescents, young adults	2 3

Table 3: Common Causes of Scrotal Masses

Detailed Breakdown of Causes

Infectious Causes

• Epididymitis and epididymo-orchitis: Usually bacterial, spreading from the urinary tract; most common in sexually active men and older adults. Presents with pain, swelling, and often fever. Distinguishing from torsion is critical 1 2 4.
• Abscess: Complication of untreated infection, presenting as a tender, fluctuant mass 2 4.

Neoplastic Causes

• Testicular cancer: The leading cause of a painless scrotal mass in young men, often detected incidentally. Tumors can be benign or malignant, with most intratesticular masses considered malignant until proven otherwise 3 6 8.
• Benign tumors: Such as adenomatoid tumors, lipomas, and cystadenomas, most commonly arise from the epididymis or spermatic cord 4 5 7.
• Malignant extratesticular tumors: Rare, but include sarcomas and lymphomas 4 7.

Traumatic Causes

• Blunt or penetrating trauma: Can lead to hematoma, rupture, fracture, or torsion. Often presents with acute pain and swelling. Ultrasound is critical for assessment 1 2.

Congenital and Developmental

• Hydrocele: Persistence of a patent processus vaginalis leads to fluid accumulation 2 4.
• Malformations: Such as cystic dysplasia or ectasia of the rete testis, often associated with kidney anomalies in children 9 10.

Vascular

• Testicular torsion: An emergency caused by twisting of the spermatic cord, compromising blood supply. Presents with sudden, severe pain, high-riding testicle, and sometimes systemic symptoms 2 3.
• Varicocele: Venous dilatation, commonly on the left, related to anatomical drainage patterns 2 4 6.

Hernia

• Inguinal hernias: Abdominal contents herniate into the scrotum, palpable as a separate mass from the testicle. Strangulated hernias are surgical emergencies 2 3 4.

Treatment of Scrotal Masses

Treatment strategies for scrotal masses depend on the underlying cause, severity of symptoms, and risk of malignancy. Prompt and accurate diagnosis ensures that emergent conditions are not missed, while avoiding unnecessary intervention in benign cases.

Treatment	Indication	Approach	Source(s)
Surgical repair	Torsion, tumor, hernia, trauma	Emergency/Planned	2 3 11 12 13
Antibiotics	Infection (epididymitis, orchitis)	Medical	1 2 4
Observation	Benign cysts, stable hydrocele	Conservative	4 6 12 14
Drainage	Abscess, large hydroceles	Procedure	2 4
Testis-sparing surgery	Select tumors, children	Organ-preserving	6 11 12 14
Radical orchiectomy	Suspected malignancy	Surgery	11 12 13
Biopsy	Indeterminate lesions	Diagnostic	3 14

Table 4: Treatment Approaches to Scrotal Masses

Treatment Pathways Explained

Emergencies

• Testicular torsion: Immediate surgical exploration and detorsion are required, ideally within 6 hours of symptom onset for salvage of the testis 2 3.
• Strangulated hernia: Urgent surgical repair to prevent tissue necrosis 3 4.
• Rupture or severe trauma: Surgery may be needed to repair or remove damaged tissue 1 2.

Infections

• Epididymitis/orchitis: Managed with antibiotics, analgesia, and scrotal support. Abscesses may require surgical drainage 1 2 4.
• Chronic infections or abscess: Surgical intervention may be necessary for persistent or complicated cases 2 4.

Tumors

• Testicular cancer: Standard treatment is radical inguinal orchiectomy (removal of the testis and spermatic cord). Testis-sparing surgery may be considered in select pediatric or benign cases, but always with careful pathology assessment 6 11 12 13.
• Benign extratesticular tumors: Observation or surgical excision depending on symptoms and growth. Most do not require urgent intervention 4 5 7 15.

Benign Lesions

• Hydroceles, spermatoceles, small cysts: Often managed conservatively. Surgery is considered for discomfort, cosmetic reasons, or complications 4 6 12 14.
• Varicocele: Surgical repair for pain, infertility, or testicular atrophy 4 6.
• Congenital malformations: Surgical correction as needed, especially if associated with other urogenital anomalies 9 10.

Imaging and Biopsy

• Ultrasound is the first-line imaging modality for all scrotal masses, helping to distinguish benign from malignant, cystic from solid, and intra- from extratesticular lesions 1 2 4 14.
• MRI may be used if ultrasound findings are indeterminate, especially before considering invasive procedures 14.
• Biopsy is generally reserved for extratesticular or scrotal wall lesions or when diagnosis remains unclear after imaging 3 14.

Follow-Up and Surveillance

• Nonpalpable or incidental testicular masses: May be managed with surveillance or excisional biopsy, depending on imaging and clinical suspicion 12 14.

Conclusion

Scrotal masses encompass a wide spectrum of conditions, from benign cysts to urgent surgical emergencies and malignancies. Accurate diagnosis relies on a combination of clinical assessment and high-resolution imaging, with ultrasound as the cornerstone. Treatment is tailored to the underlying cause, prioritizing testicular salvage in emergencies and avoiding overtreatment in benign cases.

Main points covered:

• Scrotal masses may present acutely with pain and swelling, or be painless and discovered incidentally.
• The anatomical location (intra- versus extratesticular) is key to narrowing the differential diagnosis.
• Most extratesticular masses are benign; intratesticular masses are considered malignant until proven otherwise.
• Causes include infection, trauma, tumors (benign and malignant), congenital malformations, vascular events, and hernias.
• Treatment ranges from emergency surgery (torsion, trauma, tumor) to conservative management (benign cysts, hydroceles).
• Ultrasound is essential for evaluation; MRI and biopsy play a role in select cases.
• Early recognition and tailored intervention are crucial to optimize outcomes and preserve fertility and testicular function.

If you notice a lump, swelling, pain, or other changes in your scrotum, seek medical evaluation promptly—timely assessment can make a significant difference in treatment and prognosis.