Scrotal Masses: Symptoms, Causes and Treatment

Scrotal masses are a relatively common clinical finding that can cause significant concern for patients and clinicians alike. These masses can range from benign, self-limited conditions to serious and even life-threatening emergencies. Understanding the symptoms, causes, and treatment options for scrotal masses is essential for timely diagnosis and optimal care.

Symptoms of Scrotal Masses

When it comes to scrotal masses, the symptoms can vary widely based on the underlying cause, ranging from subtle and painless lumps to acute, severe pain that requires emergency intervention. Recognizing the constellation of symptoms associated with scrotal masses is key to prompt evaluation and management, as some conditions—such as testicular torsion—require immediate attention to prevent serious complications.

Symptom	Characteristics	Associated Conditions	Sources
Pain	Acute or gradual onset	Torsion, epididymitis, trauma	1, 2, 9
Swelling	Localized or diffuse	Hydrocele, varicocele, infection	1, 3, 9
Redness	Often with warmth	Infection, inflammation	1, 3
Painless Mass	Typically slow-growing	Tumors, cysts, malformations	1, 4, 10

Table 1: Key Symptoms

Painful vs. Painless Scrotal Masses

Painful scrotal masses often indicate acute or urgent conditions. Testicular torsion, for instance, presents with sudden, severe pain, often accompanied by nausea and vomiting, and requires immediate surgical intervention to prevent loss of the testicle (2, 1). Epididymitis and orchitis tend to have a more gradual onset and are frequently associated with swelling, redness, and sometimes fever (1, 3).

On the other hand, painless scrotal masses may be discovered incidentally during self-examination or routine medical evaluation. These masses are frequently due to benign conditions like hydroceles or spermatoceles, but malignancy—particularly testicular cancer—must always be considered if the mass is intratesticular (1, 4, 10).

Associated Signs and Physical Examination

• Swelling: Can be localized to one side or affect the entire scrotum. May be soft and fluctuant (hydrocele) or firm (tumor) (1, 3).
• Redness and warmth: Suggest inflammation or infection, often seen in epididymitis or abscesses (1, 3).
• Position and consistency: A high-riding testicle and abnormal cremasteric reflex suggest torsion (2).
• Mass characteristics: Cystic masses are usually benign; solid, intratesticular masses are more concerning for malignancy (3, 10).
• Systemic symptoms: Fever, malaise, or signs of sepsis can accompany infectious causes.

When to Seek Immediate Medical Attention

Patients should seek urgent evaluation if they experience:

• Sudden, severe testicular pain
• Rapidly increasing swelling
• Redness and warmth over the scrotum
• Systemic symptoms such as fever or vomiting

Prompt recognition and intervention can be lifesaving, especially in cases of testicular torsion or strangulated hernia (2).

Causes of Scrotal Masses

Scrotal masses can result from a diverse array of conditions, ranging from benign cysts and infections to malignancies. Accurate diagnosis hinges on understanding the potential causes and their typical presentations.

Cause	Description	Typical Age Group	Sources
Infection	Epididymitis, orchitis	All ages	1, 3, 4
Trauma	Hematoma, rupture	Adolescents, adults	1, 5
Tumor	Germ cell or stromal tumor	Children, adults	4, 10, 9
Cystic Lesion	Hydrocele, spermatocele, varicocele	All ages	3, 10
Malformation	Congenital anomalies	Pediatrics	4, 10
Hernia	Inguinal hernia into scrotum	All ages	2, 9
Lymphedema	Chronic swelling, e.g., elephantiasis	Adults, obese	7, 11

Table 2: Main Causes of Scrotal Masses

Infectious and Inflammatory Causes

Epididymitis and Orchitis: These are among the most common causes of acute scrotal pain and swelling. Epididymitis can be acute or chronic and may be complicated by abscess formation. Infection is often bacterial but can also be viral or granulomatous (e.g., tuberculosis, sarcoidosis) (1, 3, 4).

Xanthogranulomatous Orchiepididymitis: This is a rare, destructive inflammatory lesion of the testis that can mimic tumors and often requires surgical removal (5).

Traumatic Causes

Testicular Trauma: Blunt or penetrating trauma may result in hematoma, rupture, or contusion of the scrotal contents. Ultrasound is crucial for assessing the extent of injury and guiding management (1, 5).

Neoplastic Causes

Testicular Tumors: In children and adults, testicular tumors are a leading cause of painless, solid intratesticular masses. Pediatric testicular tumors often present as painless swelling; yolk-sac tumors are most common in young children (4, 10). In adults, germ cell tumors predominate (9).

Paratesticular Tumors: These are usually benign (e.g., lipomas, adenomatoid tumors) but malignant types (e.g., rhabdomyosarcoma, mesothelioma, lymphoma) do occur, often presenting as large, painless extratesticular masses (3).

Cystic Lesions

Hydrocele: Fluid-filled sac around the testicle, presenting as painless swelling. Common in all age groups (3, 10). Varicocele: Dilated veins within the scrotum, often described as feeling like a "bag of worms". More common on the left side and in adolescents or young adults (1, 3). Spermatoceles/Epididymal Cysts: Benign, cystic structures arising from the epididymis (3, 10).

Congenital Malformations

Children may present with masses due to malformations like undescended testis, hernias, or supernumerary testes (4, 10).

Hernias

Inguinal hernias may extend into the scrotum and can become incarcerated or strangulated, causing pain and swelling that necessitate emergency surgery (2, 9).

Lymphedema and Elephantiasis

Chronic scrotal swelling due to lymphatic obstruction may be caused by infections (e.g., filariasis), chronic skin inflammation (hidradenitis suppurativa), or obesity-related massive localized lymphedema. These conditions may require surgical intervention for symptom relief and functional restoration (7, 11).

Treatment of Scrotal Masses

Treatment options for scrotal masses are tailored to the underlying cause, with approaches ranging from conservative management to urgent surgical intervention. Early and accurate diagnosis is essential for guiding appropriate therapy.

Condition	Typical Treatment	Urgency	Sources
Torsion	Emergent surgical detorsion/orchiectomy	Emergency	2, 1
Infection	Antibiotics, anti-inflammatories	Urgent	1, 3, 5
Tumor	Orchiectomy, possible TSS, oncology	Timely/Urgent	8, 9, 4
Cystic Lesion	Observation or surgical excision	Elective	3, 10
Hernia	Surgical repair	Emergency/Elective	2, 9
Lymphedema	Excision, reconstruction	Elective	7, 11
Malformation	Surgical correction	Elective	4, 10

Table 3: Treatment Options

Emergency Treatments

Testicular Torsion: This is a true surgical emergency. Salvage of the testicle is highly time-dependent; surgical intervention within 6 hours is critical (2, 1). Delays can result in testicular loss.

Strangulated Inguinal Hernia: Requires prompt surgical repair to prevent ischemia and necrosis of the herniated tissue (2, 9).

Management of Infections

• Epididymitis/Orchitis: Treated with appropriate antibiotics. Severe or abscess-forming infections may require drainage or, rarely, orchiectomy (1, 3, 5).
• Chronic infections like xanthogranulomatous orchitis may necessitate surgical excision (5).

Tumor Management

Testicular Tumors: Radical inguinal orchiectomy is the standard for suspected malignancy (8, 9). Testis-sparing surgery (TSS) may be considered in select pediatric or benign cases, though it carries a small risk of recurrence (8, 10). Prompt referral to urology and oncology for staging and further management is critical.

Paratesticular and Scrotal Wall Tumors: Management depends on pathology but often involves surgical excision. Malignant lesions require oncologic evaluation (3, 9).

Benign Cystic Lesions

Most hydroceles, spermatoceles, and epididymal cysts are benign and only require surgery if symptomatic or enlarging (3, 10).

Lymphedema and Elephantiasis

Large, disabling scrotal lymphedema—whether from infection, inflammation, or obesity—may be managed surgically with excision and reconstruction using local flaps or grafts. Recurrence is possible, and multiple surgeries may be needed (7, 11).

Pediatric Considerations

Children with scrotal masses require careful evaluation due to the higher incidence of tumors and congenital anomalies in this population. Many benign lesions can be managed conservatively, but solid intratesticular masses are typically treated with surgery (4, 10).

The Role of Imaging and Biopsy

Ultrasound is the first-line diagnostic tool for evaluating scrotal masses, helping to distinguish between solid and cystic lesions and guiding management (1, 3, 6). MRI is reserved for complex or large masses (6). Biopsy is generally avoided in testicular tumors due to risk of tumor spread, but may be used for scrotal skin or paratesticular lesions with suspicious features (2, 9).

Conclusion

Scrotal masses comprise a broad spectrum of conditions, from benign cysts and infections to urgent surgical emergencies and malignancies. A careful approach—including attentive symptom assessment, timely imaging, and appropriate intervention—is essential for effective management and optimal outcomes.

Key Points Covered:

• Scrotal masses may present with pain, swelling, redness, or as painless lumps; symptom recognition is vital for timely care (1, 2, 4).
• Causes range from infection, trauma, and cystic lesions to tumors, hernias, and lymphedema; age and presentation often guide the differential diagnosis (3, 4, 10).
• Treatment is tailored to the underlying pathology, with emergencies like torsion requiring rapid surgical intervention, while benign lesions may be managed conservatively (1, 2, 8).
• Imaging, especially ultrasound, plays a central role in diagnosis and management decisions (1, 3, 6).
• Multidisciplinary care and patient education are key, ensuring both immediate concerns and long-term health are addressed.

By understanding the range of presentations and causes, clinicians and patients can work together to ensure timely, effective management of scrotal masses.