Jay Simhan, MD
Jack H. Mydlo, MD
BASICS
DESCRIPTION
• A mass in the scrotum or testicle can be noted by the patient or during physical exam
• Lesions can be in scrotal wall, testicle, or paratesticular tissues
• Testicular masses can be distinguished from other common intrascrotal masses (hydrocele, varicocele, spermatocele, epididymal cyst, hernia) based on exam or imaging studies
• Most palpable testicular tumors in adults are malignant; 80% nonpalpable lesions are benign.
• Children with testicular tumors are more likely to have benign lesions (20–40% benign).
EPIDEMIOLOGY
Incidence
8,820 cases of testicular cancer in the US in 2014 with 380 deaths
Prevalence
• Testicular tumors: 0.05–2/100,000 children
• Lifetime risk 1/270
RISK FACTORS
• Malignancy: Cryptorchidism, prior testicular neoplasm or hematopoietic malignancy, HIV, family history of testicular cancer, marijuana use
• Benign mass: Recent trauma, UTI, STDs, viral illness, urethral instrumentation, congenital anomalies, previous history of scrotal surgery
Genetics
• Chromosome 12 alterations in testicular cancer:
– Genetics associated in 33% of cases
– 2.2% incidence in brothers of patients with testicular cancer
PATHOPHYSIOLOGY
• Depends upon the etiology of the mass
• Differential diagnosis can be narrowed based on patient’s age and history
ASSOCIATED CONDITIONS
Inguinal hernia in pediatric hydrocele
GENERAL PREVENTION
None (testicular self-exam may help diagnose)
DIAGNOSIS
HISTORY
• Age of the patient
– Tumor types are age-specific
– Torsion usually in prepubertal age group
• Description of the mass
– Small, discrete mass commonly neoplastic
– Diffuse enlargement with tenderness seen with infection, torsion, or trauma
• Associated pain
– Torsion: Sudden, severe, unilateral pain with nausea and vomiting. If torsion intermittent, pain may wax and wane; may have pain during sleep
– Neoplasms rarely cause severe pain, usually described as dull ache or fullness
– Orchitis pain may gradually increase as infection causes increased inflammation
• Referred pain to the scrotum without a mass can be due to renal colic, or nerve root irritation
• Prior scrotal surgery: Orchidopexy for cryptorchidism; increased risk of cancer; malignancy; postvasectomy granuloma
• History of trauma, surgery, any radiation
• Previous UTI or current lower UTI complaints suggests orchitis ± epididymitis
• Urethral discharge suggests STD-concurrent epididymo-orchitis (Chlamydia and gonorrhea are most common in men <35 yr of age).
• Urethral instrumentation: Ascending infection
• Current illnesses: Mumps, UTI
• Medical problems: Diabetes mellitus, immunodeficiency, neurologic disorders, autoimmune disorders, others
• Fever, weight loss, nausea, vomiting, hemoptysis, shortness of breath, and back pain can all be clues to possible metastatic testicular neoplasm.
• Nausea and vomiting in torsion or orchitis
ALERT
• Evaluate scrotal swelling and testicular masses urgently.
• Solid, firm testicular mass must be considered testicular cancer until proven otherwise.
• Patients may present with complaint of testicular mass when they have paratesticular mass instead.
PHYSICAL EXAM
• Fever can be marker for infection, tumor necrosis, or testicular necrosis
• Mumps orchitis: 30% with mumps parotitis, onset 3–7 days following the parotitis
• Gynecomastia: Germ cell or Leydig cell tumor
• Abdomen:
– Retroperitoneal lymphadenopathy from metastatic tumors can sometimes be palpated
– Palpate for signs of hernia
• Testes:
– Evaluate if testicular vs. paratesticular mass
– Evaluate for associated pain on palpation
– Neoplastic/cystic processes usually painless
– Torsion or epididymoorchitis is exquisitely tender
– Phren sign: Scrotal elevation relieves pain in epididymitis, but worsens pain or no effect with torsion; not reliable
• Discrete lesion vs. diffuse swelling:
– Most early-stage neoplasms or cysts are palpable discrete masses
– Orchitis and torsion lead to generalized testicular enlargement
• Position of mass in testicle:
– May be high riding or in altered position in torsion
– Bell clapper deformity: In torsion, occurs when the testicle is situated in a horizontal lie with the long axis in the anteroposterior direction
• Scrotum:
– Evaluate if the mass is within testicle, epididymis, spermatic cord, or scrotal wall
– Edema and erythema: Torsion or orchitis
– Evaluate for prior scrotal scars/past surgery
– Transilluminate to evaluate for hydrocele
– Valsalva maneuver to elicit varicocele
– Cremasteric reflex: Stroke upper thigh and observe ipsilateral testicle/scrotum for contraction (absent in torsion)
• Penis: Ulcers, induration, or discharge can be seen in epididymoorchitis (STD)
• Epididymis:
– Normally located posterior to testicle
– Pain or swelling helps make diagnosis of epididymo-orchitis. If severe, difficult to demarcate epididymis from testicle
• Extremities:
– Swelling due to malignant retroperitoneal lymphadenopathy or venous thrombosis
• Neurologic exam
• Lymphatics:
– Testicular tumor metastasizes to pelvic and retroperitoneal nodes, not inguinal nodes; tender or enlarged inguinal nodes are associated with infection
• Rectal exam: Evidence of prostatitis
• Skin: Signs of cellulitis, swelling, discoloration, or breaks in skin:
– Blue dot sign: Torsion of the appendix testes
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• WBC count to evaluate for infection or leukemia/lymphoma
• HCT to evaluate for anemia associated with malignancy
• Urine analysis and urine culture: May suggest the diagnosis of orchitis or epididymitis
• Hematuria and proteinuria: Viral infection
• Pyuria and bacteriuria: Bacterial infection
• Tumor markers:
– AFP: Elevated in embryonal cell carcinomas, teratocarcinoma, yolk sac tumors, or combined tumors, but never increased in pure seminomas
– β-hCG: Elevated in all choriocarcinomas and some embryonal cell carcinomas, yolk sac carcinomas, and seminomas
– LDH: Nonspecific; elevated in metastatic disease
• Urethral swab to rule out gonorrhea/Chlamydia
Imaging (1)
• Ultrasound, US (diagnostic procedure of choice):
– 95% sensitivity for testicular tumor diagnosis
– Specificity for malignancies is lower since US detects benign lesions as well
– Most testicular tumors have hypoechoic areas, but overall heterogeneity of the lesion is common
– Color flow Doppler is essential for the differentiation of torsion from epididymo-orchitis:
Decreased blood flow with torsion
Increased blood flow with epididymo-orchitis
Will also sometimes show increased vascularity in testicular neoplasms
• MRI: Minor role in testicular masses; can help evaluate intratesticular masses that are difficult to visualize or characterize on US
• Nuclear scintigraphy is most useful for testicular torsion, but is less convenient than US
Diagnostic Procedures/Surgery
Biopsy is avoided if there is suspicion for testicular neoplasm.
Pathologic Findings
See specific Section I and II topics.
DIFFERENTIAL DIAGNOSIS
• Adult/pediatric painful mass:
– Epididymo-orchitis: bacterial, STD, mumps, TB
– Fournier gangrene
– Henoch–Schönlein purpura (usually no mass)
– Incarcerated/strangulated hernia
– Post-vasectomy syndrome (usually no mass)
– Testicular trauma: Usually blunt; contusion, rupture; usually associated hematocele
– Torsion (testicle, testicular, or epididymal appendage)
– Tumor (infrequent unless traumatized or rapidly growing; see differential diagnosis below)
• Adult painless mass:
– Adenomatoid tumor of testis or epididymis
– Adrenal rest tumors
– Adenocarcinoma of the rete testis
– Chylocele: Usually associated with filariasis
– Fibrous pseudotumor of the tunica albuginea
– Hydrocele, primary or due to trauma, torsion, tumor, epididymitis; hydrocele of the cord
– Lipoma of the cord
– Mesothelioma of tunica vaginalis
– Polyorchidism
– Paratesticular sarcomas: Rhabdomyosarcoma, fibrosarcoma, leiomyosarcoma, liposarcoma
– Scrotal edema (insect bite, nephrotic syndrome, acute idiopathic scrotal edema)
– Scrotal wall: Sebaceous and inclusion cysts, idiopathic calcinosis, fat necrosis, malignancy
– Sperm granuloma following vasectomy
– Spermatocele (epididymal cyst)
– Testicular cysts (simple, tunica albuginea, epidermoid)
– Testicular tumor:
Germ cell tumors (95% of testicular malignancies): Seminoma, embryonal cell carcinoma, choriocarcinoma, yolk sac carcinoma teratoma (1–5%), teratocarcinoma
Gonadal stromal tumors: Leydig tumor, Sertoli cell, granulosa cell tumors
Metastatic tumors: Prostate, lung, and GI tract; rare kidney, malignant melanoma, pancreas, bladder, and thyroid
Mixed germ cell and stromal tumor (gonadoblastoma)
Angioma, fibroma, leiomyoma, hamartoma, carcinoid, mesothelioma, and neurofibroma
Malignant fibrous histiocytoma (most common soft tissue sarcoma in late adult life)
Leukemia or lymphoma
– Varicocele
• Pediatric painless mass:
– Similar to adult list; most common are: Hydrocele, hernia, varicocele, testicular teratoma, adrenal rest tumors, rhabdomyosarcoma
TREATMENT
GENERAL MEASURES
• Scrotal ultrasound is indicated in most cases of scrotal mass
• Testicular torsion is an emergency and requires immediate evaluation
MEDICATION
First Line
• Cause-specific treatment, as well as supportive care, should be applied to cases of orchitis: Bed rest, scrotal support, ice bags, and analgesics.
• Broad-spectrum antibiotics should be administered if a bacterial source is suspected.
• A patient’s sexual partners should be treated if STD is the cause.
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Testicular neoplasms: Radical orchiectomy with high ligation of the spermatic cord; inguinal incision:
– Testicular biopsy or orchiectomy through a scrotal approach is contraindicated if there is the possibility of neoplasm.
• Cystic lesions are difficult to differentiate from neoplastic lesions and are usually removed as above for testicular neoplasms.
• In children, testis-sparing surgery for benign lesions such as teratoma, Leydig cell tumor, and epidermoid cyst based on frozen biopsy findings.
ADDITIONAL TREATMENT
Radiation Therapy
Seminoma or some sarcomas
Additional Therapies
Chemotherapy for advanced testicular tumors
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Neoplasms: See tumor types in Section I or II.
• Cystic lesions: Simple periodic exam.
• Torsion: Evaluation in 6–12 mo to check for testicular atrophy and presence of new masses:
– Infertility noted as a long-term problem.
• Orchitis: If primary cause resolved, no follow-up needed.
– In prepubertal patients, epididymo-orchitis may be due to underlying urinary tract anomaly. These patients need structural evaluation of their urinary tracts.
• Trauma: After documentation of adequate healing, no follow-up is required.
COMPLICATIONS
Infertility; complications secondary to radiation or chemotherapy
FOLLOW-UP
Patient Monitoring
• Patients should be advised to perform monthly testicular self-exams.
• Patients diagnosed with cancer should have disease-specific follow-up.
Patient Resources
Medline Plus: Scrotal masses. http://www.nlm.nih.gov/medlineplus/ency/article/001283.htm
REFERENCES
1. Rybenstein RA, Dogra VS, Seftel AD, et al. Benign intrascrotal lesions. J Urol. 2004;171:1765–1772.
2. Chandra RV, Dowling RJ, Ulubasoglu M, et al. Rational approach to diagnosis and management of blunt scrotal trauma. Urology. 2007;70(2):230–234.
3. Tiemstra J, Shailendra K. Evaluation of scrotal masses. Fam Physician. 2008;78(10):1165–1170.
ADDITIONAL READING
• Khoubehi B, Mishra V, Ali M, et al. Adult paratesticular tumours. BJU Int. 2002;90(7):707–715.
• Park SB, Lee WC, Kim JK, et al. Imaging features of benign solid testicular and paratesticular lesions. Eur Radiol. 2011;21:2226–2234
See Also (Topic, Algorithm, Media)
• Paratesticular Tumors, General
• Scrotal and Testicle Trauma
• Scrotum and Testicle Mass Algorithm 
• Scrotum and Testicle, Mass Image 
• Scrotum Tumors General
• Sexually Transmitted Infections (STIs) (Sexually Transmitted Diseases [STDs]), General
• Spermatic Cord Mass and Tumors
• Testicle Pain (Orchalgia)
• Testis, Tumor and Mass, Adult, General
• Testis, Tumor and Mass, Pediatric, General
• Torsion, Testis or Testicular/Epididymal Appendages
CODES
ICD9
• 186.9 Malignant neoplasm of other and unspecified testis
• 222.0 Benign neoplasm of testis
• 608.89 Other specified disorders of male genital organs
ICD10
• C62.90 Malig neoplasm of unsp testis, unsp descended or undescended
• D29.20 Benign neoplasm of unspecified testis
• N50.8 Other specified disorders of male genital organs
CLINICAL/SURGICAL PEARLS
• Evaluate acute scrotal swelling or testicular masses urgently.
• A solid, firm testicular mass in an adult is cancer until proven otherwise.