Scrotal Masses – Causes, Complications and Treatment

Overview of Scrotal Masses

Scrotal masses refer to abnormal growths or lumps that develop within the scrotum, the pouch of skin that contains the testicles. These masses can vary in size, texture, and location, and may be caused by a range of underlying conditions. Common causes of scrotal masses include fluid-filled cysts, enlarged veins (varicoceles), hernias, and, less commonly, tumors. Since scrotal masses can originate from different sources, their identification and diagnosis are essential for appropriate medical management.

Detecting scrotal masses often involves a physical examination by a medical professional, along with additional diagnostic tools such as ultrasound imaging. Patients may notice these masses while performing self-examinations or due to discomfort or pain in the scrotal area. Prompt evaluation and diagnosis are crucial to determine the underlying cause of the mass and guide subsequent treatment decisions, if necessary.

Types of Scrotal Masses

It can encompass a variety of conditions, each with distinct characteristics and origins. Some common types of scrotal masses include:

1. Hydrocele: A hydrocele is a fluid-filled sac that forms around the testicle, causing swelling in the scrotum. It is typically non-painful and can vary in size. Hydroceles often occur due to the accumulation of fluid within the layers of the scrotal sac.
2. Varicocele: Varicoceles are enlarged veins within the scrotum that result from the backup of blood. They might cause discomfort or a dull ache. Varicoceles are commonly found on the left side of the scrotum due to the anatomy of the veins.
3. Epididymal Cyst: Also known as spermatocele, these are benign cysts filled with fluid and located within the epididymis, the coiled tube near the testicle. They are typically painless and might not require treatment unless they cause discomfort.
4. Hernia: Inguinal hernias can lead to the appearance of a scrotal mass. These occur when part of the intestine or abdominal tissue pushes through a weak spot in the abdominal wall into the inguinal canal, which is located near the scrotum.
5. Testicular Tumors: While relatively rare, tumors can develop within the testicles. These can be benign (non-cancerous) or malignant (cancerous). Testicular cancer is most common in young men and is characterized by the presence of a painless lump or swelling in the testicle.
6. Infections and Abscesses: Infections in the scrotal area, such as epididymitis or abscesses, can result in the formation of painful masses.
7. Lipomas: These are benign growths of fat cells that can develop in various parts of the body, including the scrotum.
8. Hematocele: A hematocele is a collection of blood within the scrotum, often resulting from trauma or injury.

Epidemiology

The prevalence of scrotal masses varies based on the underlying causes and the demographic factors of the population being considered. Hydroceles and varicoceles are among the more common scrotal masses. Hydroceles, often seen in newborns and older adults, can occur in about 1-2% of newborn males, but the prevalence tends to decrease over time. Varicoceles are prevalent in the male population, with estimates suggesting that they affect approximately 15-20% of adolescent and adult men. They are more commonly found on the left side due to the anatomy of the testicular veins.

Epididymal cysts are also relatively common, affecting a notable portion of the male population. Inguinal hernias are prevalent, especially in males, and their occurrence tends to increase with age. Testicular tumors, although rare compared to other scrotal masses, are the most common solid tumors in young adult men, typically occurring between the ages of 15 and 35. Their prevalence varies based on factors such as age, genetics, and geographic location. Overall, the prevalence of scrotal masses underscores the importance of medical awareness, early detection, and appropriate management strategies to address these conditions effectively.

Pathophysiology of Scrotal Masses

The pathophysiology of scrotal masses encompasses a range of underlying mechanisms that lead to the formation and development of abnormal growths within the scrotum. Various factors contribute to the different types of scrotal masses. For instance, hydroceles and hematoceles result from disturbances in the balance of fluid dynamics within the scrotal cavity. In the case of hydroceles, an accumulation of serous fluid occurs between the layers of the tunica vaginalis, the protective sac surrounding the testes. Hematoceles, on the other hand, are caused by the accumulation of blood within the scrotum, often as a consequence of trauma or injury.

Varicoceles, characterized by dilated veins within the scrotum, emerge due to venous reflux and the impaired drainage of blood from the testicles. The faulty valves within the spermatic veins hinder the efficient flow of blood, leading to blood pooling and vein enlargement. Epididymal cysts, or spermatoceles, develop as a result of blockages or obstructions within the epididymis, which disrupt the normal flow of fluid and sperm, causing cyst formation. Inguinal hernias arise from a weakening of the abdominal muscles in the inguinal region, allowing abdominal contents, such as the intestine, to protrude into the inguinal canal and sometimes extend into the scrotum.

The pathophysiology of scrotal masses underscores the importance of understanding the specific mechanisms underlying each type. This understanding aids in accurate diagnosis and guides appropriate treatment strategies. Whether driven by fluid imbalances, vascular anomalies, obstructed ducts, or anatomical weaknesses, a comprehensive grasp of the pathophysiological factors is essential for effective management and patient care.

Signs and Symptoms

Symptoms of scrotal masses vary. Some cause pain and others don’t. It depends on the cause. Symptoms of a scrotal mass might include:

• An unusual lump.
• Sudden pain.
• Dull aching or a feeling of heaviness in the scrotum.
• Pain that spreads all over the groin, stomach area or lower back.
• A tender, swollen or hardened testicle or epididymis (ep-ih-DID-uh-miss). The epididymis is the soft, comma-shaped tube above and behind the testicle that stores and transports sperm.
• Swelling in the scrotum.
• A change in color of the skin of the scrotum.
• Upset stomach or vomiting.

If an infection causes a scrotal mass, symptoms also might include:

• Fever.
• Needing to pee often.
• Pus or blood in the urine.

Causes of Scrotal Masses

A scrotal lump or other anomaly in the scrotum can be caused by a number of conditions, including:

• Testicular cancer. Testicular cancer is a type of tumor that develops from abnormal testicular tissue and is typically characterized by the presence of a painless lump in the scrotum. While some men may experience swelling or discomfort, most tumors do not produce noticeable symptoms. It’s important to consult a doctor if you detect any new lumps in your scrotum.
• Spermatocele. which is also called epididymal cyst or spermatic cyst, refers to a fluid-filled sac in the scrotum that is usually located above the testicle. This condition is typically painless and benign, meaning it is noncancerous.
• Epididymitis. Is the inflammation of the epididymis, which is a comma-shaped structure located behind and above the testicle, responsible for storing and transporting sperm. The most common cause of epididymitis is a bacterial infection, including sexually transmitted ones like chlamydia, but it can also result from a viral infection or abnormal urine flow into the epididymis.
• Orchitis. Refer to the inflammation of the testicle, typically caused by a viral infection such as mumps. However, if orchitis results from a bacterial infection, it may also infect the epididymis.
• Hydrocele. Hydrocele is a condition where there is a buildup of excess fluid between the layers of a sac surrounding the testicles, resulting in painless swelling of the scrotum. In infants, hydrocele is caused by the failure of the opening between the abdomen and scrotum to close properly during development, while in adults, it is usually caused by an imbalance in the production or absorption of fluid, often due to scrotal injury or infection.
• Hematocele. A hematocele is a condition characterized by the accumulation of blood between the layers of the sac that encloses each testicle. This condition is commonly caused by physical trauma, such as a direct impact to the testicles.
• Varicocele. Varicocele is a medical condition where the veins inside the scrotum become enlarged. These veins are responsible for carrying blood that is low in oxygen from the testicles and epididymis. It is worth noting that varicocele tends to occur more frequently on the left side of the scrotum. This is due to differences in the way blood flows on each side. If left untreated, varicocele may result in infertility.
• Inguinal hernia. Inguinal hernia is a medical condition that happens when a part of the small intestine protrudes through a weak spot or opening in the tissue that separates the abdomen and groin. In infants, this condition is commonly caused by the incomplete closure of the passageway from the abdomen to the scrotum during development. The manifestation of an inguinal hernia can be seen as a lump or mass either in the scrotum or in the upper groin area.
• Testicular torsion.  The twisting of the spermatic cord is a painful condition that occurs when the bundle of blood vessels, nerves, and the tube responsible for carrying semen from the testicle to the penis becomes entangled. If left untreated, this condition can cut off the blood supply to the testicle, which may result in the loss of the affected testicle. Symptoms of this condition include an enlarged, higher-than-normal testicle that may be positioned sideways.

Risk factors

Things that can raise the risk of a scrotal mass include:

• Undescended testicle. An undescended testicle doesn’t leave the stomach area and move down into the scrotum before birth or in the months afterward.
• Conditions present at birth. Some people are born with irregular changes in the testicles, penis or kidneys. These might raise the risk of a scrotal mass and testicular cancer later in life.
• History of testicular cancer. If you’ve had cancer in one testicle, your risk of getting cancer in the other testicle is higher. Having a parent or a sibling who’s had testicular cancer also raises your risk.

What are the possible complications?

It depends on what type of scrotal mass you have. Most lumps on your testicle are harmless. Epididymitis and orchitis may cause:

• A painful collection of pus (an abscess) in your scrotum.
• Fluid buildup in your scrotum.
• Your testicles to shrink.
• Infertility.

Testicular cancer can also cause infertility. Without treatment, it can also be fatal.

The earlier you see a healthcare provider to diagnose your scrotal mass, the better your chances of avoiding serious complications.

How to diagnosis Scrotal Masses?

Many men detect scrotal masses during self-examination, though a physician may detect it during a routine physical exam. If a mass is found, the physician may recommend an ultrasound, or he/she might place a strong light behind the testicle to see whether light passes through. A testicular tumor is too solid, but light will pass through a mass or swelling caused by a hydrocele, which is fluid. The physician will also examine the other testicle for lumps, masses or other abnormalities.

Any mass should be screened. Because other problems can cause symptoms similar to those of testicular cancer, the physician may order tests to screen out other problems, or to be sure the cancer has not spread. These tests may include:

Blood test

To detect high levels of certain proteins that are often secreted by testicular cancer. These proteins include alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG).

Imaging or x-ray tests

• CT scan: An imaging that screens for and determines the extent of the disease, and if it has reached surrounding tissues or other organs.
• Ultrasound: Images of the testes taken with a wand-like instrument called a transducer that emits sound waves and picks up the echoes as they bounce off organs.

Biopsy

Rarely performed given the risk for the spread of cancer; the affected testicle is almost always removed in its entirety for both diagnosis and treatment.

Treatment for Scrotal Masses

The treatment of scrotal masses depends on their underlying cause. Here are some common treatments for different types of scrotal masses:

Hydrocele

Small hydroceles that are not causing discomfort might not require treatment and can be monitored. If a hydrocele is large, causing discomfort, or affecting daily activities, surgical intervention (hydrocelectomy) might be recommended.

Varicocele

Mild varicoceles that are asymptomatic might not need treatment and can be monitored. If a varicocele is causing pain, discomfort, or fertility issues, surgical repair (varicocelectomy) might be considered.

Epididymal Cysts

Small, asymptomatic cysts might not require treatment and can be observed. If a cyst becomes large, painful, or causes discomfort, it can be surgically removed.

Testicular Tumors

Treatment depends on whether the tumor is benign or malignant and its stage. Benign tumors might be monitored or surgically removed if they cause symptoms. Malignant tumors usually require surgical removal of the affected testicle (radical orchiectomy), followed by further treatments like chemotherapy or radiation if necessary.

Inguinal Hernia

Hernias that are not causing symptoms might be monitored. Symptomatic hernias typically require surgical repair to prevent complications like incarceration or strangulation.

Infections (Epididymitis, Orchitis)

Bacterial infections are treated with antibiotics. Pain relief and rest might be recommended for managing symptoms.

Spermatocele

Small spermatoceles that are asymptomatic might not require treatment. If a spermatocele is causing discomfort or becoming large, surgical removal might be considered.

Lipoma

Small, painless lipomas might not require treatment and can be monitored. Surgical removal might be considered for larger lipomas causing discomfort or for cosmetic reasons.

It’s important to note that any scrotal mass should be evaluated by a medical professional to determine the underlying cause and appropriate treatment. Self-diagnosis and self-treatment are not recommended. The treatment approach will vary based on the individual’s specific situation, medical history, and the severity of the condition.

Lifestyle and home remedies

Self-exams of the testicles might help you find a scrotal mass early on. To do a self-exam, follow these steps:

• Check your testicles once a month. This is key if you’ve had testicular cancer or if a blood relative, such as your father or brother, has had it.
• Do the exam after a warm bath or shower. The heat from the water relaxes your scrotum, making it easier for you to check.
• Stand in front of a mirror. Look for swelling on the skin of the scrotum.
• Cup your scrotum with one hand to see if it feels different than usual.
• Check one testicle at a time using both hands. Place the index and middle fingers under the testicle; place your thumbs on top.
• Gently roll the testicle between the thumbs and fingers to feel for lumps. The testicles are usually smooth, oval shaped and somewhat firm. Often, one testicle is slightly larger than the other.
• Feel along the soft, comma-shaped structure that runs above and behind the testicle, called the epididymis, to check for swelling.

If you find a lump or other unusual change, seek medical care to get it checked as soon as you can.

Prevention of Scrotal Masses

Preventing scrotal masses often involves adopting healthy habits and being mindful of factors that can contribute to their development. While not all scrotal masses can be completely prevented, the following measures can help reduce the risk or minimize the likelihood of certain types of scrotal masses:

Hygiene and Self-Examination:

Practicing good hygiene in the genital area can help prevent infections that might lead to scrotal abscesses or other complications. Regular self-examination of the scrotum can help detect any changes or abnormalities early on. Any new or unusual masses should be promptly evaluated by a healthcare professional.

Protection and Safety:

Taking precautions to avoid trauma or injury to the scrotal area can help prevent hematoceles and other traumatic conditions. Wearing protective gear during activities that carry a risk of injury is important.

Safe Lifting Techniques:

Proper lifting techniques can reduce the risk of inguinal hernias, which can develop from strain on the abdominal muscles. Lift objects using your legs, not your back, and avoid lifting objects that are too heavy.

Supportive Undergarments:

Wearing supportive underwear, such as briefs or athletic supporters, can potentially reduce the risk of varicoceles by providing proper support to the scrotum and preventing blood pooling.

Sexual Health Practices:

Engaging in safe sexual practices, such as using barrier methods like condoms, can help prevent sexually transmitted infections (STIs) that might lead to scrotal infections or complications.

Regular Medical Checkups:

Regular visits to a healthcare provider for routine checkups can help identify and address scrotal masses early, before they progress or cause significant discomfort.

Maintaining a Healthy Lifestyle:

Leading a healthy lifestyle that includes a balanced diet, regular exercise, and maintaining a healthy weight can contribute to overall well-being and potentially reduce the risk of certain conditions that might lead to scrotal masses.