Scrotal mass diagnostic study of choice
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]Sujit Routray, M.D. [3]
Overview
If there is an acutely painful scrotum,there should be a strong suspicion for testicular torsion, which is an emergency condition, and emergent surgical referral should be strongly considered. Sonography may be performed if testicular torsion is not suspected to confirm the diagnosis.[1] Testicular torsion is primrily diagnosed base on the clinical presentation.[2]
Diagnostic Study of Choice
Study of choice
- Ultrasonography of the scrotom is the gold standard test for the differentiated diagnosis of scrotal mass.
- Colored ultrasonography is specific and sensitive test for the diagnosis of epididymitis.
- Testicular tortion is primarily diagnosed based on the clinical presentation.
- MRI is sensetive test for diagnosis of hematocele.
Investigations:
- Among the patients who present with clinical signs of epididymitis, the colored ultrasonography is the most specific test for the diagnosis.
- Among the patients who present with clinical signs of epididymitis, the colored ultrasonography is the most sensitive test for diagnosis.
- Among the patients who present with clinical signs of hematocele, the MRI is the most sensetive test for the diagnosis.
The comparison of various diagnostic studies for Testicular mass
| Test | Sensitivity | Specificity | disease |
|---|---|---|---|
| ultrasonography | 94 | 96 | Tosticular Tortion |
| colored ultrasonography | 100 | 90-100 | Epididymitis |
Diagnostic results
The following finding on performing ultrasonography is confirmatory for spermatocele:
- Black area next to gray area
The following finding on performing ultrasonography is confirmatory for hydrocele:
- Fluid surround testicle
The following finding on performing ultrasonography is confirmatory for varicocele:
- Retrograde blood flow to the scrotom
Sequence of Diagnostic Studies
The ultrasonography must be performed when:
- The patient presented with painless or painfull scrotal swelling as the first step of diagnosis.
- A positive transillumination is detected in the patient, to confirm the hydrocele.
Name of Diagnostic Criteria
There are no established criteria for the diagnosis of scrotal mass. Testicular tortion is primarily diagnosed based on clinical presentation.
- The evaluation of scrotal mass is as follows:
Adapted from American academy of family physicians.[3]
Evaluation of the scrotal mass | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Painful | Nonpainful | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
High-riding or horizontal testicle; nausea/vomiting? | Transilluminates? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Presumed torsion Doppler ultrasonogram, urology consult | Blue dot sign? | Hydrocele | "Bag of worms" on palpation that increases on Valsalva maneuvers | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Torsion of testicular appendage | Lack of blood flow on doppler sonogram, C-reactive protein level <24 mg per L | Varicocele | Reducible mass? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Testicular torsion; urgent surgery | Likely epididymitis/orchitis, possibly incarcerated inguinal hernia, or hemorrhagic testicular cancer | Hernia | Extratesticular and nontender | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Likely benign, further workup as needed | Doppler sonography prior to urology evaluation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Unilateral mass | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Evaluate for testicular cancer: AFP, B-HCG, and LDH levels; MRI or CT scans may be considered to look for possible metastases and cryopreservation of sperm while awaiting urology evaluation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Diagnostic Approach Based on the Nature of the Testicular Swelling
Swelling of the Testis
Swelling of the testis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tender, onset <24 hours | Nontender, gradual onset | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Torsion versus orchitis | Solid | Transilluminates | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Emergent surgical referral | Suspect testicular cancer; order sonography or refer | Hydrocele obscuring testis; order sonography to confirm | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from American academy of family physicians.[3]
Swelling of the Epididymis
Swelling of the epididymis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Diffusely swollen, tender, acute onset | Nodule, stable in size | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Epididymitis | Spermatocele; sonography to confirm | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from American academy of family physicians.[3]
Swelling of the Spermatic Cord
Swelling of the spermatic cord | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Swelling extends to inguinal ring | "Bag of worms" texture | Smooth, transilluminates | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Indirect inguinal hernia | Varicocele | Hydrocele | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from American academy of family physicians.[3]
Swelling of the Skin
Swelling of the skin | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Irregular, enlarging; occupational risk | Smooth, cystic, stable in size | ||||||||||||||||||||||||||||||||||||||||||||||||||||
TRule out squamous cell carcinoma | Sebaceous cyst | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from American academy of family physicians.[3]
References
- ↑ Scrotal mass. American Academy of Family Physicians 2016. http://www.aafp.org/afp/2008/1115/p1165.html. Accessed on March 18, 2016
- ↑ Crawford P, Crop JA (2014). "Evaluation of scrotal masses". Am Fam Physician. 89 (9): 723–7. PMID 24784335.
- ↑ 3.0 3.1 3.2 3.3 3.4 Evaluation of scrotal mass. American academy of family physicians 2016. http://www.aafp.org/afp/2008/1115/p1165.html. Accessed on March 22, 2016