Scrotal mass differential diagnosis: Difference between revisions

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[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Scrotal_mass]]
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{{CMG}};{{AE}}{{Preeti}}
{{CMG}};{{AE}}{{Preeti}}
==Overview==
Scrotal masses may be differentiated according to clinical features, laboratory findings, imaging features, histological features, and genetic studies from other diseases that cause testicular mass with discomfort, [[back pain]], [[abdominal discomfort]], or [[abdominal mass]]. Common differential diagnoses include [[yolk sac tumor]], [[teratoma]], [[choriocarcinoma]], [[embryonal cell carcinoma]], [[seminoma]], and [[lymphoma|testicular lymphoma]] (usually [[non-Hodgkin lymphoma]]).


==Differential Diagnosis==
==Differential Diagnosis==

Revision as of 17:05, 18 October 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[2]

Differential Diagnosis

The table below summarizes the findings that differentiates scrotal mass according to the clinical features, laboratory findings, imaging features, histological features, and genetic studies.

Diseases Clinical manifestations Para-clinical findings Gold standard Associated
Symptoms Physical examination
Lab Findings Past Medical History Histopathology
Unilateral /Bilateral swelling Onset Fever Urinary symptoms Tender
-ness
Erythema Discharge Inguinal Lymphadenopathy Cremasteric Reflex Blood/Urine Analysis Doppler U/S
Painful
Epididymitis[1][2]
[3][4][5][6][7][8]
Unilateral Gradual ± Dysuria, frequency, and/or urgency + - +

(Pyuria Bacteriuria)

Painful local lymphadenopathy +
  • CBC-Leukocytosis
  • Urine culture (pre-pubertal and elderly)
  • NAAT
  • Immunofluorescent antibody testing
  • Decreased epididymal blood flow
Orchitis

(Mumps)[9][10][11][12]
[13][8][7][14]

Bilateral Abrupt ± Dysuria + - ± Painful local lymphadenopathy +
  • CBC-Leukocytosis
  • raised CRP
  • Immunofluorescent antibody testing
  • Urine analysis and culture - normal
  • Increased blood flow in affected side.
  • Tubules are infiltration with neutrophiles, lymphocytes and cells resembling histiocytes
  • Microscopic destruction of spermatogenic cells
  • RT‐PCR
  • Serum immunofluorescence antibody testing.
  • Phen sign +ve
  • Testicular atrophy
  • Infertility
Testicular Torsion[15][16][17][18][19][7] Unilateral Sudden - Absent + + +

Blood in semen may be present

Absent -
  • Normal
  • Absent or decreased arterial perfusion of the testis
  • In the first 4 hours: testicular parenchyma shows edema and and desquamation of the germ cells
  • 4-8 hours partial necrosis of germ cells.
  • >24 hrs: necrosis
  • Phen sign +ve
Hematocele[20][21]
[22][23][24]
Unilateral or bilateral Sudden - Absent + + +

Blood in semen

Absent -
  • Urinalysis may be the only indication of injury to urinary tract
  • Hematuria.
Scrotal wall thickening and testicular hematoma Testicular trauma related to:
  • Increased destruction and fibrosis of the dartos fascia,.
  • Dense inflammatory cells, necrotic areas and destruction of the muscular layer.
  • Ultrasonography: to check for testicular rupture.
_
Incarcerated Hernia[25][26] Unilateral Sudden + Absent + + - Absent +
  • Normal
  • Normal
- -
  • Groin ultrasound or CT scan show presence of bowel and omentum.
  • Valsalva maneuvers performed while palpating the inguinal canal will push a hernia against the examiner's finger.
Brucellosis[27][28][29][30] Unilateral or Bilateral Sudden ± Dysuria - - ± Painful local lymphadenopathy +
  • CBC-Leukocytosis
  • raised CRP
  • Immunofluorescent antibody testing
  • Urine analysis and culture - normal
  • Increased blood flow in affected side
-
  • Culture of the organism from blood.
Antibodies are detected using:
  • Serum agglutination (standard tube agglutination)
  • Enzyme-linked immunosorbent assay
  • Rose Bengal agglutination
  • Coombs test
  • Immunocapture agglutination (Brucellacapt)
  • 2-mercaptoethanol agglutination
Torsion of the appendix testis[31][32][33][34] Unilateral or Bilateral Sudden - Absent + - - Absent +
  • Normal
  • Normal blood flow to the testis with an occasional increase on the affected side
-
  • In the first 4 hours: testicular appendages shows edema and and desquamation.
  • 4-8 hours partial necrosis of appendix cells.
  • >24 hrs: necrosis
  • scrotal ultrasound shows the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area.
  • Scrotal wall mayshow the classical "blue dot" sign, which is due to infarction and necrosis of the appendix testis
Henoch-Schonlein purpura[35][36][37][38] Unilateral Sudden - Absent + + - - -
  • Serum IgA levels are elevated
  • Elevated ESR
-
  • Sore throat 2-3 weeks back
  • Light microscopy shows leukocytoclastic vasculitis in postcapillary venules with IgA deposition
Biopsy
  • Palpable purpura
  • Age at onset is less than 20 years
  • Acute abdominal pain
Fournier's gangrene[39][40][41][42] Bilateral Sudden + Absent + + - - +
  • Leukocytosis
  • Acidosis
  • Elevated ESR and CRP
  • Blood cultures are positive in majority of patient for streptococcus.
- - -
  • Computed tomography (CT) scan shows most useful finding is presence of gas in soft tissues.
  • Patient show signs of tense edema outside the involved skin, blisters, bullae, crepitus, and subcutaneous gas.
Diseases Unilateral /Bilateral swelling Onset Fever Urinary symptoms Tender<be>-ness Erythema Discharge Inguinal Lymphadenopathy Cremasteric Reflex Blood/Urine Analysis Doppler U/S Past Medical History Histopathology Gold standard Additional findings
Painless
Fragile X Macroorchidism[43][44][45][46] Bilateral Gradual - Absent - - + Absent +
  • Normal
- - Increased volume of testis
  • FMR1 DNA analysis
  • Long and narrow face with prominent forehead and chin (prognathism)
  • Large ears
  • Intellectual Disability
Testicular Tumors[47][48][49][50] Unilateral or bilateral Gradual ± Absent ± + Present +
  • Increased serum beta-hCG or alpha fetoprotien (AFP)
- - Seminoma shows findings such as:
  • Biopsy
Hydrocele[51][52][53][54][55] Bilateral Gradual - Absent - - - Absent + -
  • Normal
- -
  • Transillumination test is positive
Varicocele[56][57][58][59] Unilateral

(Mainly left)

Gradual Local warmth Absent - ± - Absent +
  • Elevations in unstimulated luteinizing hormone and follicle stimulating hormone levels may be seen in when associated with infertility in adults
  • Thrombosis of Inferiror vena cava
  • Thrombosis of Right renal vein
  • Abdominal mass
-
  • Infertility
Spermatocele[60][55][61] Unilateral Gradual - Absent - - - Absent + -
  • Falling snow, resulting from internal echoes moving away from the transducer
  • Epididymitis
  • Trauma
  • Epididymal scarring is seen
  • Transillumination test is positive
Scrotal edema[62][63] Bilateral and can extend to perineum Gradual - Absent - - - Absent +
  • Deep Vein Thrombosis
  • Nephrotic Syndrome
  • Hepatic Cirrhosis
  • Insect Bite
-
  • Kidney or Liver biopsy
  • Occurs between 4-12 years of age.
Sebaceous cyst[64][65][66] Unilateral Gradual - Absent - - - Absent + -
  • Normal
-
  • Fibrous tissues and fluids
  • A fatty,(keratinous), substance that resembles cottage cheese,.
  • A viscous, serosanguinous fluid (containing purulent and bloody material).
  • Histological examination
  • Freely movable on palpation.
Carcinoma of the scrotum[67][68][69] - Gradual - Absent - - - Absent + -
  • Normal
-
  • keratinocytic dysplasia involving the full thickness of the epidermis without infiltration of atypical cells into the dermis.
  • The keratinocytes are pleomorphic with hyperchromatic nuclei
  • Numerous mitoses are present.
  • Biopsy
  • Scaly patch or plaque is seen over the testis.
Chylocele (Filariasis)[70][71][72] Unilateral or Bilateral Gradually

Rapidly

+ Absent - - - Absent +
  • Circulating filarial antigen (CFA) assays are positve
  • Lymphatics containing worms can be differentiated from the blood vessels by irregular movement
- -
  • CFA assay
  • Ultrasound demonstrates living worms which has been described as "filarial dance" sign.
Scrotoliths[73][74][75] Unilateral Gradual - Absent - - - Absent + -
  • Normal
  • Trauma
  • Torsion of appendix
-
  • Ultrasound
  • Ultrasound shows mobile hyperechoic extratesticular focus in the potential tunica space.

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