Scrotal Mass

Sara M. O’Hara, MD, FAAP

DIFFERENTIAL DIAGNOSIS

Common

Inguinal-Scrotal Hernia
Epididymoorchitis
Hydrocele
Varicocele
Testicular Torsion
Torsion of Testicular Appendage
Testicular Rupture/Hematoma

Less Common

Spermatocele/Epididymal Cyst
Pyocele
Tubular Ectasia
Testicular Tumors

Rare but Important

Meconium Peritonitis
Scrotal Pneumatosis
Henoch-Schönlein Purpura

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Begin by determining structural origin of scrotal mass
- Testicle
- Epididymis
- Tunica, surrounding testicle
- Spermatic cord
- Fat and connective tissues
Next, determine if mass is
- Soft tissue
- Cystic or fluid
- Vascular
- Peristalsing
- Or mixture of these
Finally, confirm normal blood flow in testicle
- Testicular ischemia can be complication of many scrotal masses

Helpful Clues for Common Diagnoses

Inguinal-Scrotal Hernia
- Typically heterogeneous, mixed soft tissue mass
- Look for hernia neck pointing to inguinal canal or frank communication with peritoneal cavity
- Peristalsis may be diminished/absent when incarcerated
- Testicle is usually displaced to bottom of scrotal sac
Epididymoorchitis
- Enlarged, hypoechoic epididymis
- May show increased echoes if there is hemorrhage
- Marked hyperemia on Doppler
- Associated hydrocele common
Hydrocele
- Fluid within tunica
- Surrounds testicle
- Should not displace or compress testicle
- Debris present with infection or trauma
- Very common in baby boys
Varicocele
- Dilated veins of pampiniform plexus
- Left side > > right
- Idiopathic type: Due to incompetent valves in internal spermatic vein
- Secondary type: Due to increased pressure on draining veins
- Most common correctable cause of male infertility
- Varicoceles increase in size during Valsalva
Testicular Torsion
- Twisting of testis and spermatic cord in scrotum
- Spontaneous or traumatic
- Results in ischemia/venous congestion
- Surgical emergency
- Testicular salvage rate drops with symptom duration
- Doppler hypoperfusion is key to diagnosis
- Always compare to asymptomatic side
- Spontaneous detorsion, may appear hyperemic
Torsion of Testicular Appendage
- Twisting of testicular or epididymal remnant
- Hypoechoic mass adjacent to testis OR
- Hyperechoic mass between testis and epididymis
- Absent Doppler flow in mass with surrounding hyperemia
- Associated hydrocele common
- Typically less painful than testicular torsion
Testicular Rupture/Hematoma
- Variable appearance depending on severity and acuity
- Hematoma initially appears as echogenic avascular mass
- Subsequently liquifies and contracts
- Search testicular capsule for any breaks
- Confirm testicular perfusion
- Ruptured testicle is surgical emergency
  - Salvage rate drops with symptom duration
- Extratesticular hematoma treated nonsurgically

Helpful Clues for Less Common Diagnoses

Spermatocele/Epididymal Cyst
- Both result from dilated epididymal tubule
- Spermatoceles
  - Contain spermatozoa and sediment
  - Most often in epididymal head
- Epididymal cysts
  - Contain clear serous fluid
  - Found anywhere in epididymis
Pyocele
- Infected collection
  - May be complication of prior trauma, surgery, bacteremia
- Loculations and debris characteristic
Tubular Ectasia
- Dilation of rete testis
- Variably sized cysts or tubules
- Radiate from mediastinum testis
- No flow on Doppler
Testicular Tumors
- Only 1-2% of all pediatric tumors
- Bimodal age peaks
  - < 2 years old and young adults
- Germ cell variety (60-77%)
  - Teratomas: Benign in pediatric patients (malignant in adults)
  - Yolk sac tumors: Elevated α-fetoprotein
  - Mixed: Variable behavior
- Seminomas: Rare in children
- Sertoli cell and Leydig cell tumors
  - Hormonally active: Gynecomastia, precocious puberty
- Juvenile granulosa cell tumors
  - 27% of all neonatal testicular tumors, benign
- Gonadoblastoma: Intersex disorders
- Leukemia/lymphoma secondary involvement, bilateral
- Cystic dysplasia: Benign, associated ipsilateral renal agenesis/dysplasia
- Extratesticular rhabdomyosarcoma
  - Highly aggressive malignancy
  - 70% retroperitoneal nodal spread at diagnosis

Helpful Clues for Rare Diagnoses

Meconium Peritonitis
- Extension into scrotum from peritoneum
- Calcification common
Scrotal Pneumatosis
- Extension from peritoneum or perineum
- Benign or infectious varieties
Henoch-Schönlein Purpura
- Marked swelling and hyperemia of peritesticular soft tissues
- Usually bilateral
- Testicles are normal

Image Gallery

Longitudinal ultrasound with extended field of view shows bowel and fat extending through the inguinal canal into the scrotum in this child with scrotal fullness. The testicle

is displaced inferiorly.

Transverse ultrasound shows the tubular appendix (calipers) extending into the right scrotal sac surrounded by fluid in this 2-month-old boy with scrotal swelling and pain.

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