Scrotal complaints are common in clinic. The first mental step for ANY acute scrotum is always to exclude torsion (Chapter 2), and the first step for any mass is to exclude cancer (Chapter 11).
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Scrotal
complaints are common in clinic. The first mental step for ANY acute
scrotum is always to exclude torsion (Chapter 2), and the first step
for any mass is to exclude cancer (Chapter 11). Once those two are
addressed, most scrotal findings are benign and can be fully
characterized by exam plus ultrasound.
EMERGENCY — confirm with scrotal Doppler US while mobilizing
the OR in parallel (Ch. 2)
Epididymitis / orchitis
GRADUAL onset over days, tender epididymis (posterior),
dysuria/fever, relief with elevation, reactive hydrocele;
cremasteric reflex intact
Antibiotics per age/risk; supportive care
Torsion of appendix testis
Focal upper-pole tenderness, “blue dot sign,” prepubertal
boy, normal flow on Doppler
Supportive (NSAIDs, rest); benign — once torsion is excluded
Incarcerated/strangulated hernia
Groin-to-scrotum bulge, GI symptoms, cannot get above the mass
Surgical evaluation urgently
Fournier's gangrene
Pain out of proportion, crepitus, dusky skin, systemic toxicity,
diabetes
SURGICAL EMERGENCY (Ch. 2)
Testicular trauma/rupture
Trauma history, exquisite pain, hematocele
Ultrasound; explore if the tunica is breached
12.2 Epididymitis / orchitis
Inflammation of
the epididymis, usually infectious, with pain that builds over days
rather than seconds. The organism depends on the patient's age and
sexual history — which is the entire basis for choosing an
antibiotic.
Patient
Likely organisms
Treatment
Sexually active men < 35
Chlamydia trachomatis, Neisseria gonorrhoeae
Ceftriaxone 500 mg IM x1 PLUS doxycycline 100 mg BID x 10 days.
Treat partners; test for other STIs including HIV
Men > 35, or with obstruction/instrumentation/insertive anal
intercourse
Enteric organisms (E. coli, etc.)
A fluoroquinolone (e.g., levofloxacin 500 mg daily x 10 days) or
TMP-SMX; culture-directed when possible
Boys (prepubertal)
Usually non-infectious/post-viral
Supportive; consider evaluating for an anatomic anomaly if
recurrent
Supportive
care matters: scrotal elevation and support, ice, NSAIDs, and
rest. Tell the patient explicitly that symptoms take WEEKS to fully
resolve and that a persistent lump (an indurated epididymis) can
linger for months — otherwise they will return convinced the
treatment failed.
Mumps
orchitis: a viral orchitis, typically 4–7 days after
parotitis; supportive care only; can cause testicular atrophy and
impaired fertility.
Watch for
abscess or pyocele if the patient worsens on appropriate
antibiotics — image and drain.
12.3 Chronic and benign scrotal findings
Finding
Description
Management
Hydrocele
Fluid between the layers of the tunica vaginalis; soft,
non-tender, TRANSILLUMINATES; you can get above it
Reassure. Repair (hydrocelectomy) if large, heavy, or
symptomatic. ALWAYS ultrasound to confirm the underlying testis
is normal — a hydrocele can hide a tumor
Varicocele
Dilated pampiniform plexus veins — a “bag of worms”; more
prominent standing and with Valsalva, decompresses when supine;
~90% LEFT-sided (the left gonadal vein drains into the left renal
vein at a right angle)
Treat if there is pain, infertility (abnormal semen parameters),
or testicular atrophy — especially in adolescents. Repair by
microsurgical subinguinal varicocelectomy or embolization
Spermatocele / epididymal cyst
Cystic nodule at the epididymal HEAD, separate from the testis;
transilluminates
Benign. Excise only if bothersome (counsel that excision can
affect fertility on that side)
Solid intratesticular mass
Firm, does NOT transilluminate, within the testis
Cancer until proven otherwise — ultrasound + tumor markers
(Chapter 11). Do not reassure
Chronic orchialgia
Testicular pain > 3 months without an identifiable cause
See Chapter 27 — multimodal, and a difficult problem; avoid
reflexive orchiectomy
Two rules that will save you
A new LEFT varicocele that
does NOT decompress when the patient lies down, or ANY new
RIGHT-sided varicocele, demands cross-sectional imaging to
exclude a retroperitoneal mass or renal tumor obstructing venous
drainage.
Any solid intratesticular mass is cancer until proven
otherwise — order a scrotal ultrasound and tumor markers. Do
not simply reassure and follow up in six months.
Varicocele embolization — the non-surgical
option we offer
What to
order before scheduling: a CT of the abdomen and pelvis with
contrast, plus pre-op labs. Order these at the visit where you
decide to treat.
Insurance
is the practical obstacle, and it is hardest when the indication
is infertility rather than pain. Start the authorization early and
be straight with the patient about coverage before you give them a
date.
Clinical Pathway
Click any node to expand
The first mental step for ANY acute scrotum is to exclude torsion; the first step for any mass is to exclude cancer. Once those two are addressed, most scrotal findings are benign and can be fully characterized by exam plus ultrasound.
Sort the acute scrotum by clue — torsion and Fournier's are the two that cannot wait.
Select a box to open its teaching details.
The two gating questions
For ANY acute scrotum — exclude torsion first (Chapter 2)
For any mass — exclude cancer first (Chapter 11)
Ch 12.1 — the acute scrotum
Time-critical
Typical clues
Sudden severe pain
High/transverse testis
Absent cremasteric reflex
Nausea
Younger patient
Action
Confirm with scrotal Doppler US while mobilizing the OR in parallel — not sequentially (Ch. 2)
Pitfalls
Waiting on imaging before mobilizing the OR costs the testis. The two happen at the same time.
Ch 12.1 — the acute scrotum
Time-critical
Typical clues
Pain out of proportion to exam
Crepitus
Dusky skin
Systemic toxicity
Diabetes
Action
SURGICAL EMERGENCY (Ch. 2)
Ch 12.1 — the acute scrotum
Torsion and Fournier's excluded — which of the remaining pictures fits?
Typical clues
GRADUAL onset over days
Tender epididymis (posterior)
Dysuria / fever
Relief with elevation
Reactive hydrocele
Cremasteric reflex intact
Action
Antibiotics per age/risk; supportive care — see the Epididymitis track
Ch 12.1 — the acute scrotum
Typical clues
Focal upper-pole tenderness
"Blue dot sign"
Prepubertal boy
Normal flow on Doppler
Action
Supportive — NSAIDs, rest
Ch 12.1 — the acute scrotum
Time-critical
Typical clues
Groin-to-scrotum bulge
GI symptoms
Cannot get above the mass
Action
Surgical evaluation urgently
Ch 12.1 — the acute scrotum
Typical clues
Trauma history
Exquisite pain
Hematocele
Action
Ultrasound; explore if the tunica is breached
Ch 12.1 — the acute scrotum
Orders
Scrotal ultrasound
Tumor markers (Chapter 11)
Pitfalls
Do not simply reassure and follow up in six months.
Ch 12.3 — two rules that will save you
The organism depends on age and sexual history — which is the entire basis for choosing an antibiotic.
Select a box to open its teaching details.
What it is
Inflammation of the epididymis, usually infectious, with pain that builds over days rather than seconds.
Exam findings
Tender posterior epididymis
Relief with elevation
Reactive hydrocele
Cremasteric reflex intact
Ch 12.2 — epididymitis / orchitis
What you are asking
Age (over or under 35)
Sexual history
Obstruction, recent instrumentation
Insertive anal intercourse
Ch 12.2 — epididymitis / orchitis
Which patient is this?
Likely organisms
*Chlamydia trachomatis*
*Neisseria gonorrhoeae*
Dosing
Ceftriaxone 500 mg IM x1 PLUS
Doxycycline 100 mg BID x 10 days
Also do
Treat partners
Test for other STIs including HIV
Ch 12.2 — epididymitis / orchitis
Likely organisms
Enteric organisms (*E. coli*, etc.)
Dosing
A fluoroquinolone — e.g. levofloxacin 500 mg daily x 10 days
or TMP-SMX
Culture-directed when possible
Ch 12.2 — epididymitis / orchitis
Likely cause
Usually non-infectious / post-viral
Management
Supportive
Consider evaluating for an anatomic anomaly if recurrent
Ch 12.2 — epididymitis / orchitis
Measures
Scrotal elevation and support
Ice
NSAIDs
Rest
Ch 12.2 — supportive care
What to say
Symptoms take WEEKS to fully resolve
A persistent lump — an indurated epididymis — can linger for months
Pitfalls
Skipping this conversation produces an avoidable return visit and an unnecessary second antibiotic course.
Ch 12.2 — supportive care
Features
A viral orchitis, typically 4-7 days after parotitis
Supportive care only
Can cause testicular atrophy and impaired fertility
Ch 12.2 — mumps orchitis
Time-critical
Trigger
Worsening on appropriate antibiotics
Action
Image and drain — abscess or pyocele
Ch 12.2 — abscess or pyocele
Characterize the scrotal finding by exam plus ultrasound — and know the two rules that will save you.
Select a box to open its teaching details.
The exam questions
Can you get above it?
Does it transilluminate?
Is it within the testis or separate from it?
Is it soft or firm?
Ch 12.3 — chronic and benign scrotal findings
Which benign finding is it?
Description
Soft, non-tender, TRANSILLUMINATES
You can get above it
Management
Reassure
Repair (hydrocelectomy) if large, heavy, or symptomatic
Pitfalls
ALWAYS ultrasound to confirm the underlying testis is normal — a hydrocele can hide a tumor.
Ch 12.3 — chronic and benign scrotal findings
Description
More prominent standing and with Valsalva; decompresses when supine
~90% LEFT-sided — the left gonadal vein drains into the left renal vein at a right angle
Treat if
Pain
Infertility (abnormal semen parameters)
Testicular atrophy — especially in adolescents
How
Microsurgical subinguinal varicocelectomy, or embolization
Ch 12.3 — chronic and benign scrotal findings
Description
At the epididymal HEAD, separate from the testis
Transilluminates
Management
Benign — excise only if bothersome
Counsel that excision can affect fertility on that side
Ch 12.3 — chronic and benign scrotal findings
Orders
Scrotal ultrasound + tumor markers (Chapter 11)
Pitfalls
Do not reassure.
Ch 12.3 — chronic and benign scrotal findings
Time-critical
Triggers for cross-sectional imaging
A new LEFT varicocele that does NOT decompress when the patient lies down
ANY new RIGHT-sided varicocele
What you are excluding
A retroperitoneal mass or renal tumor obstructing venous drainage.
Ch 12.3 — two rules that will save you
Definition
Testicular pain > 3 months without an identifiable cause
Pitfalls
A difficult problem — avoid reflexive orchiectomy (see Chapter 27).
Ch 12.3 — chronic and benign scrotal findings
The non-surgical option we offer — discuss both rather than defaulting to surgery.
Select a box to open its teaching details.
Exam
Dilated pampiniform plexus veins — a "bag of worms"
More prominent standing and with Valsalva
Decompresses when supine
~90% LEFT-sided — the left gonadal vein drains into the left renal vein at a right angle
Ch 12.3 — chronic and benign scrotal findings
Time-critical
Image the retroperitoneum if
A new LEFT varicocele that does NOT decompress when the patient lies down
ANY new RIGHT-sided varicocele
Pitfalls
Treating one of these as a routine varicocele misses a retroperitoneal mass or renal tumor obstructing venous drainage.
Ch 12.3 — two rules that will save you
Indications
Pain
Infertility (abnormal semen parameters)
Testicular atrophy — especially in adolescents
Ch 12.3 — chronic and benign scrotal findings
Local policy
our practice service
A catheter is advanced into the gonadal vein and the refluxing vein is occluded from the inside
No scrotal or inguinal incision
How to frame it
A varicocele that warrants treatment does not automatically mean an operation. Embolization is a genuine alternative to microsurgical subinguinal varicocelectomy — discuss both with the patient rather than defaulting to surgery.
Ch 12.3 — varicocele embolization
Local policy
Our protocol
CT of the abdomen and pelvis with contrast
Pre-op labs
Order these at the visit where you decide to treat
Ch 12.3 — varicocele embolization
Local policy
Our protocol
Insurance is the practical obstacle — hardest when the indication is infertility rather than pain
Start the authorization early
Be straight with the patient about coverage before you give them a date
Pitfalls
Scheduling before authorization sets up a cancelled date and an angry patient.