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Scrotal/testicular pain and/or lump/swelling

Medicine > Renal

Differential Diagnosis Schema 🧠

Acute Painful Scrotal Conditions

  • Testicular torsion: Sudden onset of severe scrotal pain, often with nausea and vomiting, and absent cremasteric reflex.
  • Epididymitis: Gradual onset of scrotal pain with possible urinary symptoms, tenderness localized to the epididymis.
  • Orchitis: Inflammation of the testicle, often associated with viral infections like mumps, presenting with testicular pain and swelling.
  • Incarcerated inguinal hernia: Scrotal swelling with severe pain, non-reducible, often with signs of bowel obstruction.
  • Trauma: History of scrotal or testicular injury, can lead to hematoma formation.
  • Fournier’s gangrene: Rapidly progressive necrotizing fasciitis of the perineum, scrotum, and genitalia, associated with severe pain and systemic toxicity.
  • Torsion of the appendix testis: More common in prepubertal boys, presents with gradual onset of pain and a small, tender nodule at the upper pole of the testis.

Chronic or Painless Scrotal Conditions

  • Hydrocele: Painless scrotal swelling, often transilluminates, fluid collection around the testicle.
  • Varicocele: Dilated veins in the pampiniform plexus, often described as a ‘bag of worms’ and more common on the left side.
  • Spermatocele: Painless cystic mass above and separate from the testicle, often associated with the epididymis.
  • Testicular cancer: Painless testicular mass, may be associated with a dull ache or heavy sensation, most common in young men aged 15-35.
  • Inguinal hernia: Painless or mildly painful scrotal swelling, reducible, may increase in size with straining.
  • Chronic epididymitis: Prolonged epididymal pain and swelling, often following an acute episode.
  • Testicular microlithiasis: Small, calcified deposits within the testicle, usually asymptomatic and found incidentally on ultrasound.
  • Epidermoid cyst: Benign, small, non-tender nodules found on the scrotal skin, typically painless.
  • Lymphadenopathy: Enlarged lymph nodes in the inguinal region, may be associated with infection or malignancy.
  • Idiopathic scrotal edema: Painless swelling of the scrotum, often self-limiting.

Key Points in History 🥼

History of Presenting Complaint

  • Onset: Determine if the pain or swelling started suddenly or gradually, and if it has changed over time.
  • Pain: Characterize the pain (e.g., sharp, dull, aching) and whether it radiates to the groin or abdomen.
  • Swelling: Ask about the size and location of the swelling, and if it changes with position or activity.
  • Associated symptoms: Investigate urinary symptoms, fever, nausea, or systemic symptoms.
  • Sexual history: Inquire about recent sexual activity, history of STIs, or urethral discharge.
  • Trauma: Ask about any history of trauma or injury to the scrotum or groin.
  • Previous episodes: Determine if the patient has had similar symptoms in the past.
  • Aggravating/relieving factors: Explore factors that make the symptoms better or worse, such as rest, movement, or lifting.
  • Systemic signs: Ask about weight loss, night sweats, or other symptoms that could indicate malignancy or infection.
  • Recent activities: Consider recent physical activities, heavy lifting, or exercise that could contribute to symptoms.
  • Fertility concerns: Discuss any concerns about fertility, as this may be relevant in the context of testicular or epididymal pathology.

Background

  • Medical history: Review for chronic conditions such as diabetes, which can predispose to infections like epididymitis.
  • Surgical history: Inquire about any previous surgeries, particularly hernia repair or scrotal surgery.
  • Medication history: Review current and recent medications, particularly antibiotics, anticoagulants, and immunosuppressants.
  • Family history: Assess for any family history of testicular cancer or other urological conditions.
  • Social history: Consider lifestyle factors such as smoking, alcohol use, and occupational risks that may contribute to symptoms.
  • Sexual history: Consider sexually transmitted infections (STIs) as a cause, especially in young, sexually active males.
  • Previous imaging or investigations: Review any prior ultrasound or other imaging studies of the scrotum or abdomen.
  • Environmental exposures: Assess for exposure to toxins or chemicals that could impact testicular health.
  • Allergies: Inquire about any drug allergies, particularly if surgical intervention is being considered.
  • Immunization status: Relevant in patients with a history of mumps, which can lead to orchitis.
  • Recent travel: Consider tropical infections or parasitic causes if the patient has traveled recently.
  • Occupational history: Consider jobs or activities that might contribute to repetitive trauma or heavy lifting.
  • Psychosocial factors: Explore the impact of symptoms on mental health, especially in cases of chronic pain or fertility concerns.
  • Sports activities: Discuss recent involvement in sports or physical activities that could cause trauma or strain.
  • Sexual practices: Assess for risk factors related to sexually transmitted infections, particularly in younger patients.
  • Dietary habits: Consider the role of diet in general health and healing, especially if the patient is immunocompromised.
  • Psychological support: Determine the need for psychological support if the symptoms are affecting the patient’s quality of life.

Possible Investigations 🌡️

Initial Investigations

  • Scrotal ultrasound: First-line imaging to assess the scrotal contents, identify torsion, masses, hydrocele, or varicocele.
  • Urine dipstick and culture: To detect urinary tract infections or sexually transmitted infections contributing to epididymitis.
  • Sexually transmitted infection (STI) screening: Consider chlamydia and gonorrhea testing in sexually active males.
  • Full blood count (FBC): To assess for signs of infection or inflammation, such as leukocytosis.
  • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Inflammatory markers that may be elevated in infection or inflammation.
  • Tumor markers: In cases of suspected testicular cancer, check alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-hCG), and lactate dehydrogenase (LDH).
  • Hernia examination: Physical examination and imaging (if necessary) to identify inguinal hernias.
  • Doppler ultrasound: To assess blood flow in cases of suspected testicular torsion or varicocele.
  • Transillumination: Simple bedside test to differentiate between solid and cystic scrotal masses.
  • Abdominal imaging: Consider in cases of suspected retroperitoneal pathology, such as lymphadenopathy or malignancy.
  • MRI: May be indicated in complex cases to further characterize masses or assess for extratesticular pathology.
  • Fine needle aspiration (FNA): For cytological examination in cases where testicular cancer or other malignancy is suspected.
  • Psychological support: Assess the need for psychological support, particularly in cases where fertility or malignancy is a concern.

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Renal