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Sunday, August 17, 2025

Testicle lumps and swellings


Introduction

A lump or swelling in the testicle is a common urological complaint that can arise from a wide range of causes, including benign conditions, infections, trauma, and malignancies. Because the testicles are highly sensitive and play a critical role in reproduction and hormonal balance, any change in their size, shape, or consistency requires careful medical evaluation. While many causes are harmless (such as cysts or hydroceles), some—such as testicular cancer or torsion—are serious and require urgent treatment.

Anatomy Overview

The testicles are paired organs located within the scrotum, connected to the body by the spermatic cord. Surrounding structures that may also give rise to lumps and swellings include:

  • Epididymis (sits behind the testicle).

  • Tunica vaginalis (fluid-containing sac around the testis).

  • Spermatic cord (contains blood vessels, vas deferens, lymphatics).

Causes of Testicular Lumps and Swellings

1. Benign Conditions

  • Hydrocele

    • Fluid accumulation in the tunica vaginalis.

    • Painless swelling, transilluminates with light.

  • Varicocele

    • Dilated veins in the pampiniform plexus (more common on the left).

    • “Bag of worms” feeling above testicle, may cause dull ache or infertility.

  • Epididymal cyst / Spermatocele

    • Fluid-filled cyst in epididymis.

    • Soft, smooth lump, usually painless.

  • Inguinal hernia

    • Loop of intestine protruding into scrotum.

    • Swelling increases on coughing/straining, may be reducible.

2. Infectious/Inflammatory

  • Epididymitis

    • Painful swelling at back of testicle, often due to STIs (Chlamydia, Gonorrhea) in younger men, or urinary pathogens in older men.

  • Orchitis

    • Infection/inflammation of the testicle itself (viral—mumps, or bacterial).

    • May cause generalized swelling and tenderness.

  • Abscess

    • Localized, painful, fluctuant swelling with fever.

3. Traumatic

  • Hematoma or swelling due to blunt injury.

  • May mimic tumor, requires ultrasound for confirmation.

4. Neoplastic (Testicular Cancer)

  • Most common in young men (15–35 years).

  • Typically presents as a firm, painless testicular lump that does not transilluminate.

  • May be associated with dull ache or heaviness.

  • Types include seminomas and non-seminomatous germ cell tumors.

  • Risk factors: cryptorchidism (undescended testis), family history, infertility.

5. Emergencies

  • Testicular torsion: twisted spermatic cord cutting off blood supply → rapid onset swelling, severe pain, nausea. Surgical emergency.

  • Strangulated hernia: trapped intestine in scrotum → painful, irreducible swelling, urgent surgery needed.

Clinical Presentation

  • Painful swelling: epididymitis, orchitis, abscess, trauma, torsion, hernia.

  • Painless swelling: hydrocele, varicocele, spermatocele, testicular cancer.

  • Acute onset: torsion, trauma, acute infection.

  • Gradual onset: hydrocele, varicocele, tumors.

Diagnostic Evaluation

History

  • Onset: sudden vs gradual.

  • Associated symptoms: pain, fever, dysuria, systemic symptoms.

  • Risk factors: STI exposure, cryptorchidism, trauma.

Examination

  • Inspection: symmetry, redness, visible swelling.

  • Palpation:

    • Consistency (firm vs cystic).

    • Tenderness (painful vs painless).

    • Location (within testicle vs epididymal vs cord).

  • Transillumination test: hydroceles and cysts transilluminate; tumors do not.

Investigations

  • Scrotal ultrasound with Doppler → first-line imaging, differentiates solid vs cystic lesions and assesses blood flow.

  • Urinalysis and urine culture → infection.

  • Blood tests: CBC, CRP, ESR for infection; serum electrolytes if systemic illness.

  • Tumor markers:

    • Alpha-fetoprotein (AFP).

    • Beta-human chorionic gonadotropin (β-hCG).

    • Lactate dehydrogenase (LDH).

  • CT/MRI: for staging testicular cancer.

Treatment

1. General Supportive

  • Rest, scrotal support.

  • Ice packs for swelling.

  • Analgesics:

    • Paracetamol (acetaminophen): 500–1000 mg every 6 hours (max 4 g/day).

    • Ibuprofen: 200–400 mg every 6–8 hours.

2. Infections

Epididymitis (Age <35, likely STI)

  • Ceftriaxone: 500 mg IM single dose, plus

  • Doxycycline: 100 mg orally twice daily for 10 days.

Epididymitis (Age >35, likely urinary pathogens)

  • Levofloxacin: 500 mg orally once daily for 10 days, or

  • Ofloxacin: 300 mg orally twice daily for 10 days.

Orchitis (Viral – Mumps)

  • Supportive only: analgesics, ice packs, bed rest.

  • Severe cases: Prednisone 40–60 mg daily for 5–7 days.

3. Hydrocele

  • Asymptomatic cases: observation.

  • Large/symptomatic: surgical hydrocelectomy.

  • Aspiration + sclerotherapy (in nonsurgical candidates).

4. Varicocele

  • Observation if asymptomatic.

  • Surgical ligation or embolization if painful, progressive, or associated with infertility.

5. Testicular Cancer

  • Radical inguinal orchiectomy = gold standard.

  • Further management:

    • Radiotherapy (seminomas).

    • Chemotherapy (cisplatin-based regimens).

  • Regular follow-up with tumor markers and imaging.

6. Testicular Torsion

  • Immediate surgical detorsion and orchiopexy (within 6 hours).

  • If non-viable → orchiectomy.

7. Inguinal Hernia

  • Reducible hernia: elective repair.

  • Strangulated/obstructed hernia: emergency surgery.

8. Chronic/Idiopathic Testicular Swellings

  • Neuropathic pain relief:

    • Amitriptyline: 10–25 mg at night.

    • Gabapentin: 300–900 mg/day in divided doses.

  • Microsurgical denervation of spermatic cord in refractory cases.

Red Flags (Urgent Referral Needed)

  • Sudden severe scrotal pain/swelling (torsion).

  • Hard, painless intratesticular lump (cancer).

  • Painful swelling with systemic illness (abscess, sepsis).

  • Irreducible scrotal hernia.

Prognosis

  • Hydrocele, spermatocele: benign, excellent prognosis.

  • Varicocele: may affect fertility, surgical correction effective.

  • Infections: good prognosis with antibiotics; untreated may cause infertility.

  • Testicular torsion: salvage possible if treated early, delayed = testicular loss.

  • Cancer: high cure rates (over 95%) if detected early.

Summary of Key Treatments with Doses

  • Paracetamol: 500–1000 mg PO every 6h (max 4 g/day).

  • Ibuprofen: 200–400 mg PO every 6–8h.

  • Ceftriaxone: 500 mg IM single dose.

  • Doxycycline: 100 mg PO BID × 10 days.

  • Levofloxacin: 500 mg PO daily × 10 days.

  • Ofloxacin: 300 mg PO BID × 10 days.

  • Prednisone: 40–60 mg PO daily × 5–7 days (severe orchitis).

  • Amitriptyline: 10–25 mg PO nightly (chronic orchialgia).

  • Gabapentin: 300–900 mg/day PO (chronic orchialgia).




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