Scrotal Mass

Scrotal pathology is a common cause of referral to the urologist. Patients will either present with a mass in the scrotum, with or without pain, or with an empty scrotum (cryptorchidism), which is covered in the next chapter. When evaluating a scrotal mass, always work through the complete differential diagnosis. This helps avoid the significant consequences of misdiagnosing testicular torsion or tumor. A thorough understanding of each pathologic condition is the best tool for correct diagnosis.

REVIEW OF PATHOLOGY

Testicular Torsion

Torsion refers to a twisting of the testis and spermatic cord around a vertical axis, resulting in venous obstruction, progressive swelling, arterial compromise, and eventually testicular infarction. Torsion must be considered in the initial diagnosis of any scrotal pathology because without immediate detorsion the testis will be lost. Two types of torsion occur: extravaginal and intravaginal.

▪ Extravaginal Torsion

Extravaginal torsion occurs in neonates (and occasionally in utero) because of incomplete attachment of the gubernaculum and testicular tunics to the scrotal wall. This incomplete attachment leaves the testis, epididymis, and tunica vaginalis free to twist within the scrotum. Extravaginal torsion accounts for <10% of all cases of testicular torsion. Infants typically present in minimal distress with a firm painless scrotal mass that does not transilluminate. Most of these testes will be gangrenous at exploration, and the salvage rate is poor. Early recognition of postnatal torsion is a clear indication for surgery because of the increased chance for testicular salvage. However, intrauterine torsion rarely results in testicular salvage, so
the indications for surgery are less clear. Removal of the infarcted testis has been recommended by some authors because of the theoretic concern of autoimmune damage to the contralateral testis, with resultant fertility problems in the adult.

▪ Intravaginal Torsion

This condition can occur at any age but is most common among adolescents. It is the result of an abnormally narrowed testicular mesentery, with the tunica vaginalis almost completely surrounding the entire testis and epididymis. This narrowed mesentery facilitates twisting of the testis within the tunica vaginalis about its vascular pedicle and gives an appearance termed the “bell clapper” deformity.

▪ Diagnosis

The typical patient presents with sudden onset of pain and swelling, occasionally associated with some minor trauma. The testis will be tender, is often high in the scrotum because of shortening by the twisted cord, and may have a transverse lie or an anteriorly positioned epididymis. Urinalysis is usually negative. Elevation of the scrotum will not relieve the pain (negative Prehn’s sign). Color-flow Doppler ultrasonography should be obtained without hesitation and has become the test of choice. A radionuclide testicular scan may be useful in equivocal cases if performed early after the onset of symptoms and before there is significant reactive hyperemia of the scrotal skin. Surgical exploration is the best diagnostic test and should not be delayed if this diagnosis is seriously considered.

▪ Treatment

Treatment consists of immediate detorsion. Correction within 6 hours of onset of pain usually results in a normal testis. Delay for more than 12 hours results in poor testicular salvage (˜20%). Manual detorsion can be attempted by either lifting the scrotum or rotating the testis about its vascular pedicle. Successful manual detorsion must still be followed by surgical orchiopexy. An unsuccessful attempt at manual detorsion requires immediate surgical exploration. The clearly infarcted testis should be removed; however, if viability is in doubt, it should be left in situ because Leydig cell function may be preserved. After detorsion, the testis should be fixed to the scrotal wall with two to three nonabsorbable sutures to prevent repeat torsion. The contralateral testis must also be fixed because of the high incidence of its subsequent torsion.

Testicular Appendages

There are five potential testicular appendages: (a) appendix testis, (b) appendix epididymis, (c) paradidymis organ of Giraldes, (d) superior Haller’s vas aberrans, and (e) inferior Haller’s vas aberrans. Only the appendix testis and the appendix epididymis are regularly found. Their only importance is that they can also undergo torsion and mimic testicular torsion. Torsion of the appendix testis is by far the most common and typically presents as acute onset of scrotal pain in an adolescent. Generally, a tender, pea-sized nodule can be palpated near the upper pole of the testis. An infarcted appendage can often be seen as a small blue/black dot through the scrotal skin (blue dot sign). Color-flow Doppler ultrasound should be performed to confirm blood flow to the testis. If the diagnosis is doubtful, surgical exploration should be performed to rule out testicular torsion; otherwise, conservative management may be considered. If surgery is performed, the infarcted appendage should simply be excised.

Testicular Tumors

Testicular cancers (see Chapter 26

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