7 Causes of Scrotum Swellings- Differential Diagnosis

The Scrotum swellings are fairly easy to approach for experienced physicians. In this post, we will discover all the differential diagnoses of scrotal swellings and how to approach them based on position.

Based on Location

Anterior and LateralHydrocele
Above and BehindEpidydimal Cyst
The superior surface of the testesSpermatocele
In the Body of TestesTesticular Cancer

Causes of Scrotum Swellings

7 causes of scrotum swellings are listed below:

  1. Inguinal Hernia
  2. Testicular tumours
  3. Acute Epididymo-orchitis
  4. Epidydimal Cyst
  5. Hydrocele
  6. Testicular Torsion
  7. Varicocele

Inguinal Hernia

Features of an inguinal hernia include:

  • Cannot “get above it”
  • Cough impulse
  • Reducible

Testicular Tumours

Features of Testicular Tumours are:

  • Often discrete testicular nodule (may have associated hydrocele)
  • +/- Symptoms of metastatic disease
  • Ix- USG Scrotum + Serum AFP + Beta-HCG required + LDH
  • If Testicular Malignancy- Orchidectomy via an inguinal approach
    • Seminoma- Raised LDH hCG
    • Teratomas (mixed tissues- cartilage, squamous epithelium)- Raised AFP

Acute Epididymo-orchitis

Features of Acute Epididymo-orchitis include:

  • Gradual Onset (>6 hours)
  • Dysuria, Pain, and urethral discharge
  • Scrotal skin is often red and tender
  • +/- Fever
  • Positive Prehn’s Sign- Relieved by elevating testis
  • M/C- Chlamydia (sexually active male)
  • Symptoms are gradual if compared to the sudden acute onset of testicular torsion
  • Often, the affected testis is placed HIGHER than the other testis
  • Symptoms of pain and swelling localized to the posterior scrotum
  • <35- Chlamydia and Gonorrhoea
  • >35- E.Coli and Pseudomonas
  • Ix- Urethral Swab and Urine R/M + C/S
  • Rx- Antibiotics

Epidydimal Cyst

Features of Epidydimal Cyst are:

  • Opalescent fluid (spermatoceles)
  • Painless, non-tender
  • Lies above and behind testis (upper pole, posterior part of testes)
  • Possible to “get above the lump” (unlike Inguinal hernia)
  • Ix- USG
  • Rx- Excision using a scrotal approach


Features of Hydrocele are:

  • Non-painful, soft fluctuant swelling
  • Possible to “get above the lump” (unlike Inguinal hernia)
  • Clear fluid
  • Transilluminate
  • Ix- USG
  • Rx
    • Children- Inguinal approach to ligate the processus vaginalis
    • Adults- Scrotal approach is preferred and the hydrocele sac is excised or plicated

Testicular Torsion

Features of Testicular Torsion include:

  • Severe, Sudden Pain (<6 Hours)
  • Tenderness and Pain NOT eased by elevation (Negative Prehn’s Sign)
  • Hx of similar episodes
  • The examination is intolerable (due to severe pain)
  • Next Step? Refer to Surgeon>Surgery>USG Colour Doppler (DO NOT PICK USG!!!)
  • Ix- USG Colour Doppler
  • Rx- Urgent Exploratory Surgery is indicated with Testicular Fixation, the contralateral testis should also be fixed


Features of Varicocele are:

  • Varicosities of the pampiniform plexus
  • Cough Impulse Present (just like Inguinal Hernia)
  • Possible to “get above the lump” (unlike Inguinal hernia)
  • MC- Left (because the left testicular vein drains into the renal vein directly at the right angle -high pressure-)
  • Dull-aching or Dragging pain that is worse after exercise or at the end of the day
  • “Bag of worms”, Bluish, Disappear on lying down
  • Hx of RCC (Varicocele + Renal Pain + Haematuria)
  • Ix- Scrotal Doppler | USG is diagnostic “not urgent”
  • Rx- Reassurance/Conservative, unless infertility or severe pain- Surgery

Check out our other guides:

What is the most common cause of a swollen testicle?

What is the most common cause of a swollen testicle

Hydrocele is the leading cause of swollen testicles. The swelling is usually not painful, soft and fluctuant. It is diagnosed through ultrasound or clinical diagnosis by a physician. Treatment usually involves conservative management and it could be left without further steps. Incision through the scrotal approach is reserved for those requiring surgical care.

How long does it take for a swollen testicle to go down?

Scrotum swellings that result from injury or acute conditions such as orchitis resolve within 5-7 days. On the other hand, hydrocele and testicular tumours can remain for a lifetime. Urgent care is required in cases of acute epididymo-orchitis and testicular torsion.

Hope you enjoyed our post on Scrotum Swellings- Differential Diagnosis Approach. Please leave feedback or queries below.

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