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Causes of painless scrotal swelling in children and adolescents

Causes of painless scrotal swelling in children and adolescents
Literature review current through: Jan 2024.
This topic last updated: Jul 19, 2022.

INTRODUCTION — The clinical presentation, diagnosis, and management of hydrocele, varicocele, spermatocele will be discussed below along with the presentation and diagnosis of testicular cancer.

Inguinal hernia, the evaluation of scrotal pain and swelling, and the causes of scrotal pain in children and adolescents are discussed separately. (See "Inguinal hernia in children" and "Evaluation of nontraumatic scrotal pain or swelling in children and adolescents" and "Causes of scrotal pain in children and adolescents".)

BACKGROUND — The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings to pathologic events that require expeditious diagnosis and treatment (eg, testicular torsion, testicular cancer).

The most common causes of painless scrotal swelling in children and adolescents include hydrocele and inguinal hernias that are not incarcerated. Less common causes are varicocele, spermatocele, localized edema from insect bites, nephrotic syndrome (swelling is usually bilateral), and rarely, testicular cancer (table 1). Scrotal swelling and testicular masses warrant prompt evaluation.

HYDROCELE — A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis. Hydroceles may be communicating or noncommunicating.

Communicating hydroceles usually develop as a result of failure of the processus vaginalis to close during development; the fluid around the testis is peritoneal fluid (figure 1 and picture 1) [1]. Noncommunicating hydroceles have no connection to the peritoneum; the fluid comes from the mesothelial lining of the tunica vaginalis (figure 2).

Hydroceles are common in newborns (whether related to delayed closure of a patent processus vaginalis or fluid trapped at the time of testicular descent is not known) [1]. The majority of hydroceles in neonates resolve spontaneously, usually by the first or second birthday [2-4].

In older children and adolescents, noncommunicating hydroceles may be idiopathic or may occur secondary to epididymitis, orchitis, testicular torsion, torsion of the appendix testis or epididymis, trauma, or tumor (reactive hydroceles). These conditions must be excluded in children and adolescents with hydrocele. (See "Evaluation of nontraumatic scrotal pain or swelling in children and adolescents" and 'Testicular cancer' below.)

Clinical presentation — Patients with hydroceles present with a cystic scrotal mass. A hydrocele that communicates with the peritoneal cavity may increase in size during the day or with the Valsalva maneuver. In contrast, noncommunicating hydroceles are not reducible and do not change in size or shape with crying or straining. Although rare, large, noncommunicating hydroceles may extend through the inguinal ring and into the abdomen creating an abdominal scrotal hydrocele. This condition is suspected when abdominal extension of the hydrocele into the abdominal cavity is present on examination and confirmed by sonogram (picture 2) [5].

In patients with testicular pain and scrotal swelling, the hydrocele may arise from epididymitis, orchitis, testicular torsion, torsion of the appendix testis or appendix epididymis, testicular rupture, testicular hematoma, or tumor as the primary etiology (reactive hydroceles); Doppler ultrasonography is usually necessary to evaluate these patients further. (See "Evaluation of nontraumatic scrotal pain or swelling in children and adolescents" and 'Testicular cancer' below.)

Diagnosis — The diagnosis of hydrocele can be made by physical examination and transillumination of the scrotum that demonstrates a cystic fluid collection. Communicating hydroceles are often reducible; noncommunicating hydroceles are not. Doppler ultrasonography may be necessary to evaluate the testicle and rule out a primary cause or to determine if an abdominoscrotal hydrocele is present.

Management — Surgical repair is indicated for communicating hydroceles that persist beyond one to two years of age and for idiopathic, noncommunicating hydroceles that are symptomatic or compromise the skin integrity [2,4].

The management of asymptomatic hydroceles in a neonate or child younger than one to two years of age usually is supportive [2,6]. Hydroceles that are present in newborns, whether communicating or noncommunicating, usually resolve spontaneously by the second birthday, unless they are accompanied by an inguinal hernia or are large [1,6]. (See "Inguinal hernia in children".)

Communicating hydroceles in patients older than two years of age rarely resolve and pose a risk for development of incarcerated inguinal hernia. Surgical repair of communicating hydroceles is usually undertaken on an elective basis [6-8].

Idiopathic noncommunicating hydroceles are often asymptomatic. Surgical repair may be indicated for symptomatic complaints and for abdominal scrotal hydroceles [5].

Reactive hydroceles usually resolve with treatment of the underlying condition. (See "Inguinal hernia in children" and "Causes of scrotal pain in children and adolescents" and "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors".)

INGUINAL HERNIA — An inguinal hernia that is not incarcerated typically presents with a nontender reducible mass. Its size increases with a Valsalva maneuver, and it does not transilluminate. The clinical presentation, diagnosis, and management of inguinal hernia in children are discussed separately. (See "Inguinal hernia in children".)

VARICOCELE — A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord in the scrotum (figure 3). The cause of primary or idiopathic varicoceles, that arise spontaneously and are not caused by obstruction of the inferior vena cava, is unknown. One etiologic theory is that primary varicoceles result from increased venous pressure and incompetent valves [7,9-11]. Varicoceles occur more commonly on the left side (85 to 95 percent) because the left spermatic vein enters the left renal vein at a 90 degree angle, whereas the right spermatic vein drains at a more obtuse angle directly into the inferior vena cava, facilitating more continuous flow (figure 4) [7,9,10]. Approximately 10 to 25 percent of all adolescent males and as many as one-third of all males examined at an infertility clinic have a varicocele. However, only 10 to 15 percent of males with varicoceles have fertility problems [10].

Clinical presentation and diagnosis — Patients with varicoceles can be asymptomatic or present complaining of a dull ache or fullness of the scrotum upon standing. The key task for the examiner is to differentiate primary varicocele from secondary varicocele caused by obstruction of the inferior vena cava.

The examination for varicocele should be performed with the patient standing [12]. The scrotum is inspected for any visible distention around the spermatic cord (indicative of a grade III varicocele). The scrotum, testes, and cord structures are then gently palpated; a palpable varicocele has the texture of a "bag of worms" (figure 3). Grade II varicoceles are palpable, but nonvisible. The patient should then be asked to perform the Valsalva maneuver; if the varicocele is palpable only with the Valsalva maneuver, it is Grade I (table 2).

The patient also should be examined in the supine position [12]. This maneuver will help to differentiate idiopathic or primary from secondary varicocele. Primary varicocele usually is more prominent in the upright position and disappears in supine, whereas secondary varicocele usually does not get much smaller with change in position from upright to supine.

If the varicocele persists in the supine position, has acute onset, or is right-sided (secondary varicocele), then processes that cause inferior vena caval (IVC) obstruction must be ruled out with Doppler ultrasonography [9]. These processes include:

IVC thrombus

Right renal vein thrombosis with clot propagation down the IVC

Abdominal mass (eg, retroperitoneal tumors, kidney tumors, or lymphadenopathy) [13]

Management — There are no clear guidelines established for treatment of a varicocele in childhood [14]. Referral to a urologist is indicated for patients with pain, decreased testicle size, or large varicoceles. Most varicoceles in adolescents are managed conservatively with observation. When more aggressive treatment is necessary, varicoceles are repaired through surgical ligation or testicular vein embolization. Based upon a systematic review of 12 trials and 39 case series, these procedures may be warranted under the following circumstances [14,15]:

Affected testicular volume is less than that of the unaffected testicle (a difference in size of >10 to 15 percent or >2 mL when assessed by ultrasonography) because loss of testicular volume is associated with a decreased sperm count and testicular growth arrest can be reversed with varicocele repair.

To alleviate symptoms such as pain, heaviness, or swelling.

Bilateral varicoceles.

When obtained, abnormal seminal fluid analysis.

Although grade of varicocele should not be the sole indication for intervention, treatment may be warranted in adolescents with large varicoceles (grade III) and abnormal semen analysis because varicocele repair has been associated with improved semen analysis in adolescents and young men. However, improved fertility and paternity after surgical treatment of varicoceles in adolescents has not been clearly established [15].

Varicocele grade does not correlate well with abnormal semen analysis or infertility in adults [16]. Studies in adolescents correlating varicocele grade, testicular size, and unstimulated hormone levels, specifically luteinizing hormone and follicle stimulating hormone concentrations, have also had conflicting results [17-22].

SPERMATOCELE (EPIDIDYMAL CYST) — A spermatocele (epididymal cyst) is a painless, fluid-filled cyst of the head (caput) of the epididymis that may contain nonviable sperm (figure 5). A spermatocele can be palpated as distinct from the testis and typically transilluminates as a cystic mass. In contrast, testicular tumors are palpated within the testis and do not transilluminate. Ultrasonography may be helpful to confirm the diagnosis of spermatocele. Spermatoceles do not affect fertility. Treatment (eg, surgical excision) is indicated to relieve discomfort.

TESTICULAR CANCER — Testicular cancer accounts for 20 percent of cancer diagnosed in males 15 to 35 years old, rendering it the most common solid tumor in males within this age group [23,24]. The epidemiology and risk factors for testicular cancer, which include cryptorchidism, family history of testicular cancer, cancer of the other testicle, human immunodeficiency virus (HIV) infection, germ cell neoplasia in situ (GCNIS, formerly called intratubular germ cell neoplasia of the unclassified type [25]), and race, are discussed in detail separately. (See "Epidemiology and risk factors for testicular cancer".)

Clinical presentation — Testicular cancer usually presents as a painless mass discovered by the patient or clinician on physical examination, although rapidly growing germ cell tumors may cause acute scrotal pain secondary to hemorrhage and infarction. Other common signs are testicular enlargement or swelling. Many patients also report an aching feeling in the lower abdomen or scrotum.

On examination, intrascrotal malignancies usually are firm, nontender masses that do not transilluminate. Some patients may have gynecomastia. The clinical presentation of testicular cancer and advanced or metastatic testicular cancer are discussed in more detail separately. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors".)

Diagnosis — Scrotal ultrasound is the initial diagnostic test of choice [23,26]. Although pathology is the definitive diagnostic test, scrotal ultrasound may help to distinguish intrinsic from extrinsic testicular lesions. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors".)

Several conditions may mimic neoplasia on ultrasound, including inflammation, hematoma, infarct, fibrosis, and tubular ectasia of the rete testis. In cases in which the ultrasound is inconclusive, magnetic resonance imaging (MRI) may help differentiate benign from malignant lesions. This was illustrated in a study of 622 patients who underwent ultrasound examination to evaluate a variety of scrotal diseases, of whom 17 had a lesion suspicious for cancer but an inconclusive ultrasound [27]. No lesion defined as benign by MRI proved to be malignant (negative predictive value 100 percent), although two benign inflammatory lesions were mistakenly thought to be malignant (positive predictive value 71 percent). These findings suggest ultrasound is sufficient in the vast majority of patients with suspected malignancy on examination, but MRI is a useful adjunct when the ultrasound result is equivocal.

Boys with lesions that are consistent with cancer should be referred to a urologist for diagnostic evaluation, which may include blood tests for various tumor markers, and radical inguinal orchiectomy. (See "Clinical manifestations, diagnosis, and staging of testicular germ cell tumors".)

Management — The treatment of testicular cancer is discussed separately.

Early detection — Prevention of testicular cancer centers on improved awareness and early detection (eg, secondary prevention). Efforts to increase awareness of testicular cancer can occur in the general community (eg, Lance Armstrong Foundation [www.livestrong.org]), in schools, and at medical visits.

Screening for testicular cancer is discussed in greater detail separately. (See "Screening for testicular cancer".)

OTHER CAUSES

Insect bites – Localized edema from insect bites may cause scrotal swelling; such swelling may be accompanied by erythema and/or pruritus.

Nephrotic syndrome – The nephrotic syndrome is characterized by nephrotic range proteinuria, hypoalbuminemia, edema, and hyperlipidemia. The edema is gravity dependent. (See "Clinical manifestations, diagnosis, and evaluation of nephrotic syndrome in children".)

Acute leukemia or lymphoma – Although rare, painless unilateral testicular enlargement can be a presenting sign of acute lymphocytic leukemia or lymphoma. (See "Overview of the clinical presentation and diagnosis of acute lymphoblastic leukemia/lymphoma in children", section on 'Presentation'.)

Other conditions producing generalized edema due to hypoproteinemia or increased hydrostatic pressure (eg, protein losing enteropathy, hepatic cirrhosis).

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Hydrocele (The Basics)" and "Patient education: Varicocele (The Basics)")

SUMMARY AND RECOMMENDATIONS

Causes – The most common causes of painless scrotal swelling in children and adolescents include hydrocele and inguinal hernias that are not incarcerated. Less common causes include varicocele, spermatocele, localized edema from insect bites, nephrotic syndrome, and rarely, testicular cancer. Clinical features provide important clues to the etiology (table 1 and algorithm 1). (See 'Background' above.)

Hydrocele – A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis (figure 2). Hydroceles may occur in reaction to testicular torsion, tumor, epididymitis, orchitis, or trauma; these conditions must be ruled out by palpation of the entire testicular surface and/or ultrasonography. Such reactive hydroceles usually resolve with treatment of the underlying condition. Surgical repair of hydroceles is indicated for hydroceles in newborns that persist beyond one year of age, for communicating hydroceles, and for idiopathic hydroceles which are symptomatic. (See 'Hydrocele' above.)

Varicocele – A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord (figure 3). Inferior vena caval obstruction must be excluded in patients with varicocele if the varicocele persists in the supine position, has acute onset, or is only right-sided. (See 'Varicocele' above.)

Spermatocele – A spermatocele (epididymal cyst) is a painless, fluid-filled cyst of the head (caput) of the epididymis that may contain nonviable sperm (figure 5). Spermatoceles do not affect fertility and rarely require excision. (See 'Spermatocele (epididymal cyst)' above.)

Testicular cancer – Testicular cancer usually presents as a painless mass in the testicle that is firm and nontender; it may be accompanied by a reactive hydrocele. Such masses must be evaluated promptly. Scrotal ultrasonography is the initial diagnostic test of choice; boys with lesions that are consistent with cancer should be referred to an urologist for additional evaluation. (See 'Testicular cancer' above.)

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