Chapter 112: Inguinoscrotal lumps

Lumps in the groin are common to both sexes but males are likely to have a greater variety of swellings in this area and several may be associated with scrotal lumps.

The commonest swellings encountered in the groin or inguinal area are hernias and enlarged lymph nodes. The diagnosis of a hernia is usually straightforward but it must be differentiated from other swellings, including Malgaigne bulgings—these are not true hernias but diffuse swellings in both inguinal regions seen in people with poor lower abdominal musculature.¹ TABLE 112.1 lists the differential diagnoses of groin lumps.

Hernias

The commonest types of hernias in the groin are inguinal, femoral and a combination of the two. Rare hernias in the region are obturator, Spigelian (low abdominal), preperitoneal inguinal and prevascular femoral. The basic parts of a hernia are shown in FIGURE 112.1 and important anatomical landmarks in FIGURE 112.2. An indirect inguinal hernia is a hernia emerging through the deep inguinal ring, originating lateral to the inferior epigastric vessels, following the path of the spermatic cord, and which can traverse the whole length of the inguinal canal (see FIG. 112.3). It may also pass through the superficial inguinal ring into the scrotum—an inguinoscrotal hernia.

Because of their narrow neck and oblique path in the inguinal canal, such hernias are often irreducible and can occasionally lead to strangulation of entrapped bowel.

A direct inguinal hernia originates medial to the inferior epigastric vessels and protrudes through the posterior wall of the inguinal canal, and is therefore separate from the spermatic cord (see FIG. 112.4). It is almost always seen in men and rarely descends into the scrotum. Due to a wider neck, strangulation and obstruction are most unusual. It must be emphasised that the distinction between a direct and an indirect inguinal hernia can be very difficult (and of no clinical benefit)¹ and the two may occur together.

A femoral hernia herniates through the femoral ring (also known as the femoral canal), which is the medial component of the femoral sheath. The hernia tends to bulge forward and then upwards as it becomes larger. The neck is lateral to the pubic tubercle (see FIG. 112.5).

Femoral hernias are often small, usually occur in females and may be unnoticed by the patient. They are particularly liable to produce bowel obstruction or strangulation.

Guidelines

Acquired hernia

• Always examine the scrotum and both sides

• Frequently bilateral

• Result from muscular weakness

• Commonest—direct inguinal

• Predisposing factors:

  • – age (more common with increasing age)

  • – obesity

  • – pregnancy

• Precipitating factors (related to above factors):

  • – increased intra-abdominal pressure:

  • – difficulty of micturition

  • – straining at stool (constipation)

  • – chronic cough (e.g. bronchitis)

  • – straining or lifting heavy objects

  • – nerve damage (e.g. post appendicectomy)

• Complications:

  • intestinal obstruction (see TABLE 112.2)

  • – incarceration

  • – strangulation

  • – sliding

The main symptoms and signs:

• lump

• discomfort or pain:

  • – a dragging pain

  • – worse after standing or walking

  • – referred to testicle (indirect inguinal)

• testicular pain—referred or with compression of the spermatic cord

• expansile impulse on coughing

Note:

• A femoral hernia is easily missed in obese patients.

• Larger femoral hernias are often irreducible.

• Always attempt reduction in the recumbent position (direct hernias usually reduce easily).

All symptomatic hernias require repair. Those patients who are not symptomatic (a third of patients with hernias)¹ and who are medically fit should also be offered surgery. This is not so much because of the risk of strangulation (which is rare) but because most patients usually become symptomatic eventually and a watch-and-wait approach delays rather than prevents surgery.² Obstructed and strangulated hernias require urgent surgery. The risk of strangulation is greatest with femoral hernias, occasional with indirect inguinal hernias and very rare with direct inguinal hernias.

While generally a very safe procedure, inguinal hernia surgery complications include bruising, numbness, haematoma, infection (1–7%), recurrence and chronic pain (defined as persisting for >3 months after surgery). Chronic pain is the most serious long-term complication of hernia repair and may persist for several years. It may be severe in up to 3% of patient¹ and can require referral to pain clinics or further surgery. Laparoscopic repair is now a popular surgical option with less severe postoperative pain.³ An increase in infertility risk and testicular atrophy on the side of the surgery has been noted but is not common.

Most patients return to work after hernia repairs in around 7 days, or 14 days for those doing strenuous work.¹

Asymptomatic inguinal hernias in patients with associated medical conditions, and who pose a significant operative risk, such as the frail elderly patient, can be treated with a watch-and-wait approach. Trusses have been used since ancient times to help patients with hernias, but can be difficult for a patient to manage and cannot be recommended as a definitive form of treatment.⁴

HERNIAS IN CHILDREN⁵

The most common hernias in infants are inguinal hernias and umbilical hernias.

• Soft, round, skin-coloured lump in umbilicus, occurring in around 15% of infants.⁶

• May increase in size in first few months

• Not painful, not tender to palpate, easily reducible

• Swelling disappears when child asleep

• Usually gradually disappears

• Most disappear by age of 12 months⁶

• Larger ones usually disappear by age of 4 years⁶

• Consider hypothyroidism

• Explanation and reassurance

• No treatment required

• Do not tape or strap (may cause strangulation and does not help)

• Refer for repair if still present at age 4 years

• More common in premature infants and boys

• Present with groin lumps—may be intermittent sightings (e.g. when crying)

• May cause intermittent pain or discomfort

• If irreducible, consider possibility of strangulation

Note: Bowel strangulation is a possibility.

Rules for surgical intervention:

• general rule is ASAP, especially in infants and for irreducible ones

• reducible herniae—the ‘6–2’ rule:

  • – birth–6 weeks: surgery within 2 days

  • – 6 weeks–6 months: surgery within 2 weeks

  • – over 6 months: surgery within 2 months

The scrotum contains the testes and distal parts of the spermatic cords, covered by layers of fascia and the dartos muscle. The testes are invested with tunica vaginalis derived from the peritoneal cavity during their descent.¹

Disorders of the scrotum may be acute or chronic and bilateral or unilateral. Lumps may be cystic, solid or otherwise, such as a varicocele, oedema or hernia. Solid lumps include a testicular tumour, epididymo-orchitis, and torsion of the testes. Cystic lumps include hydroceles, epididymal cysts and spermatoceles. A comparison of scrotal lumps appears in FIGURE 112.6 and TABLE 112.3. Lumps in the scrotum usually develop from deeper structures, particularly the testes and their coverings, rather than scrotal skin.

The cardinal sign of a true scrotal mass is that it is possible to palpate it from above (i.e. get above the lump) (see FIG. 112.7).

The patient usually presents with pain or a lump.

Examination of the scrotum

The scrotum should be examined with the patient supine and then standing. The left testis usually hangs lower than the right. On inspection note any sebaceous cysts in the scrotal skin (common); scabies if there are very pruritic nodules; and scrotal oedema, which causes taut pitting skin. Careful palpation will elicit the relevant structures in the scrotum. Gently palpate each testis and epididymis between the thumb and the first two fingers. The spermatic cord is palpable as it enters the scrotum after passing through the superficial ring and the testis and epididymis are readily palpable.

After palpation, test for translucency of any swelling in a darkened room by shining the beam of a strong torch from behind the scrotum through the swelling. Transilluminable swellings that light up with a red glow (referred to as a ‘Chinese lantern sign’) include hydroceles and cysts of the epididymis. Swellings that contain blood or other tissue, such as testicular tumours and most hernias, do not transilluminate.

Unilateral scrotal swelling

It is important to determine whether the lump is inguinoscrotal or scrotal. It is scrotal if it is possible to get above the lump. If it is not possible to get above the lump then it is a large inguinal hernia or a combined hernia and hydrocele (see FIG. 112.7). This palpation should be coordinated with the cough impulse. The next feature to determine is whether the testis and/or epididymis can be palpated or whether they are obscured by a swelling.⁵

Small testes

Normal testicular size in children and adolescents is 4–14 mL or 15–35 mL in adults (this can be assessed with an orchidometer).^7,8 Length measurement is 3.5–7.5 cm in adults (average 5 cm). Small, firm testes less than 10 mL are a feature of Klinefelter syndrome. Small soft testes indicate atrophy, which may follow mumps orchitis, oestrogen therapy, androgen deficiency or anti-androgen therapy, hypopituitarism, cirrhosis and other related conditions.

Hydrocele

A hydrocele is a collection of clear amber fluid in the tunica vaginalis and can be primary or secondary. If a hydrocele develops it is important to rule out intrascrotal disease, such as a tumour or infection. Ultrasound examination of the scrotum is helpful in assessing the state of the testis in the presence of a hydrocele. Hydroceles may be symptomless or cause dragging discomfort in the scrotum and groin.

Hydrocele in the neonate^5,9

Hydroceles present at birth are communicating (failed closure of the processus vaginalis) or (less commonly) non-communicating, where the tunica vaginalis contains fluid, which can sometimes be loculated or cystic. Transillumination will prove that it is cystic but if the diagnosis is in doubt perform an ultrasound. Hydroceles may vary in size from day to day and can appear quite large. They do not extend proximal to the external inguinal ring so it is possible to palpate above them. There is no impulse on crying or straining. Of the 5% of those born with a hydrocele, most will resolve spontaneously within 12 months. If the hydrocele is very large or persists beyond 12 months, surgical intervention should be considered. However, surgery is the most effective long-term treatment.

If underlying pathology has been excluded, hydroceles can be managed conservatively with reassurance and scrotal support.¹⁰ If the hydrocele is large and uncomfortable, simple aspiration with or without the injection of sclerosing agents can be attempted, but the fluid usually reaccumulates and there is a risk of bleeding or infection with repeated procedures. However, aspiration can prevent fluid accumulation and after two or three times can often cure the problem. This sclerotherapy may be complicated by pain and inflammatory reaction to the sclerosant. Surgery is generally considered a second-line procedure after observation with or without aspiration. However surgery is the most effective long-term treatment.

Encysted hydrocele of the cord

This is a localised fluid-filled segment of the processus vaginalis within the spermatic cord. It is palpable as a cystic lump in the upper scrotum above the testis. It characteristically moves down with traction on the testis. Treatment is not usually needed.

Epididymal cysts

These are common, often multiple, and are usually found in middle-aged/elderly men. The majority of epididymal cysts are about the size of a pea and contain a clear colourless fluid. If the cysts communicate with the vasa efferentia, a spermatocele filled with whitish fluid containing spermatozoa may form.

Epididymal cysts may be asymptomatic or they may cause discomfort and cosmetic embarrassment and if so can be excised. Fertility may be impaired in patients undergoing bilateral cyst excision.

Aspiration and injection of sclerosant agents can also be used for epididymal cysts.

Varicoceles

A varicocele is a varicosity of the veins of the pampiniform plexus (see FIG. 112.6). It is seen in 8–10% of normal males and occurs on the left side in 98% of affected patients, due to a mechanical problem in drainage of the left kidney vein. A relationship with infertility has been observed but its nature is controversial, as is whether repairing varicoceles in subfertile men improves fertility chances.¹⁰

Most varicoceles are asymptomatic and incidental findings. They can cause a dragging discomfort in the scrotum. Investigation is usually not necessary but an ultrasound is useful where the diagnosis is doubtful or a neoplasm is suspected. Treatment is indicated if it is symptomatic or for infertility. Firm-fitting underpants may relieve discomfort. Surgical treatment is by venous ligation, above the deep inguinal ring. Ligation is indicated if there is any reduction in the size of the left testis.

Haematoceles

These can be either acute, resulting from trauma such as a fall astride, sports injury or tapping of a hydrocele, or chronic, where there is no obvious history of injury. Haematoceles are anterior to the testis and not transilluminable. Surgical drainage is required with acute injury where there is a possibility of testicular rupture (associated urethral injury has to be considered); and a tumour has to be excluded with the chronic type. Pressure atrophy of the testis can occur with injury and is much more common if early drainage is not instigated.

Sperm granulomas

• Firm tender lumps

• Post-vasectomy—at cut end of vas

• Leave to resolve.

• Consider NSAIDs.

• Refer for excision if symptomatic and enlarging.

Fordyce spots

These are harmless ectopic sebaceous glands 1–3 mm in diameter that appear as small raised lumps or spots of various colours (mainly red) on the shaft of the penis (Tyson’s glands) or scrotum. They can be mistaken for genital warts. They are best left, but if unacceptable they can be treated with electrodissection or pulsed dye lasers or a micro-punch technique.

Testicular tumours^11,12

A mass that is part of the testis, and solid, is likely to be a cancer. Malignant testicular tumours account for about 1–1.5% of malignant tumours in men. They mainly affect fit young men and represent the commonest cancer in men aged 15–40 years in Australia (see TABLE 112.4). Some 90–95% of testicular tumours arise from the germ cells, and for practical purposes are classified into:

• seminomas 40%

• non-seminoma germ cell tumours (NSGCT) 60%

• Young men aged 15–40 years (NSGCTs peak in the third decade of life, seminomas peak in the fourth decade)

• Most common presentation is a painless lump in the body of one testis (only 1–2% present with bilateral tumours)

• Up to a quarter of men have pain at presentation

• Loss of testicular sensation

• Associated presentations (may mask tumour):

  • – hydrocele

  • – varicocele

  • – epididymo-orchitis

  • – swollen testis with trivial injury

  • – gynaecomastia (teratoma)

  • – back and flank pain

Those at high risk include those men with:

• cryptorchidism/orchidopexy (testicular dysgenesis syndrome)

• previous testicular cancer

• family history of testicular cancer (brother/father)

• Klinefelter syndrome

• infertility

• All solid scrotal lumps are malignant until proved otherwise and must be surgically explored.

• Beware of hydroceles in young adults.

• Tumours can mimic acute epididymo-orchitis—the so-called ‘inflammatory’ or ‘flash fire’ presentation.

If a man has a testicular lump he should visit his GP and have ultrasound screening and baseline tumour markers. If it is cancer, he should:

• be treated in a specialist centre

• undergo careful staging

• have an orchidectomy and adjunct therapy

Testicular tumours spread by direct infiltration via the lymphatics, including retroperitoneal lymph nodes, and the bloodstream. Metastases typically occur in the para-aortic nodes and so may not be detected by abdominal palpation. They are best detected by a CT scan of the abdomen and chest. Metastases also occur in the neck, brain, liver, chest and bones.

Investigations to aid diagnosis include:

• ultrasound of the testis should always be done as it can detect and diagnose with considerable precision underlying testicular lumps plus any invasion of the tunica

• tumour markers: α-fetoprotein and β-hCG—indicates teratomas

• lactic dehydrogenase may be elevated

Investigations for staging include:

• chest X-ray

• CT scanning of abdomen, pelvis and chest for node involvement (any spread is usually direct to the para-aortic nodes)

• lactate dehydrogenase—monitors secondary spread and indicates tumour mass

Note: Avoid scrotal needling biopsy because of the potential risk of tumour implantation in the scrotal wall. Avoid scrotal incisions for surgery.

The initial treatment is orchidectomy through an inguinal incision with inguinal division of the spermatic cord. Further treatment then depends on the type and staging of the tumour. Early seminomas are given radiation to the ipsilateral lymph nodes or a single dose of chemotherapy. Early NSGCTs undergo active surveillance (tumour markers, CXR, CT scans) but no further treatment. More advanced disease may have further chemotherapy or radiotherapy. The results for NSGCTs in general are not as satisfactory as for seminoma, though prognosis is good for both, with current 5-year relative survival rates of 99% for localised disease (majority of presentations), 96% for regional disease and 74% for distant disease.¹³ A comparison of the testicular tumours is summarised in TABLE 112.5.

Surgery should not affect the remaining testis but production of motile and functional sperm may be reduced. However, sperm production can be temporarily or permanently reduced following radiotherapy and chemotherapy. Pretreatment sperm storage may be discussed with the patient, and the psychological implications of testicular cancer need to be carefully monitored. A testicular prosthesis is an option. The GP may also play a role in coordinating appropriate active surveillance investigations.

Studies of testicular cancer have shown the benefits of early detection. However, studies to date indicate that there is insufficient evidence to screen routinely for testicular cancer in asymptomatic patients. It is recommended for those at high risk. This screening includes colour Doppler ultrasound and tumour markers. Evidence also indicates that, to date, there is little evidence to show that those performing testicular self-examination are more likely to detect early stage tumours or have better survival than those who do not.¹⁴

Undescended testes (cryptorchidism)¹⁵

An undescended testis is one that fails to reach the bottom of the scrotum by 3 months of age despite manual manipulation. It has stopped in the normal path of descent and can occupy the intra-abdominal, inguinal canal, emergent (just outside the external ring), high scrotal and mid-scrotal positions (see FIG. 112.8). The cause of maldescent is most probably mechanical.

After the indirect inguinal hernia, it is the most common problem in paediatric surgery. The incidence at birth is 3–4%, but this falls to 1% in the first 3 months of life as testicular descent can continue, though further descent after 3 months is rare. More than two-thirds of undescended testes are located in the superficial inguinal pouch; that is, they are palpable in the groin.

The testis is usually normal at birth but may become secondarily dysplastic if left outside the scrotum.

Retractile testis

A retractile testis is one that can be manipulated into the scrotum irrespective of the position in which it is first located. It is a common condition and requires no further investigation or treatment. The testis can be present in the scrotum under circumstances such as a warm bath but retracted out of the scrotum when cold. Cremasteric contraction is absent in the first few months after birth and is maximal between 2 and 8 years.

Ectopic testis

An ectopic testis is one that has left the normal path of descent and cannot be manipulated into the scrotum. It can be found in the perineum, upper thigh (femoral), base of the penis (prepubic), anterior abdominal wall or in the superficial inguinal pouch (see FIG. 112.9). True ectopic testes form only about 2.5% of all undescended testes.

Ascending testis

An ‘ascending’ testis is one that was in the scrotum in infancy but subsequently moved back to the groin because the spermatic cord failed to elongate at the same rate of body growth.

The examination of the testes should take place in a warm room and relaxed environment. Begin by placing one finger on each side of the neck of the scrotum to prevent a retractile testis from being retracted when palpation is commenced with the other hand. The scrotum is then carefully palpated for a testis. If impalpable the fingertips of one hand are placed just medial to the anterior superior iliac spine and moved firmly towards the pubic tubercle where the other hand waits to entrap the testis should it appear. The diagnosis then depends on carefully determining the range of movement.

• Testicular dysgenesis and dysplasia

• Susceptible to direct trauma (if in inguinal region)

• Risk of malignant change (seminoma) is 5–10 times greater than normal

The optimal time for orchidopexy is 6–12 months of age. It is considered to be satisfactory as long as the testis is in the scrotum by 2 years. The production of spermatozoa is adversely affected in undescended testes from the age of 2 years onwards. Exploration for the uncommon impalpable testis is worthwhile: 50% salvage rate, while in the other 50% either there is no testis or an abnormal and potentially neoplastic testis is removed.

The advantages of early orchidopexy are summarised in TABLE 112.6.

Injections of chorionic gonadotrophic hormones are generally not recommended. They are ineffective except for cases of borderline retractile testes.

Dangerous features (caution required)

• Unmarried

• Young <35 years old

• No children

• Emotional crisis

• Spouse not involved

Postoperative

• Avoid strenuous activity and sex for 4–7 days.

• Use alternative contraception until negative semen analysis.

• First semen analysis at 3 months.

• Inform not immediately infertile.

• Need to ejaculate 20 times.

Complications¹⁶

• Postoperative bleeding and haematoma 4–22%

• Wound infection <1.5%

• Ongoing pain—around 10%, usually mild but can be severe

• Formation of sperm antibodies ∼50%. May be a problem if subsequently requests vasectomy reversal

• Failure rate 1–2:1000 (can be from tubes not fully tied off, growing back together or a third vas deferens existing)

• Psychological and psychosexual problems

Other facts

• No difference in ejaculate appearance (sperm makes up 1% ejaculate volume) or sex drive

• No known association with prostate and testicular cancers

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Hernia, inguinal

• Scrotal lumps

• Testicle: undescended

• Testicular cancer

• Testicular self-examination