Scrotal Masses (Testicular Cancer & Benign Masses)

 

This guideline applies to adults aged 16 years and over.

 

Introduction

Over 2000 new testicular cancers are diagnosed each year in UK. It’s the commonest cancer in males aged 16 to 24 years old. The 5-year survival is almost 100%¹.

In scope: scrotal masses in adults, including testicular cancer & benign masses.

Out of scope: testicular and scrotal conditions in children and adolescents, see guideline on Paediatric Urology Surgery.

 

Red Flag Features

• Testicular cancer
• Testicular torsion
• Acute epididymo-orchitis
• Strangulated inguinal hernia

This list is not exhaustive.

 

Investigations prior to referral

Consider:

• STI screen
• Urinalysis

In the absence of red flag features, arrange scrotal ultrasound provided the scrotal swelling is not of acute onset. Arrange urgently if:

• Diagnostic uncertainty
• Persistent, unexplained scrotal symptoms
• Hydrocele in 18-40yo
• Not possible to distinguish whether scrotal swelling is testicular or extra-testicular
• History of trauma and scrotal pain if not requiring emergency assessment
• Haematocele does not follow trauma or is longstanding²

Arrange scrotal ultrasound  and renal tract ultrasound at first presentation for all varicoceles irrespective of age, onset, right or left sided.

Request serum α-FP, βhCG & LDH at time of referral if testicular cancer is confirmed on imaging.

 

Management Optimisation

In the absence of red flag features, management depends on likely underlying cause of scrotal swelling. If suspected:

• Acute epididymo-orchitis, consider STI screen and treat as per local antimicrobial guidelines.
• Inguinal hernia, follow the Hernia guideline.

 

Referral

Same-Day Assessment

Discuss with surgical on-call to arrange same-day assessment/admission if suspected:

• Testicular torsion
• Strangulated inguinal hernia
• Acute epipidymo-orchitis with systemic upset/complication

 

Suspected Cancer Pathway – Testicular

Refer via the Suspected Urology Cancer Fast Track pathway if:

• Non painful enlargement or change in shape or texture of testis.
• Imaging suspicious of testicular cancer -request serum α-FP, βhCG & LDH at time of referral.

 

Routine Urology Referral

Symptomatic benign testicular disease in a patient willing to undergo surgery.

Advise patients that:

• surgery carries risk of post op haematoma/infection/chronic pain.
• aspiration of hydrocoeles and epididymal cysts is generally not advocated due to infection and recurrence risk; they usually recur within short period of time.

 

Supporting Information

For professionals:

NICE CKS: Scrotal pain and swelling

 

References

1. NICE CKS: Urological cancers – recognition and referral, February 2021
2. NICE CKS: Scrotal Pain and Swelling, August 2024
3. J. D, Tiemstra, S. Kapoor. Evaluation of Scrotal Masses. Department of Family Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois. [2008]

 

Page Review Information

Review date	6 March 2025
Next review date	6 March 2027
GP speciality lead	Dr Laura Vines
Contributors	Mr Christopher Blake, Consultant Urologist RCHT Mr Mathi Murugesan, Consultant Urologist RCHT