From the Guidelines
The evaluation and management of scrotal swelling requires a systematic approach beginning with a thorough history and physical examination to determine the underlying cause, with ultrasound as the imaging modality of choice for distinguishing between various etiologies, as recommended by the American College of Radiology Appropriateness Criteria 1. Initial assessment should focus on differentiating between urgent conditions requiring immediate intervention (testicular torsion, strangulated hernia) and less acute causes. For painful acute swelling suggesting torsion, immediate urological consultation is necessary as surgical exploration within 6 hours maximizes testicular salvage, as emphasized in the 2024 update of the ACR Appropriateness Criteria 1. The following are key points in the evaluation and management of scrotal swelling:
- Ultrasound findings in patients with epididymitis include an enlarged and hypoechoic epididymis due to edema, reactive hydroceles, and scrotal wall thickening, with increased blood flow corresponding to hyperemia on color Doppler imaging 1.
- For epididymitis, treatment includes antibiotics such as ceftriaxone 250mg IM once plus doxycycline 100mg twice daily for 10 days (for those under 35) or levofloxacin 500mg daily for 10 days (for older men), as outlined in the European Association of Urology guidelines on urological infections 1.
- Hydroceles may be observed if asymptomatic but surgical repair is indicated for discomfort or cosmetic concerns.
- Varicoceles often require no treatment unless associated with pain or infertility, in which case surgical ligation may be considered.
- Testicular cancer presenting as a painless mass requires prompt referral for radical orchiectomy. Supportive measures for most scrotal swelling include:
- Scrotal elevation
- Ice packs for acute conditions
- Nonsteroidal anti-inflammatory drugs for pain (ibuprofen 400-600mg three times daily)
- Appropriate follow-up based on the specific diagnosis, as supported by the ACR Appropriateness Criteria 1. The rich dual blood supply to the scrotum and its anatomical connections explain why various systemic and local conditions can manifest as scrotal swelling, highlighting the importance of a comprehensive approach to diagnosis and management, as discussed in the Journal of the American College of Radiology 1.
From the Research
Evaluation of Scrotal Swelling
- Scrotal swelling can be caused by various conditions, including acute orchiepididymitis, torsion of the spermatic cord, scrotal trauma, and strangulated inguinoscrotal hernia 2
- The evaluation of scrotal swelling involves determining the underlying cause, which can be done through physical examination, medical history, and diagnostic tests such as ultrasound 3, 4
- Ultrasound is a valuable tool in evaluating scrotal swelling, as it can help determine the status of the underlying testis and detect conditions such as testicular torsion, hematocele, and intratesticular hematoma 3, 5
Management of Scrotal Swelling
- The management of scrotal swelling depends on the underlying cause, with some conditions requiring surgical intervention and others being treated conservatively 2, 3
- Early surgical intervention is recommended for conditions such as rupture of the testicle and hematocele, while hematoma of the scrotal layers and purely intratesticular hematoma can be treated conservatively 3
- In some cases, scrotal swelling can be an extraintestinal manifestation of a underlying condition, such as Crohn's disease, and treatment of the underlying condition is necessary 6
Diagnostic Considerations
- Scrotal scanning can be used to evaluate testicular perfusion and refine the indications for operation in cases of suspected testicular torsion 5
- Ultrasonography can help separate extra- from intratesticular lesions and provide information on the characteristics of the lesion, such as whether it is cystic, solid, or complex 4
- A thorough evaluation, including medical history and physical examination, is necessary to determine the underlying cause of scrotal swelling and guide management 2, 6