I have a bulge on the right side of my scrotum; what could be causing it and how should it be evaluated and managed?

Evaluation and Management of Right-Sided Scrotal Bulge

A bulge on the right side of your scrotum requires immediate evaluation with scrotal duplex Doppler ultrasound to differentiate between common causes including inguinal hernia, hydrocele, varicocele, testicular mass, or epididymal pathology. 1

Initial Diagnostic Approach

Scrotal duplex Doppler ultrasound is the definitive first-line imaging study for any newly diagnosed palpable scrotal abnormality, combining grayscale imaging with color and power Doppler to assess both structural anatomy and vascular flow. 1, 2 This single examination can:

• Differentiate intratesticular from extratesticular masses 1, 3
• Identify hernias, hydroceles, varicoceles, and solid masses 4, 3
• Assess testicular perfusion and rule out torsion if pain is present 1
• Characterize cystic versus solid lesions 5, 6

Most Common Causes by Location

Extratesticular Masses (Most Common)

• Inguinal hernia: Bowel or omentum extending into scrotum, may be reducible 6
• Hydrocele: Fluid collection around testis, transilluminates on exam 4, 3
• Varicocele: Dilated pampiniform plexus veins (>2mm diameter), typically left-sided but can be bilateral or right-sided 7
• Spermatic cord masses: Lipomas, hernias 6

Intratesticular Masses (Require Urgent Evaluation)

• Testicular tumors: Any solid intratesticular mass is malignant until proven otherwise 1, 6
• Epididymitis/orchitis: Associated with pain, fever, urinary symptoms 1, 4

Critical Red Flags Requiring Immediate Action

If the bulge is associated with acute severe pain, proceed directly to emergency evaluation as testicular torsion must be ruled out within 6 hours to salvage the testicle. 1 In equivocal cases with high clinical suspicion, surgical exploration should not be delayed for imaging. 1

Any solid intratesticular mass on ultrasound requires:

• Serum tumor markers (AFP, β-HCG, LDH) before and after any intervention 1
• Urgent urology referral for inguinal orchiectomy 1
• Chest radiograph and abdominopelvic CT for staging if malignancy confirmed 1

Specific Evaluation Algorithm

1. Physical examination should document:

   • Exact location (intratesticular vs extratesticular) 1
   • Size, consistency, mobility, transillumination 6
   • Presence of pain, tenderness, or associated symptoms 1
   • Reducibility (suggests hernia) 6
   • Valsalva maneuver effect (varicocele increases with Valsalva) 7

2. Scrotal duplex Doppler ultrasound with:

   • High-frequency (12-17 MHz) linear array transducer 3
   • Bilateral evaluation including inguinal regions 1
   • Color and power Doppler assessment of vascularity 1
   • Measurement of any dilated veins during Valsalva (varicocele) 7

3. Additional imaging is NOT routinely needed unless:

   • Ultrasound findings are equivocal, then MRI pelvis may be used as problem-solving tool 1
   • Testicular malignancy is confirmed, then CT chest/abdomen/pelvis for staging 1

Common Pitfalls to Avoid

• Do not rely on physical examination alone when a mass is palpable—ultrasound is mandatory to characterize the lesion and rule out malignancy. 1, 6
• Do not delay imaging for suspected torsion—if clinical suspicion is high, proceed directly to surgical exploration rather than waiting for ultrasound. 1
• Do not assume right-sided bulges are always benign—while varicoceles are more common on the left, right-sided masses warrant the same thorough evaluation. 7
• Do not perform routine CT or MRI as initial imaging—these modalities are not indicated for initial evaluation of scrotal masses. 1
• Do not biopsy intratesticular masses—if malignancy is suspected, proceed directly to radical inguinal orchiectomy. 1

Management Based on Diagnosis

If Varicocele Diagnosed

• Treatment only indicated if associated with infertility, abnormal semen parameters, testicular size discrepancy >20%, or significant pain affecting quality of life 8, 7
• Subclinical (non-palpable) varicoceles found only on ultrasound should NOT be treated 8, 7

If Hernia Diagnosed

• Surgical referral for inguinal hernia repair 6

If Hydrocele Diagnosed

• Observation if asymptomatic; surgical repair if symptomatic or large 3

If Testicular Mass Diagnosed

• Immediate urology referral for radical inguinal orchiectomy 1
• Sperm banking should be discussed before any intervention 1