GPAtlas🧭 When to suspect
A man presenting with a scrotal lump or swelling poses two quite different questions, and the whole of primary-care assessment turns on telling them apart. The first is the acute scrotum – sudden, severe testicular pain – where the overriding concern is testicular torsion, a surgical emergency in which the testis is salvageable for only a few hours. The second is the painless lump, where the overriding concern is testicular cancer, classically a hard, non-tender mass arising from within the body of the testis.
Most scrotal swellings are entirely benign – epididymal cysts, hydroceles and varicoceles between them account for the great majority, and fewer than 4 in 100 testicular lumps prove to be cancer. The clinical skill is therefore not to operate on everyone, but to localise the lesion (within the testis, separate from it, or unable to get above it), never miss a torsion, and never miss a cancer. Testicular cancer is the most common solid malignancy in men aged 15–44, yet when caught early it is among the most curable of all cancers, with cure rates above 95%.
The single most useful examination decision is whether the lump lies within the testis or is separate from it: an intratesticular mass is cancer until proven otherwise, whereas a lesion clearly separate from the testis is usually benign.
| Clinical picture | Likely diagnosis | Action |
|---|---|---|
| Acute, severe pain; high-riding or transverse testis; absent cremasteric reflex | Testicular torsion | Emergency – 999 / immediate surgical exploration; do not wait for imaging |
| Hard, painless lump within the testis; does not transilluminate | Testicular cancer until proven otherwise | Suspected cancer pathway referral + urgent scrotal ultrasound |
| Tender, swollen epididymis with or without testicular involvement; dysuria or urethral discharge; gradual onset | Epididymo-orchitis | Treat by likely organism; exclude torsion first if any doubt |
| Soft, smooth, fluctuant lump separate from and above the testis; transilluminates | Epididymal cyst / spermatocele | Reassure; ultrasound only if uncertain |
| Fluctuant swelling surrounding the testis; transilluminates; can get above it | Hydrocele | Ultrasound if the testis cannot be felt, or if new / tense in an adult |
| "Bag of worms"; decompresses on lying flat; usually left-sided | Varicocele | Ultrasound; refer if subfertile, right-sided, or non-decompressing |
| Cannot get above the swelling; with or without a cough impulse; reducible | Inguinoscrotal hernia | Surgical referral; emergency if irreducible / obstructed |
Source: NICE NG12
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