Causas Dolor Testicular

Causes of painless scrotal swelling in children and adolescents 2/09/15 2:00 p.m.
Official reprint from UpToDate®

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Causes of painless scrotal swelling in children and adolescents
Authors Section Editors Deputy Editor

Joel S Brenner, MD, MPH Amy B Middleman, MD, MPH, MS Ed James F Wiley, II, MD, MPH
Aderonke Ojo, MD Gary R Fleisher, MD
Laurence S Baskin, MD, FAAP
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2015. | This topic last updated: Mar 07, 2014.
INTRODUCTION — The spectrum of conditions that affect the scrotum and its contents ranges from incidental findings
to pathologic events that require expeditious diagnosis and treatment (eg, testicular torsion, testicular cancer). The most
common causes of painless scrotal swelling in children and adolescents include hydrocele and nonincarcerated inguinal
hernia. Less common causes are varicocele, spermatocele, localized edema from insect bites, nephrotic syndrome
(swelling is usually bilateral), and rarely, testicular cancer (table 1). Scrotal swelling and testicular masses should be
evaluated promptly.
The clinical presentation, diagnosis, and management of hydrocele, varicocele, spermatocele will be discussed below
along with the presentation and diagnosis of testicular cancer. Inguinal hernia, the evaluation of scrotal pain and
swelling, and the causes of scrotal pain in children and adolescents are discussed separately. (See "Overview of
inguinal hernia in children" and "Evaluation of scrotal pain or swelling in children and adolescents" and "Causes of
scrotal pain in children and adolescents".)
HYDROCELE — A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica
vaginalis. Hydroceles may be communicating or noncommunicating.
Communicating hydroceles usually develop as a result of failure of the processus vaginalis to close during development;
the fluid around the testis is peritoneal fluid (figure 1 and picture 1) [1]. Noncommunicating hydroceles have no
connection to the peritoneum; the fluid comes from the mesothelial lining of the tunica vaginalis (figure 2).
Hydroceles are common in newborns (whether related to delayed closure of a patent processus vaginalis or fluid
trapped at the time of testicular descent is not known) [1]. The majority of hydroceles in neonates resolve spontaneously,
usually by the first birthday [1,2].
In older children and adolescents, noncommunicating hydroceles may be idiopathic or may occur secondary to
epididymitis, orchitis, testicular torsion, torsion of the appendix testis or appendix epididymis, trauma, or tumor. These
conditions must be excluded in children and adolescents with hydrocele. (See "Evaluation of scrotal pain or swelling in
children and adolescents" and 'Testicular cancer' below.)
Clinical presentation — Patients with hydroceles present with a cystic scrotal mass. A hydrocele that communicates
with the peritoneal cavity may increase in size during the day or with the valsalva maneuver. In contrast,
noncommunicating hydroceles are not reducible and do not change in size or shape with crying or straining.
Examination of patients with hydroceles should include palpation of the entire testicular surface for findings of
epididymitis, orchitis, testicular torsion, torsion of the appendix testis or appendix epididymis, trauma, or tumor as the
primary etiology; doppler ultrasonography may be necessary to exclude these conditions. (See "Evaluation of scrotal
pain or swelling in children and adolescents" and 'Testicular cancer' below.)
Diagnosis — The diagnosis of hydrocele can be made by physical examination and transillumination of the scrotum that
demonstrates a cystic fluid collection. Communicating hydroceles are often reducible; noncommunicating hydroceles are
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not. Doppler ultrasonography may be necessary to evaluate the testicle and rule out a primary cause.
Management — Surgical repair is indicated for hydroceles in newborns that persist beyond one year of age, for
communicating hydroceles, and for idiopathic hydroceles that are symptomatic or compromise the skin integrity.
The management of hydrocele in a neonate or child younger than one year of age usually is supportive [2]. Hydroceles
that are present in newborns, whether communicating or noncommunicating, usually resolve spontaneously by the first
birthday, unless they are accompanied by an inguinal hernia [1,2]. (See "Overview of inguinal hernia in children".)
Communicating hydroceles in older patients rarely resolve and pose a risk for development of incarcerated inguinal
hernia. Surgical repair of communicating hydroceles is usually undertaken on an elective basis [2-4].
Idiopathic hydroceles are often asymptomatic. Surgical repair may be indicated for symptomatic complaints. Reactive
hydroceles usually resolve with treatment of the underlying condition. (See "Overview of inguinal hernia in children" and
"Causes of scrotal pain in children and adolescents" and "Clinical manifestations, diagnosis, and staging of testicular
germ cell tumors".)
INGUINAL HERNIA — The clinical presentation, diagnosis, and management of inguinal hernia in children is discussed
separately. (See "Overview of inguinal hernia in children".)
VARICOCELE — A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the
spermatic cord in the scrotum (figure 3). One etiologic theory is that varicoceles result from increased venous pressure
and incompetent valves [3,5-7]. Varicoceles occur more commonly on the left side (85 to 95 percent) because the left
spermatic vein enters the left renal vein at a 90 degree angle, whereas the right spermatic vein drains at a more obtuse
angle directly into the inferior vena cava, facilitating more continuous flow [3,5,6]. Approximately 10 to 25 percent of all
adolescent males and as many as one-third of all males examined at an infertility clinic have a varicocele. However, only
10 to 15 percent of males with varicoceles have fertility problems [6].
Clinical presentation — Patients with varicoceles can be asymptomatic or present complaining of a dull ache in or
fullness of the scrotum upon standing.
The examination for varicocele initially should be performed with the patient standing [8]. The scrotum is inspected for
any visible distention around the spermatic cord (indicative of a grade III varicocele). The scrotum, testes, and cord
structures are then gently palpated; a palpable varicocele has the texture of a "bag of worms". Grade II varicoceles are
palpable, but nonvisible. The patient should then be asked to perform the valsalva maneuver; if the varicocele is
palpable only with the valsalva maneuver, it is Grade I (table 2).
Varicocele grade does not correlate well with abnormal semen analysis or infertility in adults [9]. Studies in adolescents
correlating varicocele grade and testicular size in adolescents have had conflicting results [10-13].
The patient also should be examined in the supine position [8]. This maneuver will help to differentiate idiopathic from
secondary varicocele. Idiopathic varicocele usually is more prominent in the upright position and disappears in supine,
whereas secondary varicocele usually does not get much smaller with change in position from upright to supine.
Processes that cause inferior vena caval (IVC) obstruction must be ruled out with Doppler ultrasonography if the
varicocele persists in the supine position, has acute onset, or is right-sided [5]. These processes include IVC thrombus,
right renal vein thrombosis with clot propagation down the IVC, and abdominal mass (eg, retroperitoneal tumors, kidney
tumors, or lymphadenopathy) [14].
Management — There are no clear guidelines established for treatment of a varicocele in childhood. Most varicoceles in
adolescents are managed conservatively with observation. When more aggressive treatment is necessary, varicoceles
are repaired through surgical ligation or testicular vein embolization [8]. These procedures should be considered under
the following circumstances [8]:
Affected testicular volume is less than that of the unaffected testicle (a difference in size of >10 to 15 percent or
>2 mL when assessed by ultrasonography); loss of testicular volume is associated with a decreased sperm count
[15]; testicular growth arrest can be reversed with varicocele repair [11,16-18].
To alleviate symptoms: Pain, heaviness, swelling.
Bilateral varicoceles.
Although grade of varicocele should not be the sole indication for treatment, treatment may be warranted in adolescents
with large varicoceles (grade III) and abnormal semen analysis, since varicocele repair has been associated with
improved semen analysis in adolescents and young men [17,18].
In one study, hormonal tests and orchidometry in 76 sexually mature (Tanner V) adolescents with varicocele were
correlated with semen analysis. Twenty patients (26 percent) had abnormal semen. Unstimulated concentrations of LH
and FSH were significantly greater in adolescents with abnormal than normal semen analysis (4.1 versus 3.3 mU/mL for
LH, and 5.3 versus 3.7 mU/mL for FSH) [19]. Neither mean testicular volume nor the ratio of testicular volume on the
abnormal to the normal side differed significantly between groups. These data suggest that LH and FSH concentrations
may be more helpful than testicular volume in identifying patients with testicular dysfunction in adolescents with
varicocele.
SPERMATOCELE (EPIDIDYMAL CYST) — A spermatocele (epididymal cyst) is a painless, fluid-filled cyst of the head
(caput) of the epididymis that may contain nonviable sperm (figure 4). A spermatocele can be palpated as distinct from
the testis and typically transilluminates as a cystic mass. In contrast, testicular tumors are palpated within the testis and
do not transilluminate. Ultrasonography may be helpful to confirm the diagnosis of spermatocele. Spermatoceles do not
affect fertility. Treatment (eg, surgical excision) is indicated to relieve discomfort.
TESTICULAR CANCER — Testicular cancer accounts for 20 percent of cancer diagnosed in males 15 to 35 years old,
rendering it the most common solid tumor in males within this age group [20,21]. The epidemiology and risk factors for
testicular cancer, which include cryptorchidism, family history of testicular cancer, cancer of the other testicle, human
immunodeficiency virus (HIV) infection, intratubular germ cell neoplasia of the unclassified type (also called carcinoma in
situ or testicular intraepithelial neoplasia), and race, are discussed in detail separately. (See "Epidemiology of and risk
factors for testicular germ cell tumors".)
Clinical presentation — Testicular cancer usually presents as a painless mass discovered by the patient or clinician on
physical examination, although rapidly growing germ cell tumors may cause acute scrotal pain secondary to hemorrhage
and infarction. Other common signs are testicular enlargement or swelling. Many patients also report an aching feeling in
the lower abdomen or scrotum.
On examination, intrascrotal malignancies usually are firm, nontender masses that do not transilluminate unless
accompanied by a reactive hydrocele. Some patients may have gynecomastia. The clinical presentation of testicular
cancer and advanced or metastatic testicular cancer are discussed in more detail separately. (See "Clinical
manifestations, diagnosis, and staging of testicular germ cell tumors".)
Diagnosis — Scrotal ultrasound is the initial diagnostic test of choice [20,22]. Although pathology is the definitive
diagnostic test, scrotal ultrasound may help to distinguish intrinsic from extrinsic testicular lesions. (See "Clinical
manifestations, diagnosis, and staging of testicular germ cell tumors".)
Several conditions may mimic neoplasia on ultrasound, including inflammation, hematoma, infarct, fibrosis, and tubular
ectasia of the rete testis. In cases in which the ultrasound is inconclusive, MRI may help differentiate benign from
malignant lesions. This was illustrated in a study of 622 patients who underwent ultrasound examination to evaluate a
variety of scrotal diseases, of whom 17 had a lesion suspicious for cancer but an inconclusive ultrasound [23]. No lesion
defined as benign by MRI proved to be malignant (negative predictive value 100 percent), although two benign
inflammatory lesions were mistakenly thought to be malignant (positive predictive value 71 percent). These findings
suggest ultrasound is sufficient in the vast majority of patients with suspected malignancy on examination, but MRI is a
useful adjunct when the ultrasound result is equivocal.
Boys with lesions that are consistent with cancer should be referred to a urologist for diagnostic evaluation, which may
include blood tests for various tumor markers, and radical inguinal orchiectomy. (See "Clinical manifestations, diagnosis,
and staging of testicular germ cell tumors".)
Management — The treatment of testicular cancer is discussed separately. (See "Overview of the treatment of testicular
germ cell tumors".)
Early detection — Prevention of testicular cancer centers on improved awareness and early detection (eg, secondary
prevention). Efforts to increase awareness of testicular cancer can occur in the general community (eg, Lance
Armstrong Foundation [www.livestrong.org]), in schools, and at medical visits.
Screening for testicular cancer is discussed in greater detail separately. (See "Screening for testicular cancer", section
on 'Screening tests'.)
OTHER CAUSES
Insect bites – Localized edema from insect bites may cause scrotal swelling; such swelling may be accompanied
by erythema and/or pruritus.
Nephrotic syndrome – The nephrotic syndrome is characterized by nephrotic range proteinuria,

hypoalbuminemia, edema, and hyperlipidemia. The edema is gravity dependent. (See "Etiology, clinical
manifestations, and diagnosis of nephrotic syndrome in children".)
Other conditions producing generalized edema due to hypoproteinemia or increased hydrostatic pressure (eg,
protein losing enteropathy, hepatic cirrhosis).
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond
the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and
the keyword(s) of interest.)
Basics topics (see "Patient information: Hydrocele (The Basics)" and "Patient information: Varicocele (The
Basics)")
SUMMARY
The most common causes of painless scrotal swelling in children and adolescents include hydrocele and
nonincarcerated inguinal hernia. Less common causes include varicocele, spermatocele, localized edema from
insect bites, nephrotic syndrome, and rarely, testicular cancer (table 1). Scrotal swelling and testicular masses
should be evaluated promptly. (See 'Introduction' above.)
A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis
(figure 2). Hydroceles may occur in reaction to testicular torsion, tumor, epididymitis, orchitis, or trauma; these
conditions must be ruled out by palpation of the entire testicular surface and/or ultrasonography. Such reactive
hydroceles usually resolve with treatment of the underlying condition. Surgical repair of hydroceles is indicated for
hydroceles in newborns that persist beyond one year of age, for communicating hydroceles, and for idiopathic
hydroceles which are symptomatic. (See 'Hydrocele' above.)
A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord
(figure 3). Inferior vena caval obstruction must be excluded in patients with varicocele if the varicocele persists in
the supine position, has acute onset, or is only right-sided. (See 'Varicocele' above.)
A spermatocele (epididymal cyst) is a painless, fluid-filled cyst of the head (caput) of the epididymis that may
contain nonviable sperm (figure 4). Spermatoceles do not affect fertility and rarely require excision. (See
'Spermatocele (epididymal cyst)' above.)
Testicular cancer usually presents as a painless mass in the testicle that is firm and nontender; it may be
accompanied by a reactive hydrocele. Such masses must be evaluated promptly. Scrotal ultrasonography is the
initial diagnostic test of choice; boys with lesions that are consistent with cancer should be referred to a urologist
for additional evaluation. (See 'Testicular cancer' above.)
Boys with a history of cryptorchidism, previous testicular cancer, HIV infection, intratubular germ cell neoplasia of
the unclassified type (also called carcinoma in situ or testicular intraepithelial neoplasia), or family history of
testicular cancer are at risk of developing testicular cancer. (See 'Testicular cancer' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Baskin LS, Kogan AB. Hydrocele/Hernia. In: Pediatric Urology Practice, Gonzales ET, Bauer SB. (Eds), Lippincott
Williams & Wilkins, Philadelphia 1999. p.649.
2. Spencer Barthold J, Kass EJ. Abnormalities of the penis and scrotum. In: Clinical Pediatric Urology, 4th, Belman
AB, King LR, Kramer SA. (Eds), Martin Dunitz Ltd, London 2002. p.1093.
3. Rohn RD. Male genitalia: Examination and findings. In: Comprehensive Adolescent Health Care, Friedman SB,
Fisher M, Schonberg SK, et al. (Eds), Mosby-Yearbook, St. Louis 1998. p.1078.
4. Anderson MM, Neinstein LS. Scrotal disorders. In: Adolescent Health Care: A Practical Guide, Neinstein LS. (Ed),
Williams & Wilkins, Baltimore 1996. p.464.
5. Pillai SB, Besner GE. Pediatric testicular problems. Pediatr Clin North Am 1998; 45:813.
6. Skoog SJ, Roberts KP, Goldstein M, Pryor JL. The adolescent varicocele: what's new with an old problem in
young patients? Pediatrics 1997; 100:112.
7. Kass EJ. Adolescent varicocele. Pediatr Clin North Am 2001; 48:1559.
8. Paduch DA, Skoog SJ. Current management of adolescent varicocele. Rev Urol 2001; 3:120.
9. Vereecken RL, Boeckx G. Does fertility improvement after varicocele treatment justify preventive treatment at
puberty? Urology 1986; 28:122.
10. Lyon RP, Marshall S, Scott MP. Varicocele in childhood and adolescence: implication in adulthood infertility?
Urology 1982; 19:641.
11. Paduch DA, Niedzielski J. Repair versus observation in adolescent varicocele: a prospective study. J Urol 1997;
158:1128.
12. Costabile RA, Skoog S, Radowich M. Testicular volume assessment in the adolescent with a varicocele. J Urol
1992; 147:1348.
13. Steeno O, Knops J, Declerck L, et al. Prevention of fertility disorders by detection and treatment of varicocele at
school and college age. Andrologia 1976; 8:47.
14. Roy CR 2nd, Wilson T, Raife M, Horne D. Varicocele as the presenting sign of an abdominal mass. J Urol 1989;
141:597.
15. Haans LC, Laven JS, Mali WP, et al. Testis volumes, semen quality, and hormonal patterns in adolescents with
and without a varicocele. Fertil Steril 1991; 56:731.
16. Kass EJ, Belman AB. Reversal of testicular growth failure by varicocele ligation. J Urol 1987; 137:475.
17. Laven JS, Haans LC, Mali WP, et al. Effects of varicocele treatment in adolescents: a randomized study. Fertil
Steril 1992; 58:756.
18. Okuyama A, Nakamura M, Namiki M, et al. Surgical repair of varicocele at puberty: preventive treatment for fertility
improvement. J Urol 1988; 139:562.
19. Guarino N, Tadini B, Bianchi M. The adolescent varicocele: the crucial role of hormonal tests in selecting patients
with testicular dysfunction. J Pediatr Surg 2003; 38:120.
20. Iammarino NK, Scardino PT. Testicular cancer: the role of the primary care physician in prevention and early
detection. Tex Med 1991; 87:66.
21. Surveillance, Epidemiology, and End Results (SEER) Program. Public-use Data (1973-1998), National Cancer
Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2001, based on
August 2000 submission.
22. American Cancer Society. Cancer reference information,
www.cancer.org/docroot/cri/content/cri_2_4_3x_Can_Testicular_Cancer_Be_Found_Early_41.asp (Accessed on
November 27, 2006).
23. Muglia V, Tucci S Jr, Elias J Jr, et al. Magnetic resonance imaging of scrotal diseases: when it makes the
difference. Urology 2002; 59:419.
Topic 6448 Version 6.0
GRAPHICS
Differential diagnosis of painless scrotal mass in children
Increases with
Mass Palpation Transilluminates?
Valsalva maneuver?
Tumor Firm No No
Varicocele "Bag of worms" No Yes
Noncommunicating Fluid-filled Yes No

hydrocele
Spermatocele Small, soft, and Yes No

localized cyst
Reference:
1. Kapphahn C, Schlossberger N. Diagnostic approach to scrotal masses. Adolescent Health Update
1992; 5:1.
Graphic 57879 Version 3.0
Communicating hydrocele
A narrowly patent processus vaginalis that only permits passage of

peritoneal fluid results in a communicating hydrocele.
Adapted from Paidas, C. Inguinal hernia. In: Oski's Pediatrics. Principles and
Practice, 3rd ed, McMillan, JA, DeAngelis, CD, Feigin, RD, et al (Eds),
Lippincott Williams &Wilkins, Philadelphia 1999. p.1640.
Communicating hydrocele
Communicating hydroceles usually develop as a result of failure of the

processus vaginalis to close during development. The patent processus
vaginalis is demonstrated in Panel B.
Courtesy of Laurence Baskin, MD.
Hydrocele
A hydrocele is a fluid accumulation between the parietal and visceral

layers of the tunica vaginalis. The hydrocele depicted above is
noncommunicating (there is no connection between the hydrocele and
the peritoneum; the fluid comes from the mesothelial lining of the
tunica vaginalis ).
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Varicocele
A varicocele is a collection of dilated and tortuous veins in the

pampiniform plexus surrounding the spermatic cord. On physical
examination, the spermatic cord has a "bag of worms" appearance that
increases with standing or the valsalva maneuver.
Grading of varicoceles
Grade Size Clinical description

1 Small Palpable only with valsalva maneuver
2 Moderate Nonvisible on inspection, but palpable upon standing
3 Large Visible on gross inspection
Spermatocele
A spermatocele epididymal cyst is a painless, fluid-filled cyst of the

epididymis. It can be palpated as distinct from the testis and typically
transilluminates as a cystic mass.
Disclosures
Disclosures: Joel S Brenner, MD, MPH Nothing to disclose. Aderonke Ojo, MD Nothing to disclose. Amy B Middleman, MD, MPH, MS Ed
Nothing to disclose. Gary R Fleisher, MD Nothing to disclose. Laurence S Baskin, MD, FAAP Nothing to disclose. James F Wiley, II, MD,
MPH Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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Causes of painless scrotal swelling in children and adolescents 2/09/15 2:00 p.m.

Official reprint from UpToDate®

Causes of painless scrotal swelling in children and adolescents

Authors Section Editors Deputy Editor

the following circumstances [8]:

To alleviate symptoms: Pain, heaviness, swelling.

Nephrotic syndrome – The nephrotic syndrome is characterized by nephrotic range proteinuria,

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 6448 Version 6.0

Differential diagnosis of painless scrotal mass in children

Varicocele "Bag of worms" No Yes

Noncommunicating Fluid-filled Yes No

Spermatocele Small, soft, and Yes No

Graphic 57879 Version 3.0

A narrowly patent processus vaginalis that only permits passage of

Graphic 70784 Version 1.0

Communicating hydroceles usually develop as a result of failure of the

Courtesy of Laurence Baskin, MD.

Graphic 50831 Version 2.0

A hydrocele is a fluid accumulation between the parietal and visceral

Graphic 58679 Version 1.0

A varicocele is a collection of dilated and tortuous veins in the

Graphic 73206 Version 2.0

Grade Size Clinical description

2 Moderate Nonvisible on inspection, but palpable upon standing

3 Large Visible on gross inspection

Graphic 51251 Version 1.0

A spermatocele epididymal cyst is a painless, fluid-filled cyst of the

Graphic 67291 Version 1.0

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