29/05/2026
SCROTAL SWELLING
A Practical Surgical Approach
Scrotal swelling is a common surgical presentation. A systematic examination can usually establish the diagnosis even before investigations are ordered.
1️⃣ Is the swelling on the sc***um?
Sebaceous Cyst
• Arises from scrotal skin
• Painless, slow growing
• Te**is felt separately
• May become infected
2️⃣ Does the swelling extend above the sc***um?
Inguinoscrotal Hernia
• Cannot get above the swelling
• Expansile cough impulse present
• Usually reducible
• May contain bowel or omentum
If you cannot get above the swelling, think hernia first.
3️⃣ Is the swelling within the sc***um?
⚡ PAINFUL
Testicular Torsion
• Sudden severe pain
• High riding te**is
• Absent cremasteric reflex
• Surgical emergency
Torsion of Appendix Te**is
• Upper pole tenderness
• Blue dot sign may be present
Epididymitis
• Gradual onset pain
• Fever and dysuria
• Tender epididymis
Orchitis
• Painful enlarged te**is
• Commonly viral or bacterial
Acute painful sc***um = Torsion until proven otherwise.
HARD & PAINLESS
Testicular Tumour
• Hard irregular te**is
• Painless enlargement
• Malignancy until proven otherwise
Tuberculous Epididymo Orchitis
• Chronic nodular swelling
• May be associated with sinuses
Syphilitic Orchitis
• Rare cause of hard painless enlargement
Haematoma
• Usually follows trauma
• Firm painful or painless swelling
A painless testicular mass should always be considered malignant until proven otherwise.
SOFT
Varicocele
• “Bag of worms” feel
• More common on left side
• Associated with infertility
Epididymal Cyst
• Separate from te**is
• Soft and transilluminant
Hydrocele
• Fluctuant swelling
• Positive transillumination
• Most common cause of painless scrotal enlargement
QUICK CLINICAL PEARLS
✅ Cannot get above swelling → Hernia
✅ Sudden severe pain → Testicular torsion
✅ Hard painless te**is → Testicular tumour
✅ Bag of worms feel → Varicocele
✅ Positive transillumination → Hydrocele or Epididymal cyst
✅ Fever with epididymal tenderness → Epididymitis
TAKE HOME MESSAGE
Most scrotal swellings can be diagnosed by answering four simple questions:
Can you get above it?
Is it painful?
Is it hard or soft?
Does it transilluminate?
A careful clinical examination remains the most important investigation.
