Painless Scrotal Swelling in Children

Background

• Painless scrotal swelling can be testicular or extratesticular in origin, and the underlying causes usually do not require urgent intervention.
• The most common causes are hydrocele, varicocele, and inguinoscrotal hernia.
• Less common causes include prenatal testicular torsion, idiopathic scrotal edema, and benign or malignant neoplasm.

Evaluation

• Evaluation of painless scrotal swelling is directed toward determining the underlying cause.
• Clinical exam may be sufficient for diagnosis.
  • If scrotal mass transilluminates, consider hydrocele.
  • If mass does not transilluminate
    • Consider varicocele if mass has "bag of worms" consistency on palpation and increases with Valsalva maneuver.
    • Consider inguinoscrotal hernia if no "bag of worms" consistency and mass is reducible.
• Further evaluation may be needed if diagnosis is unclear after clinical exam.
• Consider
  • Ultrasonography.
  • Urology consultation.
  • For suspected neoplasm - serum tumor markers.

Management

• Management depends on underlying cause.
• For hydrocele
  • Surgical repair is definitive treatment, but should be preceded by a period of watchful waiting in infants because spontaneous resolution may occur.
  • 6-9 months of watchful waiting may also be considered for most late-onset hydroceles.
• For varicocele
  • Consider conservative management for asymptomatic varicocele without significant testicular hypotrophy.
  • Varicocele repair (typically varicocelectomy or percutaneous occlusion/embolization) in children and adolescents is controversial, but may be considered for pain, hypoplastic testis, or fertility concerns.
• For inguinoscrotal hernia
  • Open or laparoscopic or open herniorrhaphy is procedure of choice.
  • For incarcerated hernia, attempt manual reduction followed by surgery.
• For neonatal testicular torsion
  • Management of prenatal testicular torsion is controversial, and options ranging from reassurance only to surgical exploration with contralateral orchidopexy may be considered.
  • Postnatal testicular torsion requires urgent surgical exploration if presenting within 24 hours of symptom onset (Strong recommendation), semi-elective exploration if presenting > 24 hours after symptom onset.
• For idiopathic scrotal edema, supportive therapies may be considered, but swelling typically resolves spontaneously.
• For testicular adrenal rest tumors, primary treatment is glucocorticoids; testis-sparing surgery may be considered if increased glucocorticoid dose does not reduce tumor size.
• For spermatocele/epididymal cyst, consider reassurance only; surgical excision may be considered if painful or suspicious for malignancy.
• For neoplasm, management depends on type of tumor and may include excision, chemotherapy, or other treatments.