Scrotal mass

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]Sujit Routray, M.D. [3]

Scrotal mass may be classified into two subtypes: testicular and extratesticular.Scrotal masses may be differentiated according to clinical features, laboratory findings, imaging features, histological features, and genetic studies from other diseases that cause testicular mass with discomfort, back pain, abdominal discomfort, or abdominal mass. If there is an acutely painful scrotum,there should be a strong suspicion for testicular torsion, which is an emergency condition, and emergent surgical referral should be strongly considered.Sonography may be performed if testicular torsion is not suspected to confirm the diagnosis. According to the TNM classification and stage groupings, there are 3 stages of testicular cancer based on the size and extent of the primary tumor, number and location of any regional lymph nodes (abdominal retroperitoneal) infiltrated by tumor cells, distant metastasis, and serum tumor marker levels.Symptoms related with scrotal mass will vary, depending on the cause of the mass, which include enlarged scrotum, painless or painful testicle lump, and feeling of heaviness in the scrotum. Common physical examination findings of scrotal mass include a tender mass which is having a smooth, twisted, or irregular shape and liquid, firm, or solid in consistency. The ipsilateral inguinal lymph nodes may be enlarged or tender.The laboratory findings related with scrotal mass may vary, depending on the cause of the mass.Laboratory findings consistent with the diagnosis of testicular tumors, may include elevated serum tumor markers such as AFP, LDH, or HCG. Imaging studies for scrotal mass include scrotal ultrasound, MRI, and chest x-ray.Biopsy should be performed in patients with scrotal skin lesions to rule out skin cancer.

Reinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring was first discovered by Stromayr in 1559. In 1871, new use of carbolized catgut ligature was developed by Marcy to treat inguinal hernia. Twisted and suture-transfixed the peritoneal sac in the lateral muscles through the external ring was developed by Kocher to treat inguinal hernia.Laparoscopic approaches first used to treat inguinal hernias in 1992.There is a limited information about the historical perspective of testicular tumors. Leydig cells were first discovered by Franz Leydig who was a German anatomist in 1870.

Scrotal masses are divided to two main group:Extra testicular and Testicular.Also scrotal masses may be pain full or not painfull.The other classification is based on neoplastic or non-neoplastic masses.

Deponds on the causes phatophysiology is different. Inadequate fixation of the lower pole of the testis to the tunica vaginalis causes testicular tortion . If fixation is absent , the testis may torse (twist) on the spermatic cord, lead to produceischemia from reduced arterial inflow and venous outflow obstruction . Testicular torsion etiology include (eg, trauma, vigorous physical activity) or spontaneously. Acquired hernias due loss of mechanical integrity of the abdominal wall muscles and tendons . primary hernia due Genetic or systemic extracellular matrix disorders and defective wound healing after laparotomy and hernia repairs may predispose to incisional hernias.

Scrotal masses may be caused by tumors,injury,truma,infection.Also the causes deponds on anatomical origin.

Scrotal masses must be differentiated from other diseases that cause scrotal swelling,scrotal pain,such as testicular tortion ,epididimitis,testicular tumors,inguinal herniation and many other diseases.

Testicular cancer is a rare type cancer accounting about 0.5% of all new cancer cases in U.S. In 2018, the estimate prevalence of testicular cancer is approximately 9,310 new cases of testicular cancers in the United States. The incidence of testicular cancer is approximately 5.7 per 100,000 men per year based on 2011-2015 report in the United States. The majority of cases are reported in New Zealand. Testicular cancer commonly affects more white males than any other races and black males are less affected by it. Testicular cancer is commonly affects men aged 20-44 years old and median age is 33 years old.

Depends on the causes of scrotal masses, risk factors are different,for example in testicular tortion the most potent risk factor is undescended testicle and genetic structural defects.

According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for testicular cancer.

Common complication of testicular tortion include,Testicular ischemia:Twisting of the spermatic cord during torsion causes testicular vascular compromise, resulting in testicular injury.

If there is an acutely painful scrotum,there should be a strong suspicion for testicular torsion, which is an emergency condition, and emergent surgical referral should be strongly considered. Sonography may be performed if testicular torsion is not suspected to confirm the diagnosis,althogh color doppler ultrasound is preffered for initial diagnosis test. Testicular torsion is primrily diagnosed base on the clinical presentation.

Symptoms related with scrotal mass will vary, depending on the cause of the mass, which include enlarged scrotum, painless or painful testicle lump, and feeling of heaviness in the scrotum.Other symptoms are edema and erythem of scrotom in epididimitis and tortion, fever,dysuria and urgency in epididimitis.Low back pain and lower extremitis edema are the other presentations in scrotomal tumors.

physical examination of scrotal masses depends on causes.common physical examinations in testicular tortion is an elevated ,horizontlly aligned testicle. Also they have severe tenderness and firm in palpation.Cremastic reflex and phren sign are absent.In testicular apendix tortion ,phathognomonic sign is Blue dot,which is a nodule with blue discoloration.In hydrocele transillumination test will be positive.

The laboratory findings related with scrotal mass may vary, depending on the cause of the mass. Laboratory findings consistent with the diagnosis of testicular tumors, may include elevated serum tumor markers such as AFP, LDH, or HCG.CRP level up to 24mg /L is highly specific and sensitive for epididymitis and orchitis.

There is no ECG findings associated with scrotal masses.

There are no x-ray findings associated with scrotal masses.

Ultrasound findings associated with scrotal masses.It can differentiated extratsticular masses from intratesticular masses.By using Doppler-colored ultrasound ,specifity and sensitivity for testicular tortion will be increased.

CT scan may be helpfull in the diagnosis of testicular carcinoma and also for staging testicular tumors.

MRI may be helpfull in the diagnosis of testicular carcinoma and also for staging testicular tumors.

Radionuclide Imaging may be helpfull in testicular tortion diagnosis but because it takes time,usually is not used.

There are no other diagnostic studies associated with scrotal masses.

Scrotal masses presented with acute pain ,should be treated emergently.Patients with testicular tortion are treated with immidiate scrotal exploration,detortion and orchidopexy,whereas treatment of tortion of testicular apendage is conservative.pharmacologic medical therapy is recommended among patients with Epididimytis. In testicular tumors the first line treatment is radical orchiectomy after determining the diagnosis, treatment depends on tumor type and available options are chemotherapy and radiation.

Scrotal masses presented with acute pain ,should be treated emergently.Patients with testicular tortion are treated with immidiate scrotal exploration,detortion and orchidopexy,In testicular tumors the first line treatment is radical orchiectomy.

There are no established measures for the primary prevention of scrotal masses,but by decreasing some of the risk factors we can prevent some of the causes.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]

Reinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring was first discovered by Stromayr in 1559. MarcyIn 1871, used of carbolized catgut to treat inguinal hernia.Kohler was developed suture-transfixed and Twisted the peritoneal sac in the lateral muscles through the external ring to treat inguinal hernia.Laparoscopic approaches first used to treat inguinal hernias in 1992There is a limited information about the historical perspective of testicular tumors. Leydig cells were first discovered by Franz Leydig who was a German anatomist in 1870.

• There is a limited information about the historical perspective of testicular tumors.
• Stromayr in 1559,discoveredReinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring.^[1]

• Marcy In 1871, uses of carbolized catgut ligature to treat inguinal hernia. ^[2]
• KocherTwisted and suture-transfixed the peritoneal sac in the lateral muscles through the external ring to treat inguinal hernia.^[3]
• In 1992Laparoscopic approaches first used to treat inguinal hernias..^[4]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]Sujit Routray, M.D. [3]

Scrotal massdeponds on intra testicular or extra testicular may be classified into 6 subtypes based on their anatomical origion.Based on the exictance of pain, scrotal mass may be classified as either painfull or non painfull. The staging of testicular cancer is based on the TNMS.

Scrotal mass(intratesticular or extratesticular) may be classified according to their anatomical origin into 6 groups:

• Skin
• Tunica vaginalis testis
• Processus vaginalis testis
• Panpiniform plexus
• Epididymis
• Testis^[1]

Based on the pain existant , scrotal mass may be classified as either painfull or non painfull .^[2] The staging of testicular cancer is based on the TNMS.^[3] According table adapted from Department of Am Fam Physician. 2008 Nov 15;78(10):1165-1170.^[4]

Classification of Scrotal mass by Anatomical place

Anatomical place	Disease	Natural history	Pain	Other symptoms
Skin	Sebaceuse cyst Squamouse cell carcinoma	Acute/chronic,stable Chronic,progressive	No No	__ __
Tunica vaginalis	Hydrocele ,Hematocele	Acute /chronic,stable Acute,caused by trauma	No Yes	Transillumination Does not transilluminate well
Processus vaginalis	Indirect inguinal hernia ,Hydrocele	Acute/chronic,stable or progressive Chronic ,stable	No,Yes if strangulated No	By valsalva maneuvers may enlarge Different sizes
Panpiniform plexus	Varicocele	Chronic ,stable	No	“Bag of worms”
Epididimysis	Epididimysis ,Spermatocele	Acute ,progressive Chroic,stable	Yes No	May have UTI symptoms __
Testis	Testicular tortion, Apendix testis tortion Orchitis Testicular cancer	Acute,progressive, Acute,stable Acute,self -limitted Chronic,progressive	Yes Yes Yes No	Increase pain by elevation of testis,cremastic reflex usually abcent Blue dot sign Decrease pain by elevation of testis __

According table adapted from Am Fam Physician. 2014 May 1;89(9):723-727.^[2]

Pin full	With or without pain	Non painfull
Testicular tortion	Testicular cancer	Hydrocele
Testicular appendage tortion	Inguinal hernias	Varicocele
Epididimytis		Scrotal wall mass(skin cancer)
Orchitis
Hematocele or testicular rupture

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]

The pathophysiology of testicular cancer depends on the histological cell subtypes and findings. Most testicular cancers derived from the lack of differentiation of primordial germ cell into spermatogonia. Germ cells testicular tumor have some genetic component while most sex cord stromal testicular cancer are hormonal dependent. Most testicular cancers derived from the lack of differentiation of primordial germ cell into spermatogonia. Germ cells testicular tumor have some genetic component while most sex cord stromal testicular cancer are hormonal dependent. Most gross pathology of testicular tumors look similar on the physical appearance.On microscopic histopathological analysis of testicular cancer, fried-egg appearance is the characteristic finding of seminoma; marked nuclear atypia is the characteristic finding of embryonal carcinoma; hyaline-type globules, and Schiller-Duval bodies are characteristic findings of yolk sac tumor  ; syncytiotrophoblasts and cytotrophoblast cells are the characteristic findings of choriocarcinoma, Polymorphism with”spirene” chromatin for spermatocytic. Inadequate fixation of the lower pole of the testis to the tunica vaginalis causes testicular tortion . If fixation is absent , the testis may torse (twist) on the spermatic cord, lead to produceischemia from reduced arterial inflow and venous outflow obstruction . Testicular torsion etiology include (eg, trauma, vigorous physical activity) or spontaneously. Acquired hernias due loss of mechanical integrity of the abdominal wall muscles and tendons . primary hernia due Genetic or systemic extracellular matrix disorders and defective wound healing after laparotomy and hernia repairs may predispose to incisional hernias.

Scrotal is extention of abdominal wall contains testis , tunica vaginalis ,spermatic cord,epididimysis and appendix testis.Testis has seminiferous tubules that has germ cells,sertoli cells, and leydig cells .Germ cells develop into spermatogenesis and produce gametes.Sertoli secrete inhibin and leydig cell produce testostrone.^[1]The normal physiology of germ cells is production of gametes which are reproductive cells.After migration of these cells to gonads, they udergo meiosis to produce gametes.^[2]

• It is understood that varicocele is the result of dilation of pampiniform venous plexus along spermatic cord.^[3]
• The pathophysiology of testicular cancer depends on the histological subtype.^[4]
• Testicular tortion is produced by Inadequate fixation of the lower pole of the testis to the tunica vaginalis causes testicular tortion . If fixation is absent , the testis may torse (twist) on the spermatic cord, lead to produceischemia from reduced arterial inflow and venous outflow obstruction^[5]
• Epididimytis pathophysiology is due to spread of microorganism from urethra ,prostate , vesicle seminal or hematogenous pathogen.^[6]

Genes involved in the pathogenesis of testicular germcell tumors include:

• Gain 12p
• TDGF1
• EBAF
• SOX2
• FGF4
• ZFP42^[7]

Genes involved in the pathogenesis of testicular tortion include:

• p53
• Bax
• Bcl2^[8]

Conditions associated with testicular cancer include:

• CVD(MI,Pectoralis angina)
• Insulin resistance
• Metabolic syndrom
• Hypogonadism^[9]

On gross pathology, purple color to testicular capsule , hemorragic parynchima are characteristic findings of testicular tortion. ^[10]

On microscopic histopathological analysis, edema of interstice, slight blood extravasation, and desquamation of the germ cells are characteristic findings of first grade of testicular tortion.In grade 2 characterized by necrosis of germ cells, and in grade 3 we have fully hemorragic infarction of testis.^[11]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]Shanshan Cen, M.D. [3], Sujit Routray, M.D. [4]

Scrotal masses may be caused by tumors,injury,truma,infections. Also the causes depends on the anatomical origin.

• Scrotal mass may be caused by tumor, infection, injury, inflammation, or fluid buildup, which can cause different types of masses.^[1]

Common Causes of Scrotal Mass Adapted from American Academy of Family Physicians.[2]
Cause	Clinical Presentation	Diagnosis	Treatment
Testicular torsion	Acute unilateral pain and swelling High position of the testicle Abnormal cremasteric reflex Nausea/vomiting	Mostly clinical, with or without sonography	Surgery
Torsion of the testicular appendage	Acute unilateral pain No swelling Blue dot sign(bluish discoloration of the scrotum over the superior pole)	Sonography	Pain control
Epididymis/orchitis	Acute unilateral pain and swelling Normal position of the testicle Erythema of the scrotal skin Fever Dysuria	Mostly clinical, with or without sonography	Ceftriaxone and doxyxycline
Hematocele	History of trauma Pain and swelling	Sonography or surgerical exploraion	Main focus on pain control. Surgery, if needed
Inguinal hernia	Unilateral bulge in the scrotum Pain with Valsalva maneuvers	Physical examination, sonography	Surgery
Hydrocele	Swelling	Transillumination, sonography	Main focus on pain control. Surgery, if needed
Varicocele	Dull testicular ache while in standing position Scrotal mass	“Bag of worms” on palpation	Scrotal support, surgery if needed
Testicular cancer	Unilateral, firm nodule	Sonography, positive tumor markers	Surgery
Skin cancer	History of carcinogens Erosive, vascular, hyperkeratotic, or nonhealing; irregular border; color changes	Biopsy	Surgery

Scrotal Mass Adapted from American Academy of Family Physicians.[2]
Anatomical Origin	Lesion/Condition	Onset/Progression	Pain/Tenderness	Aggravating/Alleviating Factors, Associated Symptoms
Skin	Sebaceous cyst	Acute/chronic, stable	No	—
	Squamous cell carcinoma	Chronic, progressive	No	—
Tunica vaginalis testis	Hydrocele	Acute/chronic, stable	No	Positive transillumination
	Hematocele	Acute, caused by trauma	Yes	Negative transillumination
Processus vaginalis testis	Indirect inguinal hernia	Acute/chronic, stable or progressive	No; yes, if strangulated	May enlarge with Valsalva-type maneuvers; size may fluctuate
	Hydrocele	Chronic, stable	No	—
Pampiniform plexus	Varicocele	Chronic, stable	No	Characteristic “bag of worms” consistency
Epididymis	Epididymitis	Acute, progressive	Yes	May have symptoms of urinary tract infection (fever, chills, dysuria, frequency, and urgency)
	Spermatocele	Chronic, stable	No	—
Testis	Testicular torsion	Acute, progressive	Yes	Elevation of testis may aggravate pain; abnormal testicular lie; cremasteric reflex usually absent
	Appendix testis torsion	Acute, stable	Yes	Blue dot sign
	Orchitis	Acute, self-limited	Yes	Elevation of testis may relieve pain, may have systemic symptoms of viral illness
	Testicular cancer	Chronic, progressive	No	—

Cardiovascular	No underlying causes
Chemical / poisoning	No underlying causes
Dermatologic	Sebaceous cyst
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	Thrombosis spermatic vein
Iatrogenic	No underlying causes
Infectious Disease	Mumps, Filariasis, Leprosy, Orchitis, Syphilitic gumma, Tuberculosis, Amebiasis, Epididymitis, Granulomatous epididymitis, Seminal vesiculitis
Musculoskeletal / Ortho	No underlying causes
Neurologic	No underlying causes
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Benign: Germ cell tumor, Teratoma, Thecoma, Sertoli-Leydig cell tumor, Fibroma, Chimney sweeps’ carcinoma, Epididymis cyst, Seminal vesicle cyst, Urethral gland cyst Malignant: Germ cell tumor, Seminoma, Embryonal carcinoma, Yolk sac tumor, Choriocarcinoma, Teratoma, Granulosa cell tumor, Sertoli-Leydig cell tumor, Adenocarcinoma, Mesothelioma, Rhabdomyosarcoma, Chimney sweeps’ carcinoma, Diffuse large B-cell lymphoma Metastatic tumors: Diffuse large B-cell lymphoma
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal / Electrolyte	No underlying causes
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	Testicular injury, Testicular hematoma, Spermatic cord injury, Fracture of testis
Urologic	Hematocele，Hydrocele，Spermatocele, Varicocele, Testicular torsion, Epididymis torsion, Spermatic cord torsion, Inguinal hernia, Richter hernia, Femoral hernia, Incarcerated hernia, Irreducible hernia, Strangulated hernia, Testicular abscess, Scrotum abscess, Idiopathic scrotal edema, Seminal vesicle calculus
Miscellaneous	No underlying causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2] Preeti Singh, M.B.B.S.[3]

Scrotal masses must be differentiated from other diseases that cause scrotal swelling,scrotal pain,such as testicular tortion ,epididimitis,testicular tumors,inguinal herniation and many other diseases.

Scrotal masses must be differentiated from other diseases that cause scrotal swelling,scrotal pain,such as testicular tortion ,epididimitis,testicular tumors,inguinal herniation and many other diseases.

• The table below summarizes the findings that differentiates scrotal mass according to the clinical features, laboratory findings, imaging features, histological features, and genetic studies.

Diseases	Clinical manifestations									Para-clinical findings				Gold standard	Associated
	Symptoms				Physical examination
										Lab Findings		Past Medical History	Histopathology
	Unilateral /Bilateral swelling	Onset	Fever	Urinary symptoms	Tender -ness	Erythema	Discharge	Inguinal Lymphadenopathy	Cremasteric Reflex	Blood/Urine Analysis	Doppler U/S
Painful
Epididymitis[1][2] [3][4][5][6][7][8]	Unilateral	Gradual	±	Dysuria, frequency, and/or urgency	+	–	+ (Pyuria Bacteriuria)	Painful local lymphadenopathy	+	CBC-Leukocytosis Urine culture (pre-pubertal and elderly) NAAT Immunofluorescent antibody testing	Decreased epididymal blood flow	Enlarged (>17 mm) epididymis with a hypoechoic, hyperechoic, or heterogeneous echotexture, increased blood flow	Acute infection is characterized by infiltration of neutrophils. Chronic cases are characterized by granulomatous inflammation.	Ultrasound for diagnosis (Testicular massesor swollen testicles with hypoechoic and hypervascular areas)	Hydrocele Urinary tract infection Gonococcal infection chlamydia infection Phen sign +ve
Orchitis (Mumps)[9][10][11][12] [13][8][7][14]	Bilateral	Abrupt	±	Dysuria	+	–	±	Painful local lymphadenopathy	+	CBC-Leukocytosis raised CRP Immunofluorescent antibody testing Urine analysis and culture – normal	Increased blood flow in affected side.	Mumps, coxsackievirus infection Concurrent epididymitis Congenital abnornmalities	Tubules are infiltration with neutrophiles, lymphocytes and cells resembling histiocytes Microscopic destruction of spermatogenic cells	RT‐PCR Serum immunofluorescence antibody testing.	Phen sign +ve Testicular atrophy Infertility
Testicular Torsion[15][16][17][18][19][7]	Unilateral	Sudden	–	Absent	+	+	+ Blood in semen may be present	Absent	–	Normal	Absent or decreased arterial perfusion of the testis	Previous history of testicular torsion Family history of testicular torsion Prematurity Undescended testes Low birth weight	In the first 4 hours: testicular parenchyma shows edema and and desquamation of the germ cells 4-8 hours partial necrosis of germ cells. >24 hrs: necrosis	Doppler ultrasound> CT scan	Phen sign +ve
Hematocele[20][21] [22][23][24]	Unilateral or bilateral	Sudden	–	Absent	+	+	+ Blood in semen	Absent	–	Urinalysis may be the only indication of injury to urinary tract Hematuria.	Scrotal wall thickening and testicular hematoma	Testicular trauma related to: Sports injuries. Direct trauma Motor vehicle accidents Straddle injuries	Increased destruction and fibrosis of the dartos fascia,. Dense inflammatory cells, necrotic areas and destruction of the muscular layer.	Ultrasonography: to check for testicular rupture.	_
Incarcerated Hernia[25][26]	Unilateral	Sudden	+	Absent	+	+	–	Absent	+	Normal	Normal	–	–	Groin ultrasound or CT scan show presence of bowel and omentum.	Valsalva maneuvers performed while palpating the inguinal canal will push a hernia against the examiner’s finger.
Brucellosis[27][28][29][30]	Unilateral or Bilateral	Sudden	±	Dysuria	–	–	±	Painful local lymphadenopathy	+	CBC-Leukocytosis raised CRP Immunofluorescent antibody testing Urine analysis and culture – normal	Increased blood flow in affected side	–	Acute infection is characterized by infiltration of neutrophils. Chronic cases are characterized by granulomatous inflammation.	Culture of the organism from blood.	Antibodies are detected using: Serum agglutination (standard tube agglutination) Enzyme-linked immunosorbent assay Rose Bengal agglutination Coombs test Immunocapture agglutination (Brucellacapt) 2-mercaptoethanol agglutination
Torsion of the appendix testis[31][32][33][34]	Unilateral or Bilateral	Sudden	–	Absent	+	–	–	Absent	+	Normal	Normal blood flow to the testis with an occasional increase on the affected side	–	In the first 4 hours: testicular appendages shows edema and and desquamation. 4-8 hours partial necrosis of appendix cells. >24 hrs: necrosis	scrotal ultrasound shows the torsed appendage as a lesion of low echogenicity with a central hypoechogenic area.	Scrotal wall mayshow the classical “blue dot” sign, which is due to infarction and necrosis of the appendix testis
Henoch-Schonlein purpura[35][36][37][38]	Unilateral	Sudden	–	Absent	+	+	–	–	–	Serum IgA levels are elevated Elevated ESR	–	Sore throat 2-3 weeks back	Light microscopy shows leukocytoclastic vasculitis in postcapillary venules with IgA deposition	Biopsy	Palpable purpura Age at onset is less than 20 years Acute abdominal pain
Fournier’s gangrene[39][40][41][42]	Bilateral	Sudden	+	Absent	+	+	–	–	+	Leukocytosis Acidosis Elevated ESR and CRP Blood cultures are positive in majority of patient for streptococcus.	–	–	–	Computed tomography (CT) scan shows most useful finding is presence of gas in soft tissues.	Patient show signs of tense edema outside the involved skin, blisters, bullae, crepitus, and subcutaneous gas.
Diseases	Unilateral /Bilateral swelling	Onset	Fever	Urinary symptoms	Tender<be>-ness	Erythema	Discharge	Inguinal Lymphadenopathy	Cremasteric Reflex	Blood/Urine Analysis	Doppler U/S	Past Medical History	Histopathology	Gold standard	Additional findings
Painless
Fragile X Macroorchidism[43][44][45][46]	Bilateral	Gradual	–	Absent	–	–	+	Absent	+	Normal	–	–	Increased volume of testis	FMR1 DNA analysis	Long and narrow face with prominent forehead and chin (prognathism) Large ears Intellectual Disability
Testicular Tumors[47][48][49][50]	Unilateral or bilateral	Gradual	±	Absent	±		+	Present	+	Increased serum beta-hCG or alpha fetoprotien (AFP)	–	–	Seminoma shows findings such as: Large cells with watery cytoplasm Fried egg appearance	Biopsy	Pain in the back or abdomen Ascites Weight loss Gynecomastia Precocious Puberty Infertility
Hydrocele[51][52][53][54][55]	Bilateral	Gradual	–	Absent	–	–	–	Absent	+	–	Normal	–	–	Ultrasound: simple fluid collection	Transillumination test is positive
Varicocele[56][57][58][59]	Unilateral (Mainly left)	Gradual	Local warmth	Absent	–	±	–	Absent	+	Elevations in unstimulated luteinizing hormone and follicle stimulating hormone levels may be seen in when associated with infertility in adults	Thrombosis of Inferiror vena cava Thrombosis of Right renal vein Abdominal mass	Renal cancer Nephrectomy Nut-cracker syndrome	–	Ultrasonography: tortuous, tubular, anechoic structures adjacent to the testis corresponding to dilated veins of the pampiniform plexus with calibers of 2–3 mm during the Valsalva maneuver	Infertility
Spermatocele[60][55][61]	Unilateral	Gradual	–	Absent	–	–	–	Absent	+	–	Falling snow, resulting from internal echoes moving away from the transducer	Epididymitis Trauma	Epididymal scarring is seen	Ultrasonography: hypoechoic with posterior acoustic enhancement	Transillumination test is positive
Scrotal edema[62][63]	Bilateral and can extend to perineum	Gradual	–	Absent	–	–	–	Absent	+	Eosinophilia Hypoalbuminemia Hyperlipidemia. Proteinurea	Deep Vein Thrombosis	Nephrotic Syndrome Hepatic Cirrhosis Insect Bite	–	Kidney or Liver biopsy	Occurs between 4-12 years of age.
Sebaceous cyst[64][65][66]	Unilateral	Gradual	–	Absent	–	–	–	Absent	+	–	Normal	–	Fibrous tissues and fluids A fatty,(keratinous), substance that resembles cottage cheese,. A viscous, serosanguinous fluid (containing purulent and bloody material).	Histological examination	Freely movable on palpation.
Carcinoma of the scrotum[67][68][69]	–	Gradual	–	Absent	–	–	–	Absent	+	–	Normal	–	keratinocytic dysplasia involving the full thickness of the epidermis without infiltration of atypical cells into the dermis. The keratinocytes are pleomorphic with hyperchromatic nuclei Numerous mitoses are present.	Biopsy	Scaly patch or plaque is seen over the testis.
Chylocele (Filariasis)[70][71][72]	Unilateral or Bilateral	Gradually Rapidly	+	Absent	–	–	–	Absent	+	Circulating filarial antigen (CFA) assays are positve	Lymphatics containing worms can be differentiated from the blood vessels by irregular movement	–	–	CFA assay	Ultrasound demonstrates living worms which has been described as “filarial dance” sign.
Scrotoliths[73][74][75]	Unilateral	Gradual	–	Absent	–	–	–	Absent	+	–	Normal	Trauma Torsion of appendix	–	Ultrasound	Ultrasound shows mobile hyperechoic extratesticular focus in the potential tunica space.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]Sujit Routray, M.D. [3]

Testicular cancer is a rare type cancer accounting about 0.5% of all new cancer cases in U.S. In 2018, the estimate prevalence of testicular cancer is approximately 9,310 new cases of testicular cancers in the United States. The incidence of testicular cancer is approximately 5.7 per 100,000 men per year based on 2011-2015 report in the United States. The majority of cases are reported in New Zealand. Testicular cancer commonly affects more white males than any other races and black males are less affected by it. Testicular cancer is commonly affects men aged 20-44 years old and median age is 33 years old.

• Testicular cancer is the most common type of cancer in young males.^[1][2]
• Germ cell tumors are about 98% of testicular cancer.^[3]
  • About 55% of germ cell tumors are seminomas
  • About 44% of germ cell tumors are non-seminomas
  • About 1-2% of germ cell tumors are spermatocytic
• In the United States, the estimate prevalence of testicular cancer is approximately 9,310 new cases in 2018.^[4]
• Sex cord stromal testicular tumors are about less than 5%.

• The incidence of testicular cancer is approximately 5.7 per 100,000 men per year based on 2011-2015 report in the United States.^[4]

• Testicular cancer is more common among men aged 20-44 years old.^[2]
• Median age is 33 years old.^[2]
• Germ cell tumors of the testis are the most common cancer in young adults.^[1]
• Median age is 33-39 years old for seminomas germ cell type of testicular cancer^[3]
• Median age is 25-29 years old for non-seminoma germ cell type of testicular cancer^[3]
• Median age is 50-54 years old for spermatocytic germ cell type of testicular cancer^[3]

• The 5 years of survival rate for patients with testicular cancer are 95.3% in 2008-2014.^[4]

• Testicular cancer is more common in white males compared to other races.^[4]
• The incidence of testicular cancer in African American is lower than that among white people;^[5] however, African American subjects tend to present at later stages of the disease due to a delayed presentation.^[5]

• Shown below is a table depicting the age-adjusted incidence of testicular cancer by race in 2011-2015 in the United States.^[4]

	All Races	White	Black	Asian/Pacific Islander	Hispanic
Age-adjusted incidence	5.7 per 100,000	6.8 per 100,000	1.5 per 100,000	2.3 per 100,000	5.3 per 100,000

• The highest rates of incidence in New Zealand, followed by United Kingdom, Australia, Sweden, United States, Poland, and Spain.^[1]

• Testicular cancer is uncommon in Asia and Africa.^[3]
• The lowest incidence of testicular cancer is in India.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief:

Depends on the causes of scrotal masses, risk factors are different,for example in testicular tortion the most potent risk factor is undescended testicle and genetic structural defects.

Depends on the causes of scrotal masses, risk factors are different,for example in testicular tortion the most potent risk factor is undescended testicle and genetic structural defects.

• Common Risk factors in scrotal masses include:
  • Undecsending testicle at birth
  • Genetic deformities
  • Sexual activity
  • Bladder obstruction
  • Urogenital malformations
  • Genetic deformities
  • Abdominal wall injury
  • Cryptorchidism
  • kleinfelter syn
  • Idiopathic

• • Long time bicycle riding
  • Old age
  • White race
  • Idiopathic

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]Sujit Routray, M.D. [3]

According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for testicular cancer.^[1]

According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for testicular cancer.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]

If left untreated, patients with testicular tortion may progress to develop ischemia,atrophy, and infertility.^[1] Common complications of testicular tortion include ischemia, atrophy, and infertility.^[1] Prognosis in early stage of testicular cancer without metastases is very good, and the 10-year survival rate of patients with metastatic testicular cancer is approximately 66-94%.^[2]

• The symptoms of testicular tortion usually develop in the second decade of life, and start with symptoms such as sudden onset of testicular pain and swelling.^[3]
• If left untreated, most of patients with testicular tortion may progress to develop ischemia and testicular atrophy.^[4]

• Common complications of testicular tortion include:
  • ischemia
  • atrophy
  • infertility

• Prognosis of early stage of testicular tumor without metastasis is good.^[2]
• Depending on the extent of the testicular cancer at the time of diagnosis, the prognosis may vary. 10-year survival rate of patients with metastatic testicular cancer is approximately 66-94%.^[2]

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