A Synopsis of AFP's "Evaluation of Scrotal Masses"

A synopsis of:
Evaluation of Scrotal Masses
PAUL CRAWFORD, MD, and JUSTIN A. CROP, DO, Nellis Family Medicine Residency, Las Vegas, Nevada
Am Fam Physician. 2014 May 1;89(9):723-727.
http://www.aafp.org/afp/2014/0501/p723.pdf

     A scrotal mass is a good reason for an evaluation.  The diagnosis can first be separated by pain.  A painful high-riding or horizontal testicle may be testicular torsion. An ultrasound will show a decrease in blood flow. CRP will be less than 24 mg/L. There may be associated nausea and vomiting. Torsion will need a surgical evaluation within 6 hours to save it (time is testical). The presence of the blue dot sign (bluish skin on the superior pole) is specific for torsion of the testicular appendage. Torsion of the appendage is most common in prepubertal males. Ultrasound (and possibly exploratory surgery) is needed for diagnosis. Otherwise the differential is epididymitis, inguinal hernia, ot testicular cancer. 
     Epididymitis will present with a positive prehn sign (pain is relieved with scrotal elevation) and an elevated CRP (>24 mg/L). It is unilateral but can spread. symptoms include fever, erythema, and dysuria. Ultrasound will show increased blood flow. Chlamydia and Neisseria are common bacterial causes. 
     A non painful scrotal mass cN BE Mny things. If the mass transilluminates, it most likely is a hydrocele. A varicocele will present with a "bag of worms" on palpation (it becomes more pronounced with valsalva). Varicocele repair can have a positive impact on fertility. If it is reducible, it may be a hernia. If it is a strangulated hernia, it is a surgical emergency. Otherwise, an ultrasound and urologic evaluation is needed. Differential includes testicular cancer or ans incidental mass. 
     Testicular cancers are more likely to be malignant when discovered in children. Risk factors include Klinefelters, cryptorchidism, or a family/previous history. Testing includes AFP, beta-HCG, and lactate dehydrogenase. A mass smaller than 5mm with negative markers is more likely benign. Excision biopsy may be needed if it is considered malignant.