A lump, swelling or pain in the testicle – what it can mean

A lump, swelling or pain in the testicle is one of the most common reasons for seeing a urologist. In most cases the cause is benign: a cyst, fluid, enlarged veins or inflammation. A small proportion of lumps, however, are tumours, and some types of pain are emergencies in which every hour counts.

The scrotum is easy to examine, and an ultrasound scan gives an answer at the very first visit. Dr Penev sees patients with these complaints at his private practice in Plovdiv and in Karlovo, and when surgery is needed – at Kaspela University Hospital (UMBAL Kaspela), Plovdiv.

What lumps and swellings in the scrotum are

Epididymitis and orchitis

The epididymis is the coiled tube behind the testicle. Inflammation of it causes pain that builds up over a day or two, swelling and redness, often with a fever and burning when passing urine. In young men the cause is usually a sexually transmitted infection; in older men it is bacteria from the urinary tract, often in combination with an enlarged prostate. If the testicle is also involved, it is called orchitis.

Epididymal cysts and spermatocele

Smooth, round, fluid-filled swellings on the epididymis, separate from the testicle – painless, very common after the age of forty and benign.

Hydrocele

A collection of fluid between the layers surrounding the testicle – a soft, painless swelling of the whole half of the scrotum. It is present from birth in young children and in adults most often has no clear cause. More details are in the article on hydrocele.

Varicocele

Enlarged veins above the testicle, most often on the left, felt as a soft, uneven mass when standing up. More about varicocele and fertility is in a separate article.

Inguinal hernia

Part of the abdominal contents slips down through the groin canal towards the scrotum; the swelling gets bigger when you cough or strain and goes back in when you lie down. A hernia that suddenly becomes hard and painful and will not go back in is an emergency.

Testicular tumour

A hard, usually painless lump in the testicle itself, sometimes with a feeling of heaviness. It is most common in men between fifteen and forty years of age and, when found in time, is among the most treatable cancers. More is in the article on testicular cancer.

Symptoms

The symptoms suggest the cause but do not prove it:

• a hard, painless lump in the testicle itself – a tumour until proven otherwise;
• a soft, painless swelling above or behind the testicle – a cyst, hydrocele or varicocele;
• gradually increasing pain with swelling, redness and a fever – inflammation;
• a swelling that changes with straining and position – a hernia or varicocele.

Urgent signs: sudden severe pain in the testicle, especially with nausea, may be testicular torsion – do not wait, go straight to an emergency department or call 112 (the European emergency number). The same applies to a trapped (incarcerated) hernia and to severe pain with a high temperature.

Causes and risk factors

The causes depend on age: in children, hydrocele, hernia and torsion predominate; in teenagers and young men – torsion, varicocele, sexually transmitted infections and tumours; after the age of forty – cysts, hydrocele and inflammation linked to urinary infections and an enlarged prostate. The risk increases with unprotected sex, a catheter or difficulty passing urine, an undescended testicle in childhood, testicular cancer in the family and injuries.

Diagnosis

The consultation with Dr Penev starts with a conversation – when you noticed the change, whether it hurts, whether you have a fever or problems passing urine, and whether you have had a new sexual partner. This is followed by an examination of the scrotum lying down and standing up, of the groin canals and, where indicated, of the prostate.

The decisive test is a scrotal ultrasound scan with Doppler – within minutes it shows whether the lump is solid or fluid-filled, inside or outside the testicle, and what its blood supply is like. A urine test, a swab or blood tests for tumour markers complete the picture, and if a tumour is suspected – imaging of the abdomen and chest.

Self-examination: once a month, after a warm shower, roll each testicle between your thumb and fingers; get to know the epididymis at the back so that you do not mistake it for a lump, and watch for any new lump or change in size.

Treatment

Treatment depends on the cause. Epididymitis is treated with an antibiotic for ten to fourteen days, anti-inflammatory medicines, rest and supportive underwear. Cysts, spermatocele and hydrocele are monitored or removed surgically when they grow or cause trouble; a varicocele is operated on when it causes pain or the semen analysis gets worse; a hernia is repaired surgically. With a tumour, the testicle is removed through an incision in the groin – an operation that is both the diagnosis and the first step of treatment; before it, sperm banking and a prosthesis are discussed.

The consultation, ultrasound and non-surgical treatment take place at the practice in Plovdiv, and scrotal operations at the Department of Urology at Kaspela University Hospital.

When to see a urologist

Immediately, at an emergency department or by calling 112 – with sudden severe pain, a trapped hernia or severe pain with a high temperature.

Within a few days – with any new lump in the testicle, even a painless one, with increasing pain and swelling, or after an injury.

As a planned appointment – with a painless, soft swelling that does not change, heaviness in the scrotum or a difference in the size of the testicles.

Prevention

Using condoms during sex, prompt treatment of urinary infections and of difficulty passing urine, vaccination against mumps, protection during contact sports and monthly self-examination between the ages of fifteen and forty reduce the risk or allow a problem to be found early.

Most lumps and swellings in the scrotum are harmless, but only an examination with ultrasound gives certainty. Book an appointment with Dr Penev in Plovdiv or Karlovo – without delay if the lump is new.