Scrotal swelling is the enlargement of the scrotum due to conditions affecting the testicles, epididymis, or scrotal skin, sometimes involving the penis. It can be unilateral or bilateral, painful or painless, and occur in males of any age.

Sudden, painful scrotal swelling—especially in prepubescent males—suggests testicular torsion, a surgical emergency requiring immediate intervention to untwist and stabilize the spermatic cord.

Pathophysiology

Scrotal swelling may result from:

• Edema: fluid accumulation in the scrotum or spermatic cord

• Mass formation: cysts, tumors, or hematomas

• Inflammation or infection: orchitis, epididymitis

• Trauma: blunt or penetrating injuries

Mechanisms include:

• Impaired venous or lymphatic drainage

• Accumulation of serous, purulent, or hemorrhagic fluid

• Enlargement of scrotal contents due to infection, cysts, or neoplasms

History and Physical Examination

History:

• Onset, duration, progression, and laterality of swelling

• Pain characteristics: sudden or gradual, severity

• Recent trauma or surgery

• Urinary symptoms: dysuria, frequency, hematuria, cloudy urine

• Sexual history and risk factors for STIs

• Systemic illnesses (e.g., mumps, fever)

• Effects of activity or position on swelling

Physical examination:

• Vital signs: temperature, heart rate, blood pressure

• Abdominal exam: tenderness, masses

• Scrotal inspection: size, color, rashes, bruising, lesions

• Palpation: tenderness, firmness, cystic or solid masses, testicle position

• Transillumination: differentiate fluid-filled cysts (hydrocele, spermatocele) from solid masses

• Examine patient both supine and standing

Emergency assessment:

• If severe pain or sudden onset, assess blood flow using Doppler ultrasound

• Withhold food and fluids, insert IV line, apply ice pack

• Consider manual detorsion if testicular torsion is suspected, but surgery is still required

Medical causes

Other causes

• Surgery: postoperative hematocele or seroma

• Urinary catheterization or instrumentation may rarely lead to secondary edema

Special considerations

• Keep patient on bed rest, with scrotum elevated on a rolled towel

• Provide antibiotics, analgesics, fluids, and stool softeners

• Advise loose-fitting athletic supporter for mild/moderate swelling

• Sitz baths, heat/ice packs, and scrotal support reduce inflammation

• Prepare for needle aspiration or imaging (CT or ultrasound) if fluid collection or tumor suspected

Patient counseling

• Teach testicular self-examination technique

• Explain warning signs for torsion, infection, or tumor

• Emphasize follow-up for persistent or recurrent swelling

Pediatric pointers

• Infants: consider hydrocele, hernia, or diaper dermatitis

• Prepubescent boys: high suspicion for testicular torsion

• Children: may develop epididymitis (rare <10 years), traumatic orchitis, or post-mumps orchitis

• History may be limited: rely on thorough physical examination

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

3. Colyar MR. Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.

4. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.