SCROTAL SWELLINGS AND LUMPS
Recognising what is normal and what is not is a skill every man should have, but actually it's not as easy as it sounds! How to examine, what is normal, and some common problems are shown below.
HOW TO EXAMINE AND WHAT YOU SHOULD FEEL
The testis (ball) sits freely in the scrotum, and has a set of blood vessels coming down to it as a cord, and a tougher tube, the vas deferens, carrying sperm upwards. At the back of the testis you will feel the thick tube in which sperm are collected and slowly mature, called the epididymis. This is normally tender when squeezed, whereas the testis itself has less sensation. The testis is surrounded by a thin layer of fluid contained in a sac, called the tunica vaginalis. This allows the testis to move.
To self examine, its best done when the scrotum is relaxed and warm, for example in the bath or shower. Gently use the finger tips of both hands to firstly feel the oval shape of the testis, then identify the thick tube attached behind it (the epididymis), and then the tough cord running upwards from this, the vas deferens. The blood vessels are much softer and less distinct usually (red and blue on diagram).
The surface and consistency of the testis itself should be smooth and soft. If there is a swelling, first try to determine if it is within the testis itself or separate from it. When people feel a lump, they are often just feeling the normal epididymis next to the testis, but if the lump is within the testis itself, or feels hard or is distorting the shape of the testis, then seek urgent expert opinion.
If you've developed sudden severe pain in one testis, which is not going away after a few minutes, seek immediate medical attention as this can occasionally be due to the testis spinning around on it's cord and cutting off it's own blood supply (testicular torsion). This is an emergency as the testis will die if not resolved within 6 hours.
When the amount of fluid increases around the testis, the scrotum swells and it can become impossible to feel the testis itself. Only rarely is there a problem with the testis, and usually this swelling occurs for no obvious reason. An ultrasound scan will confirm, and an operation to drain the fluid and tie off the sac so it can't return is an option if the swelling is causing problems.
EPIDIDYMAL CYSTS / SPERMATOCOELES
These fluid swellings occur in the sperm collecting tube, the epididymis, so the testis is usually palpable as separate to the cyst. Again, these are benign, non-cancerous, and don't need removing unless causing problems.
If the epididymis becomes inflamed, for example if it is infected, or sometimes after a vasectomy, it can become swollen and painful. This is usually treated with antibiotics, but if chronic pain persists long term, the tube can be removed.
Varicose veins can be felt as a "bag of worms" above the testis, and are common, especially on the left side (1 in 6 men) due to the way the veins drain differently on the two sides. They can cause a dragging ache in the scrotum, especially after standing for a long time. If they are prominent during puberty, and the testis on that side is not growing as fast, then there is reason to intervene for sake of fertility, otherwise, it is unlikley that the varicocoele has any significance other than the discomfort it might cause. If a man suddenly develops a varicocoele in adulthood (particularly on the right), the kidneys should be scanned too, as rarely a problem there can block the long testicular vein on the right hand side which enters into the kidney vein.
Treatment could just be to wear supportive underwear, or if necessary to block the vein off internally with metal coils via the vein system without making any cuts (embolisation). Only rarely is open surgery required to tie off the veins if embolisatoin fails.
If a lump is felt within the body of the testis, particularly if it is new, hard or enlarging, it needs urgent specialist assessment or scan. Testicular tumours are more common in younger men. They are treated with removal of the testis and sometimes chemotherapy.