Diagnostic Imaging Pathways - Scrotal Mass
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This pathway provides guidance on the imaging of adult male patients with a scrotal mass.
Date reviewed: July 2018
Date of next review: July 2021
Published: April 2019
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Testicular Cyst
Image 1 (Ultrasound): Left testicular cyst with no discernable wall or flow. |
| 2 |  |
Testicular Tumour
Image 2 (Ultrasound): Solid and cystic lesion with thick walls and marked vascularity in some areas. The appearances are consistent with a tumour. |
| 3a |  |
Testicular Tumour
Image 3a: Orchidectomy specimen showing complete replacement of the normal testicular parenchyma with the classical "cut-potato" appearance of a seminoma. The tunica albuginea is intact. |
| 3b |  |
Image 3b (H&E, x2.5): Histological section of a seminoma showing groups of malignant cells with large nuclei and prominent nucleoli. There are also intervening fibrous bands with an infiltrate of lymphocytes and plasma cells. |
| 4a |  |
Testicular Tumour
Image 4a (H&E, x2.5): Orchidectomy specimen showing a teratoma with areas of cyst formation and haemorrhage. |
| 4b |  |
Image 4b (H&E, x2.5): Histological section of a teratoma (non-seminomatous germ cell tumour) showing hyaline cartilage and islands of columnar epithelium. |
| 5 |  |
Scrotal Abscess
Image 5 (Ultrasound): A central mass lesion is located superficially and in the midline towards the inferior pole of the scrotum. It has a low echogenic rim but contains echogenic material with no discernable flow within the lesion. There is inflammation of the surrounding tissues. |
Teaching Points
Teaching Points
- Ultrasound is the preferred imaging modality to evaluate a scrotal mass 1-3
- Ultrasound can be used to differentiate between intra and extra testicular masses. It is also useful for differentiating solid from cystic masses 4
- A painless solid testicular mass is pathognomonic for testicular tumour, 1 though a proportion present with pain
- A mass in the body of the testicle is likely malignant until proven otherwise and is an indication for urgent urology referral
us
Ultrasound
- Ultrasound is the preferred imaging modality to evaluate a scrotal mass 1-3
- Indications 7
- To confirm a clinical diagnosis of tumour and to assess contralateral testis
- To assess clinically solid scrotal masses
- To assess an impalpable testis within a hydrocoele
- To confirm a borderline clinical diagnosis of varicocoele in appropriate patients
- Can differentiate between testicular and extra-testicular masses with accuracy approaching 100%. 8 The vast majority of extra-testicular masses are benign 9
- Can differentiate fluid filled lesions (eg hydrocoele, spermatocoele, haematocoele etc.) from solid intra-testicular tumours 4
- Sensitivity and specificity for differentiating between benign and malignant testicular masses approaches 100% 10-12
- A mass in the body of the testis is likely malignant until proven otherwise and warrants urgent urology referral
- Some benign conditions can mimic malignancy like focal infarction, haematoma and infection that can also appear as hypoechoic mass like areas with variable internal blood flow, 4 however malignancy cannot be reliably excluded with ultrasound only so specialist referral for further investigation is still indicated
- In select situations when the diagnosis is in doubt, percutaneous biopsy may prevent unnecessary orchidectomy. 13 MRI is also performed as an adjunct to ultrasound in some centres 9
ct
Staging of Testicular Cancer
- The staging of testicular cancer requires histological staging as well as tumour markers and assessment for distant metastases 1
- Common sites of extra-testicular disease are the abdominal lymph nodes, lung, liver and bone. Abdominal retroperitoneal lymph nodes are considered regional lymph nodes 4
- CT of the abdomen and pelvis is recommended to assess for metastases to regional lymph nodes 1-3
- In older studies, the accuracy of CT for detecting metastatic retroperitoneal lymph nodes is 73-97%, with sensitivity 65-96% and specificity 81-100% 14-20
- CT chest is recommended to assess for pulmonary metastasis 2
- MRI has also been validated to assess for regional nodal metastases, 21,22 but is generally reserved for select cases where contraindication to iodinated contrast prohibits adequate assessment, or where radiation exposure is a particular concern
varico
Varicocoele Associated with Cancer
- Rarely varicocoele may be associated with a renal or retroperitoneal tumour compressing the venous drainage of the testis
- 1.8% of varicocoeles are associated with cancer, with no difference in risk between unilateral varicocoeles of either laterality or bilateral varicocoeles 23
- Varicocoele is the presenting complaint for 2.3% of renal cell carcinomas 24
- Varicocoele is often a late sign of malignancy, so history and examination should be performed to identify other signs and symptoms of malignancy 25
- Some authors suggest routine ultrasound imaging of the ipsilateral retroperitoneal area and abdomen upon demonstration of a new varicocoele, or evaluation with CT, 25,26 but there are no trials demonstrating benefit from either of these practices. The benefit of CT screening must be balanced with risk of malignancy associated with radiation exposure 23
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- National Comprehensive Cancer Network. NCCN Clinical practice guidelines in oncology (NCCN guidelines). Testicular cancer. 2016. (Guideline). View the reference
- Albers P, Albrecht W, Algaba F, Bokemeyer C, Cohn-Cedermark G, Fizazi K, et al. EAU Guidelines. Edn. presented at the EAU Annual Congress Copenhagen. European Association of Urology; 2018. (Guideline). View the reference
- Yacoub JH, Oto A, Allen BC, Coakley FV, Friedman B, Hartman MS, et al. ACR appropriateness criteria staging of testicular malignancy. J Am Coll Radiol. 2016;13(10):1203-9. (Guideline). View the reference
- Coursey Moreno C, Small WC, Camacho JC, Master V, Kokabi N, Lewis M, et al. Testicular tumors: what radiologists need to know--differential diagnosis, staging, and management. Radiographics. 2015;35(2):400-15. (Review article). View the reference
- Baird DC, Meyers GJ, Hu JS. Testicular cancer: diagnosis and treatment. Am Fam Physician. 2018;97(4):261-8. (Review article). View the reference
- Zucca E, Roggero E, Bertoni F, Cavalli F. Primary extranodal non-Hodgkin's lymphomas. Part 1: Gastrointestinal, cutaneous and genitourinary lymphomas. Ann Oncol. 1997;8(8):727-37. (Review article). View the reference
- Adeyoju AB, Collins GN, Pollard AJ, Liaw J, Brooman PJ, O'Reilly PH. A prospective evaluation of scrotal ultrasonography in clinical practice. BJU Int. 2000;86(1):87-8. (Level II evidence). View the reference
- Rifkin MD, Kurtz AB, Pasto ME, Goldberg BB. Diagnostic capabilities of high-resolution scrotal ultrasonography: prospective evaluation. J Ultrasound Med. 1985;4(1):13-9. (Level II evidence). View the reference
- Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P. US MR imaging correlation in pathologic conditions of the scrotum. Radiographics. 2007;27(5):1239-53. (Review article). View the reference
- Tallen G, Hernaiz Driever P, Degenhardt P, Henze G, Riebel T. High reliability of scrotal ultrasonography in the management of childhood primary testicular neoplasms. Klin Padiatr. 2011;223(3):131-7. (Level III evidence). View the reference
- Guthrie JA, Fowler RC. Ultrasound diagnosis of testicular tumours presenting as epididymal disease. Clin Radiol. 1992;46(6):397-400. (Level II evidence). View the reference
- Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010;29(1):11-21. (Level II evidence). View the reference
- Shaida N, Berman LH. Percutaneous testicular biopsy for indeterminate testicular lesions. The British Journal of Radiology. 2012;85(Spec Iss 1):S54-S8. (Review article). View the reference
- Epstein BE, Order SE, Zinreich ES. Staging, treatment, and results in testicular seminoma. A 12-year report. Cancer. 1990;65(3):405-11. (Level III evidence). View the reference
- Leibovitch L, Foster RS, Kopecky KK, Donohue JP. Improved accuracy of computerized tomography based clinical staging in low stage nonseminomatous germ cell cancer using size criteria of retroperitoneal lymph nodes. J Urol. 1995;154(5):1759-63. (Level II evidence). View the reference
- Husband JE, Barrett A, Peckham MJ. Evaluation of computed tomography in the management of testicular teratoma. Br J Urol. 1981;53(2):179-83. (Level III evidence). View the reference
- Richie JP, Garnick MB, Finberg H. Computerized tomography: how accurate for abdominal staging of testis tumors? J Urol. 1982;127(4):715-7. (Level II evidence). View the reference
- Hilton S, Herr HW, Teitcher JB, Begg CB, Castellino RA. CT detection of retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria. AJR Am J Roentgenol. 1997;169(2):521-5. (Level II evidence). View the reference
- Strohmeyer T, Geiser M, Ackermann R, Mumperow E, Hartmann M. Value of computed tomography in the staging of testicular tumors. Urol Int. 1988;43(4):198-200. (Level II-III evidence). View the reference
- Thomas JL, Bernardino ME, Bracken RB. Staging of testicular carcinoma: comparison of CT and lymphangiography. AJR Am J Roentgenol. 1981;137(5):991-6. (Level II-III evidence). View the reference
- Sohaib SA, Koh DM, Barbachano Y, Parikh J, Husband JE, Dearnaley DP, et al. Prospective assessment of MRI for imaging retroperitoneal metastases from testicular germ cell tumours. Clin Radiol. 2009;64(4):362-7. (Level II-III evidence). View the reference
- Kok HK, Leong S, Torreggiani WC. Is magnetic resonance imaging comparable with computed tomography in the diagnosis of retroperitoneal metastasis in patients with testicular cancer? Can Assoc Radiol J. 2014;65(3):196-8. (Review article). View the reference
- DeWitt ME, Greene DJ, Gill B, Nyame Y, Haywood S, Sabanegh E, Jr. Isolated right varicocele and incidence of associated cancer. Urology. 2018 (Level II evidence). View the reference
- Skinner DG, Colvin RB, Vermillion CD, Pfister RC, Leadbetter WF. Diagnosis and management of renal cell carcinoma. A clinical and pathologic study of 309 cases. Cancer. 1971;28(5):1165-77. (Level II evidence). View the reference
- El-Saeity NS, Sidhu PS. "Scrotal varicocele, exclude a renal tumour". Is this evidence based? Clin Radiol. 2006;61(7):593-9. (Review article). View the reference
- Tyloch JF, Wieczorek AP. Standards for scrotal ultrasonography. Journal of Ultrasonography. 2016;16(67):391-403. (Review article). View the reference
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