Testicular swellings - differential diagnosis Urological Emergencies
Testicular swellings differential diagnosis
Introduction
Acute and subacute scrotal swellings are common in the emergency department and span benign, self‑limiting conditions to time‑critical surgical emergencies.
Rapid, accurate differentiation is essential: missed or delayed recognition of testicular torsion risks loss of the testis, while a painless testicular mass requires urgent investigation for malignancy.
Use history, focused examination, bedside tests and, where appropriate, urgent imaging or urology input to guide management and disposition.
Clinical approach and priorities
- Triage: sudden severe unilateral scrotal pain - particularly with nausea or vomiting - is a red flag for testicular torsion and requires immediate action.
- Initial ED tasks: take a targeted history (onset, progression, trauma, urinary or sexual symptoms, prior scrotal disease, cryptorchidism).
- Initial ED tasks: perform a focused examination (inspection, palpation, transillumination, cremasteric reflex, groin/abdomen for hernia).
- Provide analgesia and scrotal support early.
- Arrange early urology discussion where indicated.
- Imaging: urgent scrotal Doppler ultrasound is the investigation of choice when the diagnosis is uncertain.
- Do not delay surgical exploration for imaging when torsion is strongly suspected.
- Time sensitivity: testicular salvage falls with increasing ischaemia time; a commonly quoted window for best salvage is approximately 6 hours from onset, though viability is variable.