Differentials
| Presenting Feature | What might it be? | What might I find? | |
|
Scrotal lump |
Hydrocele |
Idiopathic, or secondary to malignancy, torsion, trauma, orchitis.
Soft, painless scrotal swelling due to fluid within tunica vaginalis. Fluctuant, smooth swelling, testis palpable within, irreducible, transilluminates. |
|
|
Varicocele |
Swelling of pampiniform plexus, most common on left side.
Scrotal swelling, heavy, throbbing pain, sub-fertility, may cause testicular atrophy. ‘Bag of worms’ palpable, ↑on standing, separate from testis. |
||
|
Epididymal cyst |
Common, fluid filled sac at epididymal head, often incidental find.
Soft, smooth, round lump, separate from testis, at superior pole of testis. Large cysts will transilluminate. |
||
|
Testicular cancer |
RF: young age 15-35, undescended testes, infertility, family history.
Painless lump, arising from testis, firm, irregular, not fluctuant. |
||
|
Inguinal hernia |
RF: male, obesity, constipation, heavy lifting. May occur in infants.
Groin lump which may extend into scrotum. Cannot get above it on palpation, cough impulse. |
||
|
Testicular pain |
Testicular torsion |
Urological emergency. Typically young/teenage boys playing sport.
Acute rapid onset unilateral testicular +/- abdominal pain, vomiting. Firm, swollen, elevated or retracted testis, horizontal lie, rotation. Absent cremastueric reflex (not reliable to rule in/out torsion). |
|
|
Epididymo-orchitis |
Causes: e.coli, chlamydia, gonorrhoea, mumps.
Unilateral, painful scrotal swelling, heaviness, onset minutes-hours. Testicular tenderness, ↑over epididymis, urethral discharge if STI. |
||
|
Prostatitis |
Acute bacterial, or chronic prostatitis (symptoms >3 months).
Pelvic pain – can radiate to perineum, testes, scrotum or penis. LUTS, sexual dysfunction, bowel pain, prostate tenderness. |
||
|
Scrotal haematoma |
Iatrogenic (post-procedure), traumatic, non-traumatic (rare).
Large will require scrotal explorative surgery. Small – managed with scrotal support, anti-inflammatory analgesia. |
||
|
Miscellaneous |
Single testicle |
Causes: undescended or retractile testicle, orchidectomy, congenital absence (rare). | |
|
Testicular atrophy |
Causes include: unilateral – trauma, torsion, varicocele, mumps.
Bilateral – hypogonadism, chemotherapy, liver cirrhosis, etc. |
||
Checklist
| Preparation | Wash – Name – Explain | |
| Chaparone | ||
| Allow to undress | ||
| Position patient lying flat on couch | ||
| Ask patient to cover with sheet | ||
| General Inspection | Expose patient | |
| Put on gloves | ||
| Pain | ||
| Obvious testicular asymmetry | ||
| Clues in bed space | ||
| Closer Inspection | Presence of both testicles in scrotum | |
| Redness | ||
| Swelling | ||
| Scars | ||
| Skin changes | ||
| Palpation | Palpate each testis systematically | |
| Lump or swelling | ||
| Tenderness | ||
| Spermatic cord | ||
| Epididymal head | ||
| Attempt to get above swelling | ||
| Cough impulse | ||
| Transillumination | ||
| Special Tests | Examine stading | |
| Prehn’s test | ||
| Offer cremaster reflex | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
“I have been asked to carry out a testicular examination. This involves looking at the scrotum and then feeling each testicle to check for any lumps or pain. There will be a chaperone present while I carry out this examination. Are you happy for me to do that?”
Ask the patient to undress from the waist down and position them lying supine on the examination couch. Cover the patient until you are ready to start the examination.
General Inspection
Put on gloves for the examination. Expose the patient and check that they are comfortable.
Look at the patient and around the bed space for useful clinical signs:
- Pain – acute testicular pain occurs in testicular torsion, epididymo-orchitis, acute prostatitis, and scrotal haematoma.
- Obvious scrotal asymmetry (e.g., gross swelling, redness)
- Clues in the bed space (e.g., medication packets, scrotal support)
Closer Inspection
Inspect the scrotum for:
- Presence of both testes (e.g., undescended or retractile testis in children, or prior orchidectomy)
- Colour (e.g., erythema, bruising)
- Swelling (e.g., epididymo-orchitis, hydrocele, haematoma, varicocele)
- Scars – indicating prior surgery to the scrotum e.g., orchidectomy.
- Skin changes (e.g., rashes)
Palpation
Palpate each testicle individually and systematically. If the patient has presented with a unilateral complaint, e.g., a lump, start by examining the unaffected side first.
Palpate the testis between your index finger and thumb, ensuring you are able to feel the testis within the scrotum and evaluating the approximate size.
Palpate the testis specifically for:
- Lumps
- Tenderness
- Anatomical landmarks
If a testicular lump is present, evaluate its size, character (e.g., firm, fluctuant, smooth, irregular, ‘bag of worms’ etc.), and whether it is separate from the testis (e.g., epididymal cyst, varicocele).
Try to transilluminate any swelling by shining a light through the swelling, e.g., with a pen torch. A hydrocele or a large epididymal cyst will transilluminate.
Can you palpate above the lump? It is not possible to ‘get above’ an inguinal hernia on palpation.
A hernia will usually generate a positive cough impulse (lump feels larger when patient coughs due to increased intra-abdominal pressure).
Palpate the spermatic cord (located in the neck of the scrotum) and the epididymis (posterior to the testis).
Special Tests
Special tests during testicular examination include:
- Examining the patient standing – a varicocele becomes more visible with gravity when standing.
- Prehn’s test
- Cremasteric reflex
Prehn’s test involves lifting the scrotum and evaluating whether pain is improved with elevation (epididymitis) or unchanged (testicular torsion).
The cremasteric reflex is examined by stroking the patient’s inner thigh and observing for activation of the cremaster muscle and elevation of the testis on the same side. The cremasteric reflex is lost in testicular torsion.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the testicular examination findings you may wish to carry out further investigations, e.g., ultrasound scan of the scrotum or testing for sexually transmitted infection.
Last updated Aug 2025
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
