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Scrotal pain and masses
Sudden severe testicular pain in an adolescent is torsion until proven otherwise and needs immediate surgery; a hard painless testicular lump is a tumour until proven otherwise and needs an urgent ultrasound — and the other causes (epididymitis, hydrocele, varicocele) are diagnosed only after these are excluded.
Why it matters in the exam
The exam presents a 13-year-old with 4 hours of testicular pain and vomiting, a 21-year-old with a few hours of pain, a 30-year-old with a month of discomfort and swelling, and a question asking which listed factor does not raise testicular cancer risk. It asks for the next step.
Time is the decisive factor in torsion: the chance of saving the testis is very high in the first six hours and falls quickly afterwards — so with high suspicion you do not wait for ultrasound.
The family doctor is usually the first to see the boy or the man, so the quick decision — who goes straight to theatre, who has an ultrasound that week and who is treated with antibiotics — is the whole point. Inguinal swelling also appears in questions.
Key points
- Sudden pain in an adolescent — torsion; immediate surgery, time is critical.
- Hard painless lump — tumour; urgent ultrasound and markers.
- Gradual pain with fever — epididymitis; treat according to age.
- A hydrocele transilluminates; a tumour does not.
- Right-sided varicocele — abdominal imaging.
Summary table
| Condition | Clues | Work-up | Treatment |
|---|---|---|---|
| Testicular torsion | Sudden severe pain, nausea and vomiting, high-riding horizontal testis, absent cremasteric reflex; usually aged 12–18 | High suspicion — straight to surgery; otherwise Doppler ultrasound | Immediate surgery and fixation of both testes |
| Torsion of the appendix testis | Child aged 7–12, pain at the upper pole, "blue dot" | Clinical or Doppler | Supportive care |
| Epididymitis | Gradual pain, fever, dysuria, cremasteric reflex preserved | Urinalysis and culture, tests for gonorrhoea and chlamydia | Under 35 and sexually active — ceftriaxone 500 mg as a single injection and doxycycline for 10 days; older — cover enteric bacteria |
| Testicular tumour | Hard lump, usually painless, does not transilluminate | Urgent ultrasound, markers: AFP, β-hCG, LDH | Inguinal orchidectomy; no biopsy through the scrotum |
| Hydrocele | Soft swelling that transilluminates | Ultrasound in an adult to exclude a tumour | Observation; surgery when bothersome |
| Varicocele | "Bag of worms" on the left, fills on standing | Standing examination; a right-sided varicocele or one that does not empty lying down — abdominal imaging | Linked to reduced fertility; surgery as needed |
Free exam questions
מטופל בן ,24 בריא בד"כ. בבדיקת אולטרהסאונד אשכים נמצא גוש חשוד היפואקוגני עם זרימת דם בתוכו, בקוטר 18 מ"מ בקוטב התחתון של אשך ימין. האשך הנגדי תקין. בדיקת CT ללא עדות לפיזור, ובדיקת מרקרים בדם שלילית. מהו הטיפול המומלץ? (the question as examined, in Hebrew)
- א. כריתה חלקית של הקוטב התחתון של האשך, והחלטה ניתוחית בהתאם לתשובה הפתולוגית בחתך קפוא
- ב. כריתה רדיקלית של אשך ימין בגישה מפשעתית
- ג. מעקב סונוגרפי צמוד אחר הממצא
- ד. ביופסיה מילעורית וטיפול בקרינה מקומית
בן ,23 עבר כריתה רדיקלית של אשך שמאלי. מרקרים לאחר הניתוח תקינים. ב- CT גוש inter 35% , ס"מ 3 ס"מ. בתשובה היסטולוגית התהליך באשך בקוטר 2.8 בקוטר aorto-caval LVI , ללא rete testis חודר ל seminoma, 65% Teratoma. מה הטיפול? (the question as examined, in Hebrew)
- א. BEP x3 כימותרפיה ע"י
- ב. כימותרפיה ע"י BEPx3 משולבת עם קרינה
- ג. RPLND ראשוני
- ד. קרינה כמונותרפיה
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Sources
- American Urological Association / European Association of Urology, 2023–2024 — Guidelines on paediatric urology (acute scrotum) and on testicular cancer
- CDC, 2021 — Sexually transmitted infections treatment guidelines — epididymitis
- Goroll AH, Mulley AG. Primary Care Medicine, 8th edition (2020) — Evaluation of scrotal pain, masses and swelling
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.