Scrotal mass overview

# Overview
Scrotal mass may be classified into two subtypes: testicular and extratesticular.Scrotal masses may be differentiated according to clinical features, laboratory findings, imaging features, histological features, and genetic studies from other diseases that cause testicular mass with discomfort, back pain, abdominal discomfort, or abdominal mass. If there is an acutely painful scrotum,there should be a strong suspicion for testicular torsion, which is an emergency condition, and emergent surgical referral should be strongly considered.Sonography may be performed if testicular torsion is not suspected to confirm the diagnosis. According to the TNM classification and stage groupings, there are 3 stages of testicular cancer based on the size and extent of the primary tumor, number and location of any regional lymph nodes (abdominal retroperitoneal) infiltrated by tumor cells, distant metastasis, and serum tumor marker levels.Symptoms related with scrotal mass will vary, depending on the cause of the mass, which include enlarged scrotum, painless or painful testicle lump, and feeling of heaviness in the scrotum. Common physical examination findings of scrotal mass include a tender mass which is having a smooth, twisted, or irregular shape and liquid, firm, or solid in consistency. The ipsilateral inguinal lymph nodes may be enlarged or tender.The laboratory findings related with scrotal mass may vary, depending on the cause of the mass.Laboratory findings consistent with the diagnosis of testicular tumors, may include elevated serum tumor markers such as AFP, LDH, or HCG. Imaging studies for scrotal mass include scrotal ultrasound, MRI, and chest x-ray.Biopsy should be performed in patients with scrotal skin lesions to rule out skin cancer.

# Historical percpective
Reinforcement of the anterior wall of the inguinal canal and tightening of the external inguinal ring was first discovered by Stromayr in 1559. In 1871, new use of carbolized catgut ligature was developed by Marcy to treat inguinal hernia. Twisted and suture-transfixed the peritoneal sac in the lateral muscles through the external ring was developed by Kocher to treat inguinal hernia.Laparoscopic approaches first used to treat inguinal hernias in 1992.There is a limited information about the historical perspective of testicular tumors. Leydig cells were first discovered by Franz Leydig who was a German anatomist in 1870.

# Classification
Scrotal masses are divided to two main group:Extra testicular and Testicular.Also scrotal masses may be pain full or not painfull.The other classification is based on neoplastic or non-neoplastic masses.

# Pathophysiology
Deponds on the causes phatophysiology is different.
Inadequate fixation of the lower pole of the testis to the tunica vaginalis causes testicular tortion . If fixation is absent  , the testis may torse (twist) on the spermatic cord, lead to produceischemia from reduced arterial inflow and venous outflow obstruction . Testicular torsion etiology include (eg, trauma, vigorous physical activity) or spontaneously. Acquired hernias due  loss of mechanical integrity of the abdominal wall muscles and tendons . primary hernia due Genetic or systemic extracellular matrix disorders  and defective wound healing after laparotomy and hernia repairs may predispose to incisional hernias.

# Causes
Scrotal masses may be caused by tumors,injury,truma,infection.Also the causes deponds on anatomical origin.

# Differentiating scrotal masses from Other Diseases
Scrotal masses must be differentiated from other diseases that cause scrotal swelling,scrotal pain,such as testicular tortion ,epididimitis,testicular tumors,inguinal herniation and many other diseases.

# Epidemiology and Dermographics
Testicular cancer is a rare type cancer accounting about 0.5% of all new cancer cases in U.S. In 2018, the estimate prevalence of testicular cancer is approximately 9,310 new cases of testicular cancers in the United States. The incidence of testicular cancer is approximately 5.7 per 100,000 men per year based on 2011-2015 report in the United States. The majority of cases are reported in New Zealand. Testicular cancer commonly affects more white males than any other races and black males are less affected by it. Testicular cancer is commonly affects men aged 20-44 years old and median age is 33 years old.

# Risk Factors
Depends on the causes of scrotal masses, risk factors are different,for example in testicular tortion the most potent risk factor is undescended testicle and genetic structural defects.

# Screening
According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for testicular cancer.

# Natural History,Complications,and Prognosis

## Complications
Common complication of testicular tortion include,Testicular ischemia:Twisting of the spermatic cord during torsion causes testicular vascular compromise, resulting in testicular injury.

# Diagnosis

## Diagnosis Study of Choice
If there is an acutely painful scrotum,there should be a strong suspicion for testicular torsion, which is an emergency condition, and emergent surgical referral should be strongly considered. Sonography may be performed if testicular torsion is not suspected to confirm the diagnosis,althogh color doppler ultrasound is preffered for initial diagnosis test.
Testicular torsion is primrily diagnosed base on the clinical presentation.

## History and Symptoms
Symptoms related with scrotal mass will vary, depending on the cause of the mass, which include enlarged scrotum, painless or painful testicle lump, and feeling of heaviness in the scrotum.Other symptoms are edema and erythem of scrotom in epididimitis and tortion, 
fever,dysuria and urgency in epididimitis.Low back pain and lower extremitis edema are the other presentations in scrotomal tumors.

## Physical Examination
physical examination of scrotal masses depends on causes.common physical examinations in testicular tortion is an elevated ,horizontlly aligned testicle.
Also they have severe tenderness and firm in palpation.Cremastic reflex and phren sign are absent.In testicular apendix tortion ,phathognomonic sign is Blue dot,which is a nodule with blue discoloration.In hydrocele transillumination test will be positive.

## Laboratory Findings
The laboratory findings related with scrotal mass may vary, depending on the cause of the mass. Laboratory findings consistent with the diagnosis of testicular tumors, may include elevated serum tumor markers such as AFP, LDH, or HCG.CRP level up to 24mg /L is highly specific and sensitive for epididymitis and orchitis.

## Electrocardiogram
There is no ECG findings associated with scrotal masses.

## X-ray
There are no x-ray findings associated with scrotal masses.

## Echocardiography and Ultrasound
Ultrasound findings associated with scrotal masses.It can differentiated extratsticular masses from intratesticular masses.By using Doppler-colored ultrasound ,specifity and sensitivity for testicular tortion will be increased.

## CT scan
CT scan may be helpfull in the diagnosis of testicular carcinoma and also for staging testicular tumors.

## MRI
MRI may be helpfull in the diagnosis of testicular carcinoma and also for staging testicular tumors.

## Other Imaging Findings
Radionuclide Imaging may be helpfull in testicular tortion diagnosis but because it takes time,usually is not used.

## Other Diagnostic Studies
There are no other diagnostic studies associated with scrotal masses.

# Treatment

## Medical Therapy
Scrotal masses presented with acute pain ,should be treated emergently.Patients with testicular tortion are treated with immidiate scrotal exploration,detortion and orchidopexy,whereas treatment of  tortion of testicular apendage is conservative.pharmacologic medical therapy is recommended among patients with Epididimytis. In testicular tumors the first line treatment is radical orchiectomy after determining the diagnosis, treatment depends on tumor type and available options are chemotherapy and radiation.

## Surgery
Scrotal masses presented with acute pain ,should be treated emergently.Patients with testicular tortion are treated with immidiate scrotal exploration,detortion and orchidopexy,In testicular tumors the first line treatment is radical orchiectomy.

## Primary Prevention
There are no established measures for the primary prevention of scrotal masses,but by decreasing some of the risk factors we can prevent some of the  causes.

# Refrences