History

• Onset of swelling– sudden or gradual
• Any previous episodes? (intermittent torsion or epididymo-orchitis)
• Sexual history
• Pain - epididymal cysts are usually painless but may cause a mild ache or discomfort in the scrotum
• Associated symptoms which may indicate other pathology – nausea, vomiting, fever, abdominal pain, weight loss, back pain, urinary symptoms

Examination

• Where is the swelling in relation to the testis? (separate from the testis)
• Size
• Tenderness
• Does it transilluminate?

Differential Diagnosis

• Testicular cancer – solid, firm and sometimes painful mass involving all or part of testis
• Testicular torsion - acute severe unilateral scrotal pain and swelling
• Epididymo-orchitis - acute unilateral scrotal pain and/or swelling possibly with fever, dysuria, urethral discharge or parotid swelling
• Hydrocele – gradual onset painless fluctuant ovoid swelling enveloping the testis or located above the testis along the spermatic cord
• Haematocele - sudden or gradual onset swelling with pain and tenderness usually following trauma
• Varicocele - gradual onset swelling (usually left side), usually painless may cause all dragging scrotal discomfort on standing
• Inguinal hernia - sudden or gradual onset swelling, often with dull dragging discomfort in the scrotum

Acute scrotal pain and tenderness may indicate testicular torsion or strangulated inguinal hernia and is a surgical emergency. Associated symptoms such as nausea, vomiting or abdominal pain may also be present.

Testicular cancer can present with testicular pain. Unilateral testis enlargement or change in shape or texture – refer on Suspected cancer fast-track pathway.

Arrange an urgent ultrasound scan of the scrotum, provided a scrotal swelling is not of acute onset, only if:

• There is diagnostic uncertainty.
• There are persistent, unexplained testicular symptoms.
• It is not possible to distinguish if the scrotal swelling is testicular or extra-testicular.
• A hydrocele is detected in a person aged 18–40 years.
• There is a history of trauma and scrotal pain.

Reassure the patient that most epididymal cysts do not require treatment or imaging.

Consider referral if the patient has significant symptoms affecting quality of life and the cyst measures more than 10 millimetres (surgical treatment for smaller cysts may have a higher risk than benefit as symptoms are less likely to be cyst related).

Patients being referred should have an ultrasound scan prior to referral and the scan report should be attached to the referral.

Referral Criteria

• Significant impact on quality of life

AND

• Size greater than 10mm (surgical treatment for smaller cysts may have a higher risk than benefit as symptoms are less likely to be cyst related)

AND

• Ultrasound scan confirms diagnosis

Referrals without this information may be returned

Referral Instructions

e-Referral Service Selection

Specialty: Urology

Clinic Type: Not otherwise specified

Service: DRSS-Western-Urology-Devon ICB- 15N

Referral Form

DRSS Referral Form

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2023