EPIDIDYMAL CYSTS

Introduction

Lumps and swellings in the testicles are a relatively common symptom in boys and men and can have a number of different causes.

The vast majority of testicular lumps and swellings are caused by benign (non-cancerous) conditions that may not need treatment but it is important to know what is normal for you and to see your GP if you notice any changes in your testicles so they can try to identify the cause.

What causes testicular lumps and swellings?

There are many possible reasons why your testicles may become swollen or develop a lump. Some of the main causes are:

• Varicoceles – swellings caused by swollen and enlarged veins within the scrotum.
• Hydroceles – swellings caused by a build-up of fluid around the testicle.
• Epididymal cysts – lumps caused by a collection of fluid in the epididymis (a coiled tube behind the testicles).
• Epididymo-orchitis – inflammation of the epididymis and testicles.
• Inguinal hernias – where fatty tissue or a part of your bowel pokes through into your groin, which can cause the scrotum to become enlarged.

A sudden and severely painful swelling in one of your testicles can be a sign of a condition called testicular torsion, which is where the blood supply to a testicle is interrupted.

In rare cases, testicular lumps can be a sign of testicular cancer. Cancer Research UK estimates that fewer than four in every 100 testicular lumps are cancerous.

Read more about the causes of testicular lumps and swellings.

Seeing a urologist

You should see a urologist if you notice any lumps, swellings or changes in your testicles.

Your doctor will ask you about your symptoms and examine your testicles to try to identify the cause of the problem.

In some cases you may be referred for further tests, such as an ultrasound scan of your scrotum, to confirm a diagnosis.

If you experience sudden or severe pain in your testicles, it is important to contact your doctor immediately or visit your nearest accident and emergency (A&E) department as soon as possible because urgent treatment may be required.

How testicular lumps and swellings are treated?

Treatment for testicular lumps and swellings will depend on the underlying cause. Many conditions do not need to be treated if they are not causing any or many problems and they are not cancer.

Some lumps and swellings will improve over time and simple measures such as taking over-the-counter painkillers or wearing supportive underwear may be enough to relieve any pain or discomfort in the meantime.

Surgery may be recommended to drain away any fluid or remove any solid lumps, if the problem gets worse.

Testicular torsion will require urgent surgery to restore blood flow to the affected testicle because the testicle will start to die if not treated within a few hours of the problem developing.

Causes of testicular lumps and swellings

Most testicular lumps and swellings are caused by benign (non-cancerous) conditions, although occasionally they can be a symptom of testicular cancer.

It's important to see a doctor urgently if you notice a lump or swelling in one of your testicles so that a cause can be identified.

Some of the main causes of scrotal  lumps and swellings are outlined below.

Benign scrotal lumps and swellings

Most of these conditions are largely harmless and may not require treatment.

Varicoceles

Varicoceles are soft lumps that usually develop gradually above the testicle and mostly on the left side of the scrotum (the loose sac of skin that contains the testicles). They are sometimes described as feeling like a "bag of worms".

The exact cause of varicoceles is not clear, but it is widely thought that they occur as the result of abnormalities in the veins in the testicles leading to a build-up of excess blood in the veins, which makes them swell.

The size of varicoceles can vary. Some may only be noticeable when you touch them. Others can be larger and seen easily. The side of the scrotum that contains the varicoceles may hang slightly lower than the other side.

Besides a lump, varicoceles do not usually cause any other symptoms, although some men experience a heavy feeling or aching pain in their scrotum or groin especially when standing or at the end of the day.

In a few cases, varicoceles have been linked to infertility in men. However, there is no evidence that treating them significantly improves your chances of being able to father a baby.

Hydroceles

Hydroceles are swellings in the scrotum caused by a build-up of fluid around the testicle in a layer called the tunica vaginalis.

During pregnancy, a male baby's testicles develop inside his abdomen (tummy) and they pass down into the scrotum through a passage once they are formed. This passage usually closes before birth, but in some cases it stays open. If the passage remains open, fluid can pass from the abdomen into the scrotum, causing the swelling associated with a hydrocele.

In most cases affecting babies, the fluid is absorbed into the surrounding tissue during the child's first year or two of life, and the hydrocele disappears.

Hydroceles that develop in men or older boys may be caused by inflammation (swelling) of the scrotum resulting from problems such as an injury or infection.

Epididymal cysts

An epididymal cyst is a small, smooth fluid-filled swelling that slowly develops in the epididymis (a coil-like structure behind the testicles that helps to store and transport sperm).

They are often painless, but the affected testicle may sometimes ache or feel heavy. You may also experience some pain and discomfort if the cyst puts pressure on other structures in or around your testicle.

It's not clear what causes epididymal cysts, but they tend to be more common in middle-aged men.

Epididymo-orchitis

Epididymo-orchitis is the inflammation of the epididymis as well as the testicle, causing the affected testicle to become swollen, painful and tender over a matter of hours or days.

It's not always clear what causes epididymo-orchitis, but the condition is often linked to an infection, including:

• Sexually transmitted infections (STIs), such as chlamydia and gonorrhoea
• Urinary tract infections (UTIs)
• Mumps

Epididymo-orchitis can sometimes lead to a reduced sperm count in affected men, although this is rarely significant enough to cause infertility.

Inguinal hernias

An inguinal hernia occurs when fatty tissue or a part of your bowel, such as the intestine, pokes through from the abdomen and into the scrotum (Indirect inguinal hernia).

The hernia can appear as a swelling or lump in your groin, or as an enlarged scrotum. The lump is often painless, but it can become suddenly and severely painful if the blood supply to the section of organ or tissue trapped in the hernia has become cut off (strangulation).

If you think you have a hernia that has become strangulated, you should visit your nearest accident and emergency (A&E) department as soon as possible because urgent surgery may be required.

Inguinal hernias occur when the tissue or bowel pushes through a weak spot in the surrounding muscle wall (the abdominal wall) into the inguinal canal. The inguinal canal is a channel through which blood vessels to the testicles pass.

Inguinal hernias occur mainly in men. Most are thought to be due to ageing. This is because as you get older, the muscles surrounding your abdomen can become weaker. They can also sometimes appear suddenly due to strain on the abdomen, such as straining on the toilet if you have constipation or carrying and pushing heavy loads.

Testicular torsion

Testicular torsion is a benign but serious condition caused by the spermatic cord (the cord that supplies the testicles with blood) becoming severely twisted.

Unlike the other types of benign testicular lumps and swellings, testicular torsion is a medical emergency. You shouldr visit your nearest accident and emergency (A&E) department as soon as possible if you suspect you have testicular torsion.

Signs and symptoms of testicular torsion include:

• A sudden, severe pain in one of your testicles
• Swelling of the scrotum

If the spermatic cord becomes severely twisted, the blood supply for the affected testicle can be interrupted. If this is not treated quickly with surgery, there is a risk of losing the affected testicle.

Testicular torsion can occur at any age, but is most common in boys aged 13-17 and is rare in men over 30. It can also affect newborn babies and even unborn babies in the womb.

Most cases happen for no apparent reason, although the problem can occur in boys who are born with an unusually loose spermatic cord and it can develop after an injury to the testicles.

You may also be at a higher risk of developing testicular torsion if you have a history of undescended testicles (where a boy is born without both testicles in their scrotum).

Testicular cancer

Although the vast majority of testicular lumps and swellings are benign, a lump in one of the testicles can sometimes be a sign of testicular cancer.

Cancer Research UK estimates that fewer than four in every 100 testicular lumps are caused by cancer.

Lumps associated with testicular cancer tend to develop slowly on the testicle itself (as opposed to the scrotum) are usually:

• Painless (although some men do experience pain or discomfort)
• Solid and firm
• Not tender to touch

Unlike many other types of cancer, the risk of testicular cancer does not keep increasing as you get older. The condition is most often diagnosed in boys and men between the ages of 15 and 49 and is uncommon in men older than this.

ANY NEW LUMPS OR BUMPS IN THE SCROTUM NEED URGENT INVESTIGATION

Diagnosing testicular lumps and swellings

Most testicular lumps are not caused by testicular cancer and many do not necessarily need any treatment but it is best to get them checked out.

Your doctor will ask you whether you have:

• Felt any pain, and if so, when it was, how severe it was, how suddenly it developed and how long it has lasted.
• Any other symptoms, such as pain when you urinate or any discharge from your penis, which could be a sign of an infection.
• A history of trauma, such as a sports injury to your groin.

They will also want to examine your testicles to check:

• The size of your testicles, position of the lump or swelling, whether the lump causes & pain when it is touched and whether the lump is firm or soft.

Your doctor may hold a small light or torch against the lump in your testicle to see whether light passes through it. This can help differentiate between solid lumps and lumps caused by a build-up of fluid (such as hydroceles).

Further tests

Depending on what your doctor thinks may be the cause of your symptoms, you may be referred to a specialist – such as a urologist (a doctor specialising in conditions affecting the urinary system) – for further assessment or your doctor may arrange more tests.

If testicular torsion is suspected, you will usually be referred to hospital for an urgent assessment to see whether an immediate operation is necessary.

Testing for infections,

Your doctor may take a urine sample if they suspect your lump or swelling may be caused by an infection. They may also use a swab (small cotton bud) to collect a sample of cells and fluid from your urethra (the tube that carries urine out of the body). This sample can also be tested to see if you have an infection.

You may be referred to a genitourinary medicine (GUM) clinic if it is thought you may have a sexually transmitted infection (STI).

Ultrasound scan

An ultrasound scan is used if there is any uncertainty about the cause of your lump or swelling. This is a painless scan that uses high frequency sound waves to create an image of the inside of your scrotum.

An ultrasound scan can help give a clearer indication of whether the lump is solid or filled with fluid and can help determine the likelihood of the lump being cancerous.

Treating testicular lumps and swellings  

Treatment for your testicular lump or swelling will depend on the underlying cause. Some lumps may not need to be treated at all if they are not causing any problems.

Treating varicoceles

In most cases, varicoceles do not require treatment. They usually do not cause other symptoms or long term problems.

Although varicoceles are sometimes associated with infertility, most men's fertility is not affected and there is currently not enough evidence to suggest that treating varicoceles will help improve your chances of fathering a child.

If you have a varicocele that is causing pain or discomfort, taking simple painkillers such as Paracetamol and wearing supportive underwear may help initially.

Your GP can refer you to a urologist (a doctor specialising in conditions affecting the urinary system) who can discuss the option of surgery with you if your varicocele is still causing your problems.

Surgery

Procedure : Excision of epididymal cysts

Indication:  Cysts within the epididymis

Incision:     Scrotal

Risks:         Common (> 1 in 10):   

• Swelling of the scrotum lasting several days

• Seepage of fluid from the wound lasting several days

                    Occasional (one in 10 to one in 50):

• Recurrence of the cyst
• Further cysts developing.
• Blood collection in scrotum (can require surgical drainage)
• Infection requiring antibiotics

                    Rare (< one in 50)

• Scarring of the epididymis causing impaired fertility
• Chronic scrotal pain

Alternative therapy: Observation

                               Aspiration of fluid - high risk of recurrence and infection

Post - operatively:

Keep wound clean and dry for 24 hours.

Shower rather than bath until area heals and avoid soap.

Wear supportive underwear / scrotal support until the swelling has settled.

Avoid strenuous exercise or heavy lifting for 4 to 6 weeks.

Stitches will dissolve in 4 to 6weeks. 

If you develop a temperature, increased redness or drainage at the site of the operation please contact me directly.

In many cases, a technique called varicocele embolisation can be used to treat problematic varicoceles.

A tiny tube is inserted into a vein in your groin or neck and X-ray equipment is used to guide it to the affected veins in your testicles. Metal coils or a special liquid are then passed through the tube to block the affected veins. The blood will then bypass the blocked veins, reducing the swelling associated with the varicocele.

Most varicocele embolisation procedures are carried out on an outpatient basis, which means you will not have to stay in hospital overnight. It is usually carried out under local anaesthetic (you will be awake during the procedure but the affected area will be numbed). 

Varicocele embolisation is a safe and effective procedure, although you may experience some swelling or bruising where the tube was inserted for a few days afterwards. There is also a small risk of infection, which can be treated with antibiotics and there is a possibility the varicocele could recur later on.

Some varicoceles need surgery to directly tie off or remove the affected veins. This is usually performed under general anaesthetic (where you are asleep) and involves making incisions (cuts) in your groin or abdomen.

Treating hydroceles

Hydroceles in newborn babies usually disappear by the time the baby reaches two years of age. Treatment is usually only needed if they persist for longer than this or cause pain or discomfort.

Treatment may also be recommended in boys or adults with a hydrocele that is particularly large or is causing any other symptoms. In such cases, you can be referred to a surgeon to discuss your options.

Surgery

A surgical procedure known as a hydrocelectomy is often recommended for hydroceles.  

In children, an incision is made in the groin before sealing the passage between the abdomen (tummy) and the scrotum that allows fluid to flow into the scrotum. In adults, the incision is made in the scrotum, the fluid is drained away and the incision is closed using dissolvable stitches.

Both procedures are usually carried out under general anaesthetic and most people will be able to return home soon after having the operation.

You may experience some discomfort, swelling  and fluid seepage from the wound after the procedure  but this should only last for a few days. Taking simple painkillers and wearing supportive underwear may help reduce any discomfort in the meantime.

As with a varicocele embolisation, there is a small risk of infection after a hydrocelectomy and there is a possibility the hydrocele could recur.

Treating epididymo-orchitis

As epididymo-orchitis is often thought to be caused by bacterial infections, such as sexually transmitted infections (STIs) and urinary tract infections (UTIs), treatment will usually involve a 10-14 day course of antibiotic tablets.

If your doctor suspects epididymo-orchitis has occurred as a complication of a mumps infection, antibiotics are not used because mumps is caused by a virus.

In these cases, the swelling and pain in the testicles will usually resolve within a week or two. Wearing supportive underwear, applying cold or warm compresses to your testicles and taking simple painkillers may help reduce discomfort in the meantime.

Treating inguinal hernias

You may be referred to a surgeon to discuss the option of having an operation to push the bulge back into place and strengthen the weakness in the abdominal wall.

This operation will be carried out urgently if there are signs that the blood supply to the tissue forming the lump has become interrupted (strangulated) because this can cause the affected tissue to die.

There are two ways that an inguinal hernia repair can be performed:

• Open surgery – where one cut is made to allow the surgeon to push the lump back into the abdomen
• Keyhole (laparoscopic) surgery – a less invasive but more difficult technique where several smaller cuts are made, allowing the surgeon to use various special instruments to repair the hernia

There are advantages and disadvantages to both methods. The type of surgery you have will depend on which method suits you and your surgeon’s experience. With both types of surgery, you should be able to go home the same day or the day after.

An inguinal hernia repair is a routine operation with very few risks. Although it is not uncommon for a hernia to recur at some point after surgery.

Treating testicular torsion

If you have testicular torsion, you will need surgery as soon as possible to untwist the testicle. Permanent injury to the testicle can occur within hours of having testicular torsion, which may affect your fertility or result in the loss of your testicle.

Surgery for testicular torsion is carried out under general anaesthetic. The surgeon will make an incision in your scrotum before untwisting the spermatic cord (the cord that supplies the testicles with blood). The testicle (or testicles) will then be stitched to the inside of the scrotum to prevent the spermatic cord twisting again.

The longer you wait before having surgery, the higher the risk that your surgeon will not be able to save the trapped testicle. Research has found that when men have surgery within six hours of testicular torsion occurring, nine out of 10 twisted testicles will be saved. However, if the surgery is delayed for 24 hours, only one out of 10 twisted testicles will be saved.

If it is not possible to save the affected testicle, the surgeon will need to remove it and seal the spermatic cord. In these cases, another operation can be carried out at a later date to fit a replacement artificial (prosthetic) testicle.

Treating testicular cancer

If you have been diagnosed with testicular cancer, you will be cared for by a team of clinicians who will help decide the best treatment for you.

This will depend on factors such as the specific type of testicular cancer you have and how far it had spread before it was diagnosed.

Surgery to remove the affected testicle will be recommended in most cases and this may sometimes be followed by a course of chemotherapy or radiotherapy.

If you want, you can have a prosthetic testicle inserted into your scrotum so that the appearance of your testicles is not greatly affected.

In rare cases where it is necessary to remove both testicles, you will become infertile. However, you may be able to bank your sperm before the operation to allow you to father children in the future.