Scrotal Swelling: Underlying Conditions and Treatment

How the scrotum's contents can swell

Each half of the scrotum contains a testicle, the epididymis (a coiled tube behind the testicle that stores sperm), and the spermatic cord, which carries the vas deferens, arteries and a network of veins. A thin sac (the tunica vaginalis) surrounds the testicle. Swelling arises when:

• fluid collects in the sac (hydrocele)
• veins enlarge (varicocele)
• the epididymis or testicle becomes inflamed (epididymitis, orchitis)
• blood supply is cut off (torsion)
• a cyst or tumor grows
• abdominal contents push down through the inguinal canal (hernia)
• the scrotal wall fills with fluid or becomes infected

Practical advice on recognizing emergencies and when to go to the ER is on our page about scrotal swelling as a symptom.

Conditions that cause scrotal swelling

Diagnosis

Examination

The doctor examines while you stand and lie down, feels each testicle and epididymis, checks whether a lump is separate from the testicle (cysts and hydroceles usually are; tumors arise from it), shines a light through the scrotum (fluid glows), and asks you to cough or strain to reveal a hernia or varicocele.

Scrotal ultrasound with Doppler

Ultrasound is the main imaging test. It shows:

• blood flow to each testicle (absent or reduced in torsion, increased in infection)
• fluid around the testicle
• dilated veins of a varicocele
• cysts versus solid masses inside the testicle
• hernia contents

Other tests

• urine dipstick and culture; nucleic acid tests for chlamydia and gonorrhea
• tumor markers (AFP, beta-hCG, LDH) and CT scanning if a tumor is found
• semen analysis for men with varicocele and fertility concerns

Treatment by cause

Testicular torsion

Surgery (scrotal exploration) to untwist the testicle and stitch both testicles in place to prevent recurrence. Salvage rates are highest within 6 hours of pain onset and fall sharply after 12 to 24 hours. A testicle that has died is removed; a prosthesis can be placed later.

Epididymitis and orchitis

• Under 35 or STI risk: antibiotics that cover gonorrhea and chlamydia, and treatment of sexual partners.
• Over 35 or urinary cause: antibiotics that cover urinary bacteria, and investigation of the urinary tract.
• Scrotal support, ice, rest and NSAIDs if safe for you (follow the label dose).
• Swelling may take several weeks to settle completely.

Hydrocele

Most hydroceles in babies resolve by 12 to 24 months. In adults, small painless hydroceles can be left alone. Surgery (hydrocelectomy) is offered for large or uncomfortable ones. Draining with a needle is generally avoided because fluid returns and infection can occur.

Varicocele

No treatment is needed for most. Repair, by microsurgery or by blocking the vein through a catheter (embolization), is considered for persistent pain, reduced testicular size in adolescents, or infertility with abnormal semen analysis.

Spermatocele and epididymal cysts

Usually left alone. Removal is offered if large or painful, with a small risk of affecting fertility on that side.

Inguinal hernia

Surgical repair, open or laparoscopic, is recommended for most hernias in men with symptoms and for all hernias in infants, because of the risk of strangulation.

Testicular cancer

Removal of the affected testicle through a groin incision (radical inguinal orchiectomy), followed, depending on type and stage, by surveillance, chemotherapy, radiotherapy or lymph node surgery. Cure rates exceed 95% overall. Sperm banking is discussed before treatment.

Scrotal edema and skin causes

Treating heart, liver or kidney disease, raising the scrotum, compression, and antibiotics for cellulitis. Fournier gangrene needs emergency surgical debridement and IV antibiotics.

Complications

• loss of a testicle after delayed torsion treatment
• abscess or chronic pain after epididymitis
• reduced fertility from varicocele, infection or loss of a testicle
• bowel strangulation from an untreated hernia

Frequently asked questions

How is scrotal swelling treated?

Treatment depends on the cause. Testicular torsion needs emergency surgery. Epididymitis is treated with antibiotics and scrotal support. Hydroceles, varicoceles and cysts often need no treatment, or a planned operation if bothersome. Hernias are usually repaired surgically. Testicular cancer is treated by removing the testicle and further therapy if needed.

What test is used to diagnose scrotal swelling?

A scrotal ultrasound with Doppler is the main test. It shows blood flow to the testicles, fluid, enlarged veins, cysts and solid masses. Urine tests and STI tests check for infection, and blood tumor markers are used if a testicular tumor is found.

Does a hydrocele need surgery?

Not always. In babies, most hydroceles disappear by age 1 to 2. In adults, small painless hydroceles can be monitored. Surgery is recommended when a hydrocele is large, uncomfortable, growing, or linked to a hernia.

Can a varicocele affect fertility?

Yes, in some men. Varicoceles are found in about 15% of men overall but in a higher proportion of men with infertility. Repair may improve semen quality in men with abnormal semen analysis and a palpable varicocele. Many men with varicoceles have normal fertility.

How long does epididymitis swelling last?

Pain usually improves within a few days of starting antibiotics, but swelling and firmness can take several weeks to resolve completely. See your doctor if symptoms do not improve within 3 days or if swelling persists beyond a few weeks.