Introduction
Testicular and scrotal examination tests your ability to systematically examine an intimate area while maintaining patient dignity. Testicular cancer is the most common malignancy in men aged 15-35 — recognising a hard, painless testicular mass as a red flag is essential and frequently tested.
💎 Clinical Pearl
Always offer a chaperone and document whether it was accepted. Expose only when necessary. Warm your hands. Examine the normal side first for comparison.
Preparation
- Introduce yourself, confirm patient identity
- Explain the examination and offer a chaperone; document decision
- Position: standing initially, then supine for palpation
- Expose groin and scrotum; maintain dignity with a sheet
1. Look
Standing
| Finding | Significance |
|---|---|
| Asymmetry | Normal (left often lower); marked asymmetry = pathological |
| Erythema or oedema of scrotal skin | Epididymo-orchitis, Fournier's gangrene |
| Visible dilated veins above left testis | Varicocele (bag of worms appearance) |
| Swelling or fullness | See differential below |
Ask patient to perform Valsalva manoeuvre: a varicocele becomes more prominent.
2. Palpation (Supine)
Palpate each structure in order:
- 1Testis proper — smooth, firm, ovoid, 4 x 3 cm in adults
- 2Epididymis — posterolateral to testis; palpate head (superior), body, and tail (inferior)
- 3Vas deferens — cord-like, arising from the epididymis tail
- 4Spermatic cord — palpate between thumb and forefinger above the testis
| Finding | Significance |
|---|---|
| Hard, irregular, non-tender mass from testis | Testicular malignancy until proven otherwise |
| Smooth separate mass at epididymis head | Epididymal cyst |
| Tense, non-reducible, transilluminates | Hydrocele |
| Tender testis and epididymis, systemically unwell | Epididymo-orchitis |
| Soft reducible mass, cough impulse, can get above it | Inguinal hernia descending into scrotum |
3. Transillumination
Place a pen torch against the posterior scrotal wall in a darkened room.
🧠 Mnemonic
Fluid = Fire (red glow). Solid = Shadow (no glow).
Fluid-filled lesions (hydrocele, epididymal cyst) transilluminate bright red. Solid lesions (testicular tumour, haematoma, orchitis) do not transilluminate.
Key Differentials
| Condition | Key features | Transillumination |
|---|---|---|
| Hydrocele | Fluctuant, cannot get above it, non-tender | Yes |
| Epididymal cyst | Separate from testis, smooth, at head or body | Yes |
| Varicocele | Worm-like above testis, disappears supine, left-sided | No |
| Epididymo-orchitis | Tender epididymis and testis, STI risk, fever | No |
| Testicular torsion | Sudden severe pain, high-riding testis, absent cremasteric reflex | No |
| Testicular cancer | Hard, non-tender, irregular testicular mass | No |
| Inguinal hernia | Cough impulse, reducible, bowel sounds | No |
Testicular Cancer
⚠️ Red Flag
Any hard, non-tender, irregular testicular mass in a man aged 15-40 is testicular cancer until proven otherwise. Refer urgently under the 2-week wait rule.
Risk factors: undescended testis (cryptorchidism), family history, Klinefelter syndrome.
Types: seminoma (peak age 25-35, radiosensitive) and non-seminomatous GCT (peak age 15-25, chemosensitive).
Investigations: scrotal ultrasound (first-line), beta-hCG, AFP, LDH. Do NOT biopsy through the scrotum.
How to Present
"On examination of the right scrotum there was a hard, non-tender, irregular mass arising from the right testis. The mass did not transilluminate. The epididymis and spermatic cord were normal. There was no inguinal lymphadenopathy. These findings are highly suspicious for testicular malignancy. I would urgently refer to urology and organise scrotal ultrasound with tumour markers including beta-hCG, AFP, and LDH."
"What is the most important differential for a painless testicular lump in a young man?"
Testicular malignancy — specifically seminoma (peak age 25-35) or non-seminomatous germ cell tumour (peak age 15-25). Any hard, non-tender, irregular mass arising from the testis in a man under 40 must be assumed malignant until proven otherwise and requires urgent urology referral. Never biopsy through the scrotum as this disrupts lymphatic drainage.
"How do you differentiate a hydrocele from a testicular tumour clinically?"
A hydrocele is a fluid collection around the testis: fluctuant, non-tender, transilluminates with a bright red glow, and you cannot get above it in the scrotum. A testicular tumour is a solid, hard, irregular mass arising from the testis proper: it does not transilluminate and does not separate from the testis on palpation. Ultrasound confirms the diagnosis.
"What is testicular torsion and how do you recognise it?"
Testicular torsion is twisting of the spermatic cord causing ischaemia of the testis. It presents with sudden onset severe testicular and scrotal pain in a young male. Signs include a high-riding horizontally orientated testis, absent cremasteric reflex, and severe tenderness. It is a urological emergency requiring surgical detorsion within 6 hours to preserve function.
"What do you find on examination of a varicocele and what is the clinical significance of a right-sided varicocele?"
A varicocele is dilated pampiniform plexus veins producing a soft, worm-like fullness above the testis that increases on Valsalva and disappears when the patient lies supine. Varicoceles occur predominantly on the left. A right-sided varicocele that does not decompress on lying flat should prompt investigation for a right-sided renal mass compressing the right renal vein.
Related guides: [Urology History OSCE](/blog/urology-history-osce) | [Hernia Examination OSCE](/blog/hernia-examination-osce) | [Abdominal Examination OSCE](/blog/abdominal-examination-osce)