Weighty issue of fluid in the sacs

Dear Dr G,

I am a 35-year-old chap who exercises on a regular basis and eat very healthily.

I recent read an article you on the importance of doing regular medical check-ups. I am also aware men should really do examinations on regular basis, including self-examination of scrotal lesions.

I recently checked my own testicles and realised one of them was swollen.

The lump is quite painless, but it is getting bigger and now the right side is almost doubled in size.

I went to the doctors who assured me the lump is essentially a fluid in my sac.

I was asked to have an ultrasound to confirm this before a surgical intervention.

Truthfully, the lump is beginning to affect my life as it tends to get in the way during sexual intercourse.

I am worried and would like to put Dr. G on the spot for assurance about this fluid in my scrotal sac.

Why is fluid getting into my scrotal? Where is it coming from?

Can the ultrasound ascertain the lump is non-cancerous?

I am fearful this may be cancer and yet too scared to get the scan.

The doctors was asking me to consider operations as he thinks there is no chance of medicine making any difference.

I am really worried about this sudden increase in the size of my balls. Really hope you can help.

Yours truly,

Lumpy Leonard

A hydrocele is an accumulated fluid around the testicle resulting in testicular swelling. This is often caused by excessive fluid drained from the abdominal cavity, trapped by a layer around the testicle, called tunica vaginalis.

The accumulation of fluid in the scrotum can be congenital or acquired in nature. Hydrocele can arise spontaneously as primary hydrocele, developed in both childhood and adults particularly in older men.

The etiology of primary hydrocele is essentially unknown but thought that the accumulation of serous fluid is caused by the impaired absorption.

Secondary hydrocele is less common, when repeated infections, or cancer-induced occlusion of the lymphatic system results in accumulation of excessive fluid.

The second type of fluid accumulation in the scrotal sacs are epididymal cysts. This is a collection of serous fluid as a painless lump arising from the side of the testicle. Instead of surrounding the whole testicle, epididymal cysts arise from the sides of the testicles, therefore often felt separate from the rest of the testicle. These can be multiple and bilateral.

Epididymal cysts are very common with estimated incidence between 5-20% of adult population and rarely affects children.

The smaller cysts may remain undetected until they increase in size, raising concerns and necessity for medical attention.

Again the etiology of epididymal cysts is unknown, however it is thought the accumulation of excessive sperm in the testicular tubular systems is responsible.

Both the hydrocele and epididymal cysts are easily diagnosed in the clinical setting. One examination technique, described as trans-illumination, is to shine light on the scrotum, so the reflected light will demonstrate a fluid-filled structure.

On the other hand, the epididymis can easily be palpable with pearl-like characteristics. The definitive diagnosis for both these benign scrotal conditions is ultrasound scan.

Majority of men with hydrocele and epididymal cysts do not require surgical intervention, as the conditions are usually asymptomatic.

Occasionally, the enlarged scrotal sacs due to the fluids can result in pain during intercourse and even embarrassment with partners.

However, when the lesions become enlarged, the pressure sensation or the irritation of the stretched scrotal skin resulting in constant irritation may necessitate aspiration or surgical corrections.

Although needle aspiration of the cysts and hydrocele may be the simpler option, such method of extraction of fluid will result in recurrence over short interval. Simple surgical corrections are usually definitive.

The accumulation of fluid in the scrotum is very common. Both these conditions are benign in nature and unlikely to cause long-term complication. Although the changes in size of the testicles may be a sign of aging, this can raise concerns and anxiety, especially the fear of cancer. Although most testicular lumps may just be simple benign fluid-filled structures such as hydrocele and epididymal cysts, this still require proper diagnosis and reassurance. The English essayist and caricaturist Sir Max Beerbohm once said: “Some people are born to lift heavy weights, some are born to juggle golden balls.”

When men with strange lumps arising from the sac is putting Dr. G on the spot for opinion, his view is simply: “Do not juggle the heavy weight of anxiety of the abnormal balls, have the balls to get the golden balls checked out for proper diagnosis!”