Uneven sac dragging me down

Dear Dr. G,

I am a 30-year-old man who works out regularly and has routine check-ups, which includes testicular self-examination.

I recently noticed a lump on my right testicle. It is painless but has grown to almost the size of the testicle itself, giving me a lopsided appearance.

Aware of the risk of testicular cancer, I visited a doctor who told me the lump was fluid build-up in my sac. I was asked to have an ultrasound to rule out other causes of swelling.

My urologist said surgery is the only treatment.

I am relieved it wasn't cancer but I am puzzled how fluid can accumulate down there.

Where is it coming from? Is an ultrasound sufficient to determine what the lump is?

Lastly, I'm worried if the operation will affect my sexual performance or fertility.

Please help, I'm terrified!

Yours truly,

Saggy Sam

The accumulation of fluid in the scrotum is very common. A hydrocele is fluid around the testicle that causes swelling, often due to excessive fluid from the abdominal cavity, trapped by a layer around the testicle called the tunica vaginalis.

There are two types of hydroceles: primary and secondary. Primary hydroceles can develop in both childhood and adulthood, especially in older men, and are thought to be caused by impaired fluid absorption. Secondary hydroceles are less common and result from repeated infections or cancer-induced occlusion of the lymphatic system. The prevalence of hydroceles can be as high as 20% in a general population and its incidence increases with age.

Epididymal cysts, on the other hand, are painless lumps caused by excess fluid in the epididymis alongside the testicle. These can be unilateral or bilateral, solitary or multiple, and vary in size. They are usually separate from the testicle and often go unnoticed until they grow larger.

Again, its aetiology is unknown, but is thought to be from the accumulation of excessive sperm in the testicular tubular system.

Both hydroceles and epididymal cysts are benign and do not pose a risk of progressing to cancer. However, fluid can accumulate quickly without any clear reason.

They are easily diagnosed, with one method being trans-illumination, where light is shined on the scrotum to show the fluid-filled structure. However, the definitive diagnosis is to have an ultrasound scan.

Most men with hydroceles and epididymal cysts are asymptomatic and do not require surgery. But if the swelling causes discomfort, aspiration or surgery may be necessary. Although needle aspiration (removal of the fluid only) is simpler, it often leads to recurrence.

Hydroceles and epididymal cysts do not typically cause sexual dysfunction. However, a large amount of fluid accumulation can cause discomfort and pain during intercourse, or worse, impair the act itself!

Simple surgical correction is usually definitive. It may cause temporary inconvenience but is better for the long term.