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Testicular Examination for MRCS Part B: Scrotal Lumps and What They Mean

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

Examine the scrotum standing then supine: inspect, palpate both testes and epididymes, ask whether you can get above the lump, test for a cough impulse, transilluminate, and examine the groin nodes and abdomen.

Examine the scrotum with the patient standing and then supine. Inspect, palpate both testes and both epididymes, then answer three questions about any lump: can you get above it, does it have a cough impulse, and does it transilluminate. Those three answers give you the diagnosis.

Key takeaways

Scrotal examination is an intimate examination, so explain it, gain consent and offer a chaperone.
If you cannot get above the lump it is an inguinoscrotal hernia until proved otherwise.
A lump that transilluminates and surrounds the testis is a hydrocele.
A lump separate from and above the testis is epididymal.
NICE NG12 says to consider a suspected cancer pathway referral for a non-painful enlargement or change in shape or texture of the testis.

How is this station marked in MRCS Part B?

A physical examination station is marked out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication, and professionalism carry 4 marks each. The examiner also gives the station a separate global rating of pass, borderline or fail.

Two things follow from that split. More than half the marks sit outside your knowledge of the condition, so a silent, technically correct examination scores poorly. And you are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

How do I start the testicular examination?

Wash your hands in view of the examiners, introduce yourself, explain that you need to examine the scrotum and why, and gain verbal consent.

The GMC guidance on intimate examinations asks you to explain what the examination involves, to say that the patient can ask you to stop at any time, and to offer a chaperone and explain their role. Expose from the waist down and keep the patient covered when you are not examining.

Why examine the patient standing first?

Because a varicocele and a small reducible hernia both disappear on lying down. Inspect the scrotum from the front and the side while the patient stands, lifting the scrotum to see its posterior surface.

Scrotal size, symmetry and skin changes including sebaceous cysts, ulceration and sinuses.
An obvious swelling, and whether it is focal or involves the whole hemiscrotum.
Scars in the groin or scrotum from previous surgery.
The classic bag of worms appearance of a varicocele.

How do I palpate the scrotum?

Ask about pain, then palpate the normal side first so the patient knows what to expect and you have a comparison.

Palpate each testis between thumb and forefinger, assessing size, consistency, surface and tenderness.
Identify the epididymis running along the posterolateral aspect of each testis.
Trace the spermatic cord up to the external ring.
Decide whether any lump is part of the testis, separate from it, or surrounding it.

Can you get above the lump, and why does it matter?

Try to bring your finger and thumb together above the swelling and below the external ring. If you can, the swelling arose in the scrotum. If you cannot, it is coming down from the inguinal canal and is an inguinoscrotal hernia until proved otherwise.

Ask the patient to cough while you palpate. An expansile cough impulse supports a hernia, and the swelling of a hernia typically reduces or disappears when the patient lies down.

What does transillumination show?

Hold a pen torch against one side of the swelling in a darkened bay and look from the opposite side. A fluid-filled swelling glows and a solid one does not.

A swelling that transilluminates and surrounds the testis, so that the testis cannot be felt separately, is a hydrocele.
A swelling that transilluminates and lies separate from and above the testis is an epididymal cyst or spermatocele.
A solid, craggy swelling arising from the body of the testis that does not transilluminate must be treated as a tumour until proved otherwise.

How do I complete the examination?

Lie the patient down and repeat inspection and palpation, noting whether the swelling changes.
Palpate the inguinal lymph nodes, which drain the scrotal skin.
Say that testicular lymphatic drainage is to the para-aortic nodes, so you would examine the abdomen rather than expect inguinal nodes in testicular cancer.
Offer a full abdominal examination, and examination of the chest and breasts if a germ cell tumour is suspected.
Cover the patient, thank them, wash your hands and present.

What should I say about referral and investigation?

Name the NICE NG12 recommendations. Recommendation 1.6.7 is to consider a suspected cancer pathway referral for a non-painful enlargement or change in shape or texture of the testis, and 1.6.8 is to consider an urgent direct access ultrasound scan for unexplained or persistent testicular symptoms.

Add that acute severe testicular pain with a high-riding or transversely lying testis is a suspected torsion and needs immediate surgical exploration rather than imaging.

What are the most common mistakes at this station?

Examining only the abnormal side, so there is no comparison.
Never trying to get above the lump, which is the single most useful manoeuvre.
Failing to offer a chaperone before exposure.
Looking for inguinal nodes to stage a testicular tumour rather than saying para-aortic.
Ordering imaging in a suspected torsion instead of calling for theatre.

MRCS Part B Questions has a scrotal examination station with a marked checklist at /Sample-Questions. Reviewed and updated 15 September 2026.

Key evidence

Suspected cancer: recognition and referral (NG12), recommendations by site of cancer — NICE (2023)
Intimate examinations and chaperones — General Medical Council (2024)
Clinical Methods, 3rd edition: Inguinal Canal and Hernia Examination — NCBI Bookshelf (1990)

FAQ

What does it mean if you cannot get above a scrotal lump?

It means the swelling is continuous with the contents of the inguinal canal rather than arising within the scrotum, so an inguinoscrotal hernia is the working diagnosis. Confirm it by looking for a cough impulse and by seeing whether the swelling reduces when the patient lies flat.

Does a hydrocele always transilluminate?

Usually, but not reliably in every case. A long-standing hydrocele with a thickened sac, or one containing blood or infected fluid, may transilluminate poorly. If a swelling does not transilluminate and the testis cannot be felt separately, say that an ultrasound scan is needed to exclude an underlying tumour.

How do I tell a testicular from an epididymal lump?

Locate the epididymis first, running along the posterolateral surface of the testis, then decide whether the lump is part of that structure or part of the testis itself. A lump you can clearly separate from the testis is usually benign, while a lump arising within the body of the testis is a tumour until proved otherwise.

Where do testicular tumours spread to?

The testis drains to the para-aortic lymph nodes, following its embryological origin, whereas the scrotal skin drains to the inguinal nodes. That is why you examine the abdomen rather than the groin when staging a suspected testicular tumour, and why inguinal nodes suggest scrotal skin pathology instead.

Should I examine a suspected torsion?

Examine gently and briefly, then act. Acute severe pain of sudden onset with a swollen, high-riding or horizontally lying testis is a torsion until proved otherwise, and the correct answer is immediate surgical exploration. Imaging that delays exploration costs the testis and costs marks.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

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