Hypospadias, in which the urethra opens on the underside of the penis, is infrequently seen (Fig. 40-9). However, it is important that hypospadias is recognized early, preferably at the initial newborn examination. It can occur with or

Table 40-4 Selected Differential Diagnosis of Scrotal Masses with Physical Findings


Physical Finding

Epididymitis, orchitis

Tender mass



Inguinal hernia

Does not transilluminate

Testicular torsion

Pain and loss of cremasteric reflex

Torsion of the appendix testis

Blue dot sign


Tender scrotum, edema, trauma history


Solid mass


Nontender cystic mass


Bag of worms appearance

Figure 40-9 Hypospadias. (From Borer JG, RetikAB. Hypospadias. In Wein AJ[ed]. Campbell-Walsh Urology, 9th ed, vol IV, Philadelphia, Elsevier, 2007.)

without chordee (curvature). Circumcision should be withheld and a urology consultation obtained. Hypospadias must be differentiated from ambiguous genitalia, which implies an intersex disorder. Epispadias, in which the meatus is located on the dorsal surface of the penis, is uncommon and is usually associated with extrophy of the bladder.

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