The advanced practice registered nurse (APRN) is assessing a 17 year-old patient who presents with complaints of a nontender mass in the right scrotum, which "comes and goes" per patient report. During the physical exam of the genitalia, the APRN asks the patient to "cough". While the patient coughs, the APRN uses their index finger to assess the inguinal canal and notes a bulge touching the finger during coughing. What is the most likely cause of the mass?

Scrotal and inguinal masses in adolescents require careful physical examination to differentiate between infectious, congenital, and hernia-related causes. A mass that “comes and goes” and becomes more prominent with increased intra-abdominal pressure suggests a herniation of abdominal contents through the inguinal canal. The cough impulse test is a key diagnostic maneuver used to detect hernias. Findings such as a bulge felt against the examiner’s finger during coughing strongly indicate an indirect inguinal hernia. Rationale: A. Acute orchitis is an inflammatory condition of the testicle usually caused by viral or bacterial infection, commonly presenting with scrotal pain, swelling, tenderness, and sometimes fever. The affected testis is typically painful rather than nontender. It does not present as a reducible mass that changes with coughing or physical strain. B. Indirect inguinal hernia occurs when abdominal contents protrude through the deep inguinal ring into the inguinal canal and potentially into the scrotum. It often presents as a soft, intermittent, nontender mass that increases with coughing or straining due to increased intra-abdominal pressure. The presence of a bulge felt against the examiner’s finger during coughing is a classic positive cough impulse test confirming herniation. C. Acute epididymitis presents with scrotal pain, swelling, and tenderness, often associated with urinary symptoms or sexually transmitted infections in adolescents. The scrotum is usually erythematous and tender on palpation. It does not produce a reducible or intermittent mass that changes with coughing. D. Hypospadias is a congenital abnormality of the urethral meatus where the opening is located on the ventral surface of the penis rather than at the tip. It is identified at birth or early childhood and is unrelated to scrotal masses or hernias. It does not produce inguinal swelling or changes with coughing.