From the Guidelines
The workup for a 63-year-old man with left testicular pain and a mass present for one month should begin with a thorough history and physical examination, followed by urgent urological referral due to concern for testicular cancer. Initial evaluation should include scrotal ultrasound with Doppler to characterize the mass and assess blood flow, as recommended by the American College of Radiology Appropriateness Criteria 1. Laboratory tests should include complete blood count, comprehensive metabolic panel, and tumor markers including alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH), as suggested by the American Urological Association guideline 1. Some key points to consider in the workup and management of testicular cancer include:
- Scrotal ultrasound with Doppler is the diagnostic modality of choice for evaluating testicular masses 1
- Serum tumor markers, including AFP, β-hCG, and LDH, should be measured before orchiectomy to support the diagnosis of testicular cancer 1
- Inguinal orchiectomy is the primary treatment for most patients with a suspicious testicular mass, and it has both diagnostic and therapeutic aims 1
- Staging with CT scan of the abdomen and pelvis with contrast and chest imaging (X-ray or CT) should be performed if malignancy is suspected 1
- The definitive treatment typically involves radical inguinal orchiectomy (surgical removal of the affected testicle) for both diagnosis and treatment, as fine-needle aspiration is contraindicated due to the risk of tumor seeding 1
- Prompt evaluation is essential, as testicular cancer can grow rapidly, but it is highly treatable when caught early, with excellent survival rates even in advanced disease 1
From the Research
Workup for Testicular Pain and Mass
The workup for a 63-year-old man with left testicular pain and a testicular mass present for 1 month involves several steps:
- A thorough physical examination to determine whether the lump is intra- or extra-testicular, as palpable intra-testicular lesions are highly likely to be malignant 2
- Laboratory tests, such as C-reactive protein level, to help differentiate between possible causes like epididymitis/orchitis and testicular torsion 3
- Scrotal ultrasound to confirm the diagnosis and to evaluate the mass, as Doppler ultrasonography can help identify testicular torsion or other conditions 3
- Referral to a urologist if ultrasonography shows an intratesticular mass, as timely referral is indicated for testicular malignancies 3
- Consideration of other possible causes, such as inguinal hernias, hydrocele, varicocele, and scrotal skin lesions, which may require different management approaches 3
Possible Causes and Management
Possible causes of testicular pain and mass include:
- Testicular cancer, which is rare but has a high survival rate if diagnosed early 2
- Epididymal cysts or spermatoceles, which are common and usually benign 2
- Hydrocele, which is a fluid collection between the parietal and visceral layers of the tunica vaginalis 2
- Testicular torsion, which requires urgent evaluation and surgical intervention 3
- Testicular granulomatous vasculitis, which is uncommon and can be misdiagnosed 4
- Metastatic cancer, such as colon cancer, which can present as a testicular mass 5
Diagnostic Approach
The diagnostic approach should involve a combination of physical examination, laboratory tests, and imaging studies to determine the cause of the testicular pain and mass. A careful assessment of testicular and extratesticular causes is essential, and relief of symptoms may not always be possible 6.