What workup is recommended for a patient with a complaint of testicles feeling full and normal testosterone levels?

Evaluation of Testicular Fullness with Normal Testosterone Levels

For a patient complaining of testicular fullness with normal testosterone levels, a thorough urologic workup should focus on ruling out testicular malignancy, varicocele, epididymitis, and reproductive tract obstruction as these conditions can significantly impact morbidity and mortality.

Initial Evaluation

Physical Examination

• Careful testicular examination to assess:
  • Testicular size, consistency, and presence of masses 1
  • Presence and consistency of vasa and epididymides 1
  • Presence of varicocele 1
  • Signs of epididymal tenderness or swelling

Laboratory Evaluation

• Semen analysis (two samples at least one month apart) 1
  • Evaluates ejaculate volume, sperm concentration, motility, and morphology
  • Low volume (<1.5 mL) may indicate reproductive tract obstruction
• Post-ejaculatory urinalysis if ejaculate volume is less than 1 mL 1
  • To rule out retrograde ejaculation

Imaging Studies

Testicular Ultrasound

• Essential for evaluating testicular fullness 2
• Should determine:
  • Presence of intratesticular vs. extratesticular pathology
  • Presence of calcifications (which may indicate tumor)
  • Vascular flow assessment with color Doppler
  • Evaluation for varicocele

Transrectal Ultrasound (TRUS)

• Indicated if ejaculatory duct obstruction is suspected 1
• Particularly useful in patients with:
  • Low ejaculate volume
  • Palpable vasa
  • Normal testicular size

Additional Testing Based on Initial Findings

If Testicular Mass or Calcification Is Found

• Serum tumor markers 2, 1:
  • Alpha-fetoprotein (AFP)
  • Beta-human chorionic gonadotropin (β-hCG)
  • Lactate dehydrogenase (LDH)
• Complete blood count, liver enzymes, creatinine, and electrolytes 2

If Reproductive Tract Obstruction Is Suspected

• Follicle-stimulating hormone (FSH) level 1
  • Normal FSH with azoospermia suggests obstruction
  • Elevated FSH suggests primary testicular failure

If Infertility Is a Concern

• Reproductive health evaluation 1
  • Semen analysis
  • FSH measurement
  • Genetic testing if severe oligospermia (<5 million sperm/mL) or azoospermia 1

Differential Diagnosis to Consider

1. Varicocele: Common cause of testicular fullness, may require surgical correction if symptomatic
2. Epididymitis: May present with testicular fullness and discomfort
3. Testicular tumor: Critical to rule out due to mortality risk
4. Hydrocele: Fluid collection around testicle causing fullness
5. Spermatocele: Sperm-containing cyst in epididymis
6. Ejaculatory duct obstruction: Can cause sensation of fullness due to backup of seminal fluid

Management Approach

The management approach should be guided by the specific diagnosis:

1. If testicular mass or suspicious calcification is found:

   • Urgent urological referral for possible radical inguinal orchiectomy 1, 2
   • Sperm banking discussion prior to intervention 2

2. If varicocele is identified:

   • Consider surgical repair if symptomatic or associated with fertility issues

3. If ejaculatory duct obstruction is diagnosed:

   • Transurethral resection of ejaculatory ducts may be indicated

4. If no specific pathology is identified but symptoms persist:

   • Consider urological referral for further specialized evaluation

Important Caveats

• Testicular fullness with normal testosterone should never be dismissed as insignificant, as it may represent early testicular malignancy
• Isolated testicular microlithiasis without other abnormalities requires no further evaluation but patient education on testicular self-examination is recommended 2
• Focal intratesticular calcification or calcification with associated mass indicates surgical exploration 2
• Delay in diagnosis of testicular torsion or malignancy can significantly impact morbidity and mortality outcomes

Remember that early detection of testicular malignancy is critical for survival, making thorough evaluation of any testicular complaint essential, even when hormone levels are normal.