What is the treatment for an enlarged testicle (testicular enlargement)?

Treatment Approach for Testicular Enlargement

The primary treatment for testicular enlargement depends on the underlying cause, with radical inguinal orchiectomy being the standard treatment for suspected testicular cancer, which is the most concerning cause of testicular enlargement. 1

Initial Diagnostic Evaluation

A thorough diagnostic workup is essential before determining treatment:

1. Testicular Ultrasound: High-frequency (>10 MHz) ultrasound is the first-line imaging to determine if the mass is intratesticular or extratesticular 1

   • Assess size, multiplicity, and characteristics of the lesion
   • Evaluate the contralateral testicle

2. Serum Tumor Markers:

   • Alpha-fetoprotein (AFP)
   • Human chorionic gonadotropin (hCG)
   • Lactate dehydrogenase (LDH) 1, 2

3. Additional Testing:

   • Complete blood count, liver enzymes, creatinine, and electrolytes if malignancy is suspected 2
   • Chest X-ray if testicular cancer is suspected 1

Treatment Algorithm Based on Diagnosis

1. Suspected Testicular Cancer

• Radical Inguinal Orchiectomy: Standard treatment for suspected testicular malignancy 1

  • Performed through an inguinal incision
  • Spermatic cord is divided at the internal inguinal ring
  • Avoid scrotal approach as it increases local recurrence risk 1
  • Sperm banking should be discussed before surgery 1, 2

• Post-Orchiectomy Management:

  • Further treatment depends on histology (seminoma vs. non-seminoma) and stage
  • May include surveillance, radiotherapy, or chemotherapy 1

2. Small Testicular Masses with Consideration for Organ Preservation

• Testis-Sparing Surgery: May be considered in specific circumstances 1:

  • Single testicle
  • Excellent compliance for follow-up
  • Single tumor <2 cm located at lower pole
  • Normal preoperative endocrine function
  • Small or indeterminate testicular masses with negative tumor markers

• Frozen Section Analysis: Should be performed intraoperatively to differentiate malignant from benign lesions 1

3. Benign Conditions

• Epididymitis/Orchitis:

  • Trial of antibiotics if infectious etiology is suspected 1
  • Follow-up ultrasound to ensure resolution

• Hydrocele/Varicocele:

  • Surgical repair if symptomatic or causing testicular atrophy

• Testicular Torsion:

  • Immediate surgical exploration and detorsion
  • Orchiopexy of the affected and contralateral testicle 3

Special Considerations

Fertility Preservation

• Discuss sperm banking before any surgical intervention, especially with bilateral involvement 2
• Assess hormonal function (testosterone, LH, FSH) before treatment 1

Contralateral Testis Evaluation

• Consider biopsy of the contralateral testis in high-risk patients:
  • Testicular volume <12 ml
  • History of cryptorchidism
  • Age <40 years 1

Follow-up After Treatment

• For stage I disease after orchiectomy:
  • Chest X-ray and clinical examination at 1 month
  • Then every 3 months for 2 years
  • Then every 6 months up to 5 years 1

Common Pitfalls and Caveats

1. Delayed Diagnosis: Any persistent testicular mass or swelling warrants prompt evaluation, as delay in diagnosis correlates with higher stage at presentation 1

2. Misdiagnosis as Infection: Testicular cancer may initially present with discomfort mimicking epididymitis/orchitis. Persistent symptoms despite antibiotics require ultrasound evaluation 1

3. Scrotal Violation: Avoid scrotal approach for suspected testicular tumors as this increases risk of local recurrence 1

4. Normal Tumor Markers: Normal serum tumor markers do not exclude the presence of testicular cancer; approximately 30-40% of patients with testicular cancer have normal markers 1

5. Benign Testicular Enlargement in Adolescents: Transitory unilateral testicular enlargement can occur during puberty and may not require intervention 4, 5

By following this structured approach to testicular enlargement, appropriate treatment can be initiated promptly, maximizing the chance for cure while preserving fertility and hormonal function when possible.