What is the initial workup for a patient presenting with a testicular mass and pain?

Initial Workup for Testicular Mass and Pain

A scrotal ultrasound with Doppler should be the first diagnostic test for any patient presenting with a testicular mass and pain, followed by serum tumor markers (AFP, hCG, LDH) prior to any treatment. 1

Diagnostic Algorithm

Step 1: Imaging

• Scrotal ultrasound with Doppler (high-frequency >10 MHz) 1
  • Evaluates whether mass is intratesticular or extratesticular
  • Assesses size, echogenicity, vascularity, and contralateral testis
  • Detects hypoechoic mass with vascular flow (highly suggestive of malignancy)
  • Nearly 100% sensitive for detection of intrascrotal masses 1
  • Can differentiate between traumatic, infectious, and neoplastic causes

Step 2: Laboratory Testing

• Serum tumor markers (must be drawn BEFORE orchiectomy) 1

  • Alpha-fetoprotein (AFP)
  • Human chorionic gonadotropin (hCG)
  • Lactate dehydrogenase (LDH)
  • Note: Normal levels do not exclude malignancy (limited sensitivity) 1

• Additional laboratory tests if infection suspected:

  • Complete blood count
  • Urinalysis
  • STI testing (particularly for N. gonorrhoeae and C. trachomatis) 2

Step 3: Clinical Decision Making

Based on ultrasound findings and tumor markers:

1. Solid intratesticular mass with abnormal tumor markers:

   • High suspicion for testicular cancer
   • Requires urgent urological consultation for radical inguinal orchiectomy 1, 2

2. Solid intratesticular mass with normal tumor markers:

   • Still consider malignant until proven otherwise
   • Urological consultation for likely inguinal orchiectomy 1
   • For small (<2 cm) or indeterminate masses, testis-sparing surgery may be considered 1

3. Indeterminate findings with normal tumor markers:

   • Repeat imaging in 6-8 weeks 1

4. Signs of infection (epididymitis/orchitis):

   • Antibiotics and supportive measures (scrotal elevation, rest) 2
   • Follow-up ultrasound to ensure resolution

5. Signs of testicular torsion:

   • Urologic emergency requiring immediate surgical exploration
   • Salvage rates >90% if surgery within 6 hours of symptom onset 2

Important Considerations

• Fertility preservation: Offer sperm banking before orchiectomy 1
• Avoid scrotal approach: Inguinal approach is mandatory if cancer is suspected 1
• Avoid MRI as initial evaluation: Not recommended for initial diagnosis of testicular lesions 1
• Testicular microlithiasis: Does not require further evaluation unless other risk factors are present 1
• Small masses: 50-80% of non-palpable or incidentally detected masses <2 cm may be benign 1

Pitfalls to Avoid

1. Delaying ultrasound: Prompt imaging is essential, especially when torsion is suspected
2. Missing tumor markers: Must be obtained BEFORE any surgical intervention 1
3. Scrotal approach: Increases risk of local recurrence in testicular cancer 1
4. Assuming pain rules out cancer: While testicular cancer often presents as painless mass, pain does not exclude malignancy 2
5. Relying solely on physical exam: Ultrasound is necessary to confirm location and characteristics of mass 3

Follow-up

• For suspected cancer: Staging with CT abdomen/pelvis after orchiectomy
• For infection: Clinical reassessment after antibiotic course
• For indeterminate masses: Repeat ultrasound in 6-8 weeks 1
• For trauma-related findings: Follow-up ultrasound in 2-4 weeks to ensure resolution 4

Remember that any solid mass in the testis should be managed as malignant until proven otherwise, and prompt urological consultation is essential for optimal outcomes 1.