What is the initial workup for a patient presenting with a painless scrotal mass?

Workup for Painless Scrotal Mass

Ultrasound of the scrotum (either standard or duplex Doppler) is the definitive initial imaging test for evaluation of a painless scrotal mass. 1, 2

Initial Assessment

Clinical Evaluation

• Perform targeted examination of:
  • Both testes
  • Abdomen
  • Supraclavicular fossae
  • Chest (to identify gynaecomastia)
  • Determine if mass is testicular or extratesticular

Laboratory Testing

• Serum tumor markers:
  • Alpha-fetoprotein (AFP)
  • Human chorionic gonadotropin (hCG)
  • Lactate dehydrogenase (LDH)
  • These support diagnosis and may indicate germ cell tumor histology 1

Imaging Approach

Primary Imaging

• High-frequency (>10 MHz) scrotal ultrasound with color/power Doppler 1, 2
  • Determines if mass is intratesticular or extratesticular (98-100% accuracy) 1
  • Evaluates size, characteristics, and presence of multifocal disease
  • Assesses contralateral testicle
  • Nearly 100% sensitive for detection of intrascrotal masses 1

Ultrasound Findings Interpretation

• Intratesticular masses: Consider malignant until proven otherwise

  • Hypoechoic or inhomogeneous patterns are suspicious for malignancy 1
  • Seminomas often appear homogeneously hypoechoic
  • Nonseminomatous germ cell tumors typically appear nonhomogeneously hypoechoic with areas of calcification/necrosis 1

• Extratesticular masses: Usually benign

  • Common findings include hydrocele, varicocele, epididymal cyst

Management Algorithm Based on Ultrasound Results

1. Intratesticular solid or mixed cystic lesion:

   • Requires additional imaging or surgical exploration 1
   • Inguinal orchidectomy is standard approach for suspected testicular cancer 1
   • Testis-sparing surgery only for select cases (single testicle, tumor <2cm, lower pole location) 1

2. Extratesticular lesion:

   • Most are benign and can be managed conservatively
   • Follow-up ultrasound may be indicated

3. Indeterminate lesions:

   • Consider MRI in select cases where ultrasound cannot definitively determine if mass is intratesticular or extratesticular 1
   • MRI may aid in distinguishing benign from malignant testicular masses 1

Important Considerations

• Ultrasound alone cannot always definitively differentiate benign from malignant testicular lesions 1
• Tumor markers have limitations due to low sensitivity; normal levels do not exclude disease 1
• Nuclear medicine scans are not routinely used for initial evaluation of painless scrotal masses 1
• The American College of Radiology recommends ultrasound as the initial and often only imaging technique needed prior to surgery 1

Pitfalls to Avoid

• Do not perform scrotal approach for orchidectomy (higher local recurrence rate) 1
• Do not rely solely on tumor markers for diagnosis (limited sensitivity) 1
• Do not assume extratesticular masses are always benign; some require further evaluation
• Do not delay imaging for intratesticular masses, as testicular cancer requires prompt treatment

By following this algorithm, clinicians can efficiently evaluate painless scrotal masses and determine appropriate management to optimize patient outcomes.