What is the evaluation and management approach for a patient presenting with a scrotal mass?

Evaluation and Management of Scrotal Masses

Any solid mass in the testis identified by physical exam or imaging should be managed as a malignant neoplasm until proven otherwise. 1

Initial Diagnostic Approach

Clinical Assessment

• Evaluate for risk factors:
  • History of cryptorchidism
  • Family history of testicular cancer
  • Personal history of testicular cancer
  • Testicular atrophy (volume <12 ml)
  • Age <40 years 2

Immediate Diagnostic Steps

1. Scrotal ultrasound with Doppler - Gold standard initial imaging test 1

   • High-frequency (>10 MHz) ultrasound should be performed 2
   • Nearly 100% sensitive for detection of intrascrotal masses 1
   • 98-100% accurate for distinguishing intratesticular from extratesticular masses 1
   • Assess for:
     • Solid vs. cystic components
     • Vascular flow patterns
     • Multiplicity of lesions
     • Contralateral testicular abnormalities 2

2. Serum tumor markers - Must be obtained before any treatment, including orchiectomy 1

   • Alpha-fetoprotein (AFP)
   • Human chorionic gonadotropin (hCG)
   • Lactate dehydrogenase (LDH) 1, 2
   • Note: Normal markers do not exclude testicular cancer (30-40% of testicular cancers have normal markers) 2

3. Fertility counseling

   • Discuss risks of hypogonadism and infertility 1
   • Offer sperm banking prior to orchiectomy, especially important if:
     • No normal contralateral testis
     • Known subfertility 1, 2

Management Algorithm Based on Ultrasound Findings

1. Intratesticular Solid Mass

• High suspicion for malignancy (approximately 90% of intratesticular masses are malignant) 3
• Management:
  • Radical inguinal orchiectomy with high ligation of spermatic cord at internal inguinal ring 2
  • Consider testis-sparing surgery only in specific situations:
    • Synchronous bilateral tumors
    • Tumor in solitary testis
    • Small tumors (<2 cm) with normal tumor markers 1, 2
    • Must be performed at experienced centers with intraoperative frozen section 1

2. Indeterminate Findings with Normal Tumor Markers

• Management:
  • Repeat ultrasound imaging in 6-8 weeks 1, 2
  • If persistent or growing, consider surgical exploration

3. Testicular Microlithiasis

• Management:
  • If isolated finding without solid mass or risk factors: No further evaluation needed 1
  • If accompanied by risk factors (cryptorchidism, prior testicular cancer, family history): Regular follow-up due to increased risk of germ cell tumor 2

4. Extratesticular Mass

• Usually benign (epididymal cysts, spermatoceles, hydroceles are most common) 3
• Management:
  • Conservative management for asymptomatic epididymal cysts or hydroceles 2
  • Surgical intervention if symptomatic or concerning features

5. Painful Scrotal Mass

• Urgent evaluation required to rule out testicular torsion 4
• Characteristics suggesting torsion: rapid onset, nausea/vomiting, high testicular position, abnormal cremasteric reflex 4
• If torsion suspected: immediate surgical exploration (must occur within 6 hours of symptom onset) 4
• If epididymitis/orchitis suspected: appropriate antibiotic therapy

Post-Orchiectomy Management (If Malignancy Confirmed)

• Depends on tumor stage, histology, and risk factors 2
• Options include:
  • Surveillance
  • Adjuvant radiotherapy
  • Single-agent carboplatin (for stage I seminoma)
  • Platinum-based chemotherapy regimens (for advanced disease) 2

Follow-Up Recommendations

• For testicular cancer: Regular follow-up including chest X-ray and clinical examination at 1 month, then every 3 months for 2 years, then every 6 months up to 5 years 2
• For benign conditions managed conservatively: Follow-up ultrasound at 6-8 weeks to ensure stability 2

Common Pitfalls to Avoid

1. Delaying diagnosis - Testicular cancer has excellent prognosis when diagnosed early (5-year survival approaches 100% for stage I disease) 2, 3

2. Using MRI as initial imaging - MRI should not be used for initial evaluation of testicular lesions 1

3. Failing to obtain tumor markers before orchiectomy - These are essential for staging and management 1

4. Misinterpreting ultrasound findings - No ultrasound criteria can definitively differentiate benign from malignant testicular lesions; all hypoechoic or inhomogeneous lesions should be considered suspicious 1

5. Performing transscrotal biopsy - This approach risks tumor seeding and is contraindicated 2

6. Neglecting fertility preservation - Sperm banking should be discussed before any surgical intervention 2