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

Management Approach for Scrotal Mass

Any solid mass in the testis should be managed as a malignant neoplasm until proven otherwise, with immediate referral for high-frequency scrotal ultrasound with Doppler and measurement of serum tumor markers. 1

Initial Evaluation

1. Scrotal Ultrasound with Doppler

   • Gold standard initial imaging with nearly 100% sensitivity for detection of intrascrotal masses 1
   • Distinguishes intratesticular from extratesticular masses with 98-100% accuracy 1
   • Determines size, multiplicity, and characteristics of the lesion 1
   • Evaluates the contralateral testicle 1

2. Laboratory Testing

   • Serum tumor markers must be obtained before any treatment, including orchiectomy 1:
     • Alpha-fetoprotein (AFP)
     • Human chorionic gonadotropin (hCG)
     • Lactate dehydrogenase (LDH)
   • Complete blood count, creatinine, electrolytes, and liver enzymes 2
   • Note: Normal serum tumor markers do not exclude testicular cancer (30-40% of testicular cancers have normal markers) 1

3. Additional Imaging

   • Chest radiograph 2
   • If testicular cancer is confirmed: abdominopelvic CT scan to assess retroperitoneal nodes 2
   • Chest CT if abdominopelvic CT shows retroperitoneal adenopathy or abnormal chest radiograph 2

Management Algorithm

For Intratesticular Mass

1. Fertility Counseling

   • Discuss sperm banking before any intervention 2, 1
   • Especially important with no normal contralateral testis or known subfertility 1

2. Surgical Management

   • Standard approach: Radical inguinal orchiectomy 2, 1

     • Performed through an inguinal incision
     • Tumor-bearing testis resected with spermatic cord at level of internal inguinal ring

   • Testis-sparing surgery considerations (limited cases) 1:

     • Synchronous bilateral tumors
     • Tumor in solitary testis
     • Small tumors (<2 cm) with normal tumor markers
     • Must be performed at experienced centers with intraoperative frozen section

3. Post-orchiectomy Management

   • Based on histology (seminoma vs. nonseminoma) and stage 2, 1
   • Options include surveillance, adjuvant radiotherapy, or chemotherapy 1

For Extratesticular Mass

• Generally benign but requires proper characterization 3
• Management depends on specific diagnosis:
  • Epididymitis/orchitis: Antibiotics, anti-inflammatory medications 4
  • Hydrocele: Observation or surgical repair if symptomatic
  • Varicocele: Observation or intervention based on symptoms and fertility concerns
  • Inguinal hernia: Surgical repair, emergent if strangulated 4

Important Clinical Considerations

• Testicular cancer has excellent prognosis when diagnosed early, with five-year survival rates approaching 100% for stage I disease 1

• Diagnostic accuracy is critical: 44% of final clinical diagnoses differ between primary care physicians and specialist practitioners 5

• Painful scrotal masses require urgent evaluation to rule out testicular torsion, which requires surgical intervention within 6 hours of symptom onset 4

• Characteristics suggesting testicular cancer vs. benign conditions:

  • Malignancy: Firm, painless intratesticular mass
  • Epididymitis: Gradual onset of pain, increased blood flow on ultrasound 4

• Patient education on testicular self-examination is crucial for early detection 1

Common Pitfalls to Avoid

1. Misdiagnosis: Testicular cancer may be misdiagnosed as epididymitis - ultrasound is essential for accurate diagnosis 6

2. Delayed Referral: Patients with suspected testicular cancer should be referred under expedited pathways (e.g., 2-week rule) 5

3. Overlooking Tumor Markers: Obtain serum tumor markers before any intervention, including orchiectomy 2, 1

4. Neglecting Fertility Concerns: Sperm banking must be discussed before any therapeutic intervention 2, 1

5. Inadequate Follow-up: Regular post-treatment surveillance is essential to detect recurrence early 1