What is the next step in evaluating a 29-year-old male with intermittent bilateral dull testicular pain, a family history of testicular cancer and thyroid disease, and a small left epididymal cyst?

Evaluation of Testicular Pain with Family History of Testicular Cancer

For a 29-year-old male with intermittent bilateral testicular pain, a small left epididymal cyst, and family history of testicular cancer, the next step should be scrotal ultrasound with Doppler, serum tumor markers (AFP, hCG, LDH), and sperm banking counseling prior to any interventions.

Initial Diagnostic Workup

Imaging

• Scrotal ultrasound with Doppler is the gold standard initial imaging test with nearly 100% sensitivity for detection of intrascrotal masses 1
  • Already planned in this case and appropriate as first-line imaging
  • High-frequency (>10 MHz) ultrasound helps determine if masses are intratesticular or extratesticular 1
  • Will help characterize the known left epididymal cyst and evaluate for any occult testicular masses

Laboratory Testing

• Serum tumor markers must be obtained:
  • Alpha-fetoprotein (AFP)
  • Human chorionic gonadotropin (hCG)
  • Lactate dehydrogenase (LDH) 2, 1
• These markers should be drawn before any treatment, including potential orchiectomy 2
• Important caveat: Normal serum tumor markers do not exclude testicular cancer, as 30-40% of patients with testicular cancer have normal markers 1
• Additional baseline labs: Complete blood count, creatinine, electrolytes, and liver enzymes 1

Risk Factor Assessment

This patient has significant risk factors that warrant thorough evaluation:

• Family history of testicular cancer (brother) is a known risk factor 1
• Age <40 years is another risk factor 1

Management Considerations

Fertility Preservation

• Offer sperm banking counseling prior to any interventions, especially given the family history of testicular cancer 2, 1
• Discuss risks of hypogonadism and infertility that could result from potential treatments 2

Differential Diagnosis

• Epididymal cysts are common (27% of scrotal masses) and typically benign 3
• However, the presence of risk factors (family history) increases concern for potential malignancy
• Bilateral pain is less typical for testicular cancer but doesn't exclude it

Follow-up Plan

• If ultrasound confirms only an epididymal cyst with no intratesticular lesions and tumor markers are normal:

  • Consider repeat imaging in 6-8 weeks as recommended for indeterminate findings 2
  • For asymptomatic epididymal cysts, clinical follow-up to document stability is justified 4
  • For symptomatic cysts, surgical excision may be considered 4

• If ultrasound reveals any intratesticular mass:

  • Urgent referral to urology for consideration of inguinal orchiectomy 2, 1
  • Additional imaging (abdominopelvic CT) would be indicated if testicular cancer is confirmed 1

Important Considerations

• Palpable intratesticular lesions have approximately 90% likelihood of malignancy, whereas extratesticular lesions (like epididymal cysts) are usually benign 3
• Testicular microlithiasis alone does not require further evaluation unless accompanied by other risk factors (like family history) 2, 1
• Patient education on testicular self-examination is crucial 1
• MRI should not be used as initial evaluation for testicular lesions 2

Pitfalls to Avoid

• Don't dismiss testicular pain in young men, especially with family history of testicular cancer
• Don't rely solely on normal tumor markers to exclude malignancy
• Don't delay appropriate imaging and urological consultation when risk factors are present
• Don't forget fertility preservation counseling before any interventions