What is the initial evaluation and management for a male presenting with a suprapubic mass?

Initial Evaluation and Management of Suprapubic Mass in Males

The initial evaluation of a male presenting with a suprapubic mass should include urinalysis, imaging with ultrasound, and consideration of cystoscopy as these masses should be managed as potentially malignant until proven otherwise. 1

Diagnostic Approach

Initial Assessment

• Obtain a complete medical history focusing on urinary symptoms, duration of the mass, and risk factors for urological conditions 1
• Perform physical examination including digital rectal examination to assess prostate characteristics and any palpable masses 1
• Conduct urinalysis to evaluate for infection, hematuria, or other abnormalities 1

Imaging Studies

• Perform transabdominal or transrectal ultrasound as the first-line imaging modality for evaluation of a suprapubic mass 1
• Ultrasound can effectively differentiate between cystic and solid masses, assess vascularity, and determine relationship to surrounding structures 1
• For solid masses, ultrasound with Doppler should be obtained to assess vascularity which may suggest malignancy 1

Laboratory Testing

• Measure serum tumor markers if testicular involvement is suspected, including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) 1
• Assess renal function if hydronephrosis is present or if surgical intervention is being considered 1
• Measure post-void residual volume to evaluate for urinary retention 1

Differential Diagnosis

Urological Causes

• Bladder distention due to urinary retention (most common cause of a suprapubic mass) 2
• Bladder cancer (particularly if hematuria is present) 1
• Prostatic enlargement (benign prostatic hyperplasia or prostate cancer) 1
• Urethral stricture with secondary bladder distention 2

Non-Urological Causes

• Abdominal wall tumors (primary or metastatic) 3, 4
• Ectopic or wandering spleen (rare) 5
• Retrovesical masses (seminal vesicle cysts, prostatic utricle cysts, sarcomas) 6

Management Algorithm

For Suspected Urinary Retention

1. Perform bladder scan or straight catheterization to confirm and quantify retention 2
2. If confirmed, proceed with immediate bladder decompression via urethral catheterization 2
3. Consider alpha-blocker therapy (e.g., tamsulosin) prior to catheter removal to improve chances of successful voiding 2
4. Evaluate for underlying cause (BPH, neurological conditions, medications, constipation) 2

For Suspected Malignancy

1. If solid mass is identified on ultrasound, consider:

   • Cystoscopy to evaluate for bladder involvement 1
   • CT or MRI for further characterization and staging 1
   • Biopsy for definitive diagnosis if mass is accessible 6

2. For suspected testicular involvement:

   • Scrotal ultrasound with Doppler is essential 1
   • Obtain serum tumor markers (AFP, hCG, LDH) prior to any intervention 1
   • Consider inguinal orchiectomy or testis-sparing surgery with frozen section analysis for definitive diagnosis 1

For Suspected Infection

1. Obtain urine culture 1
2. Initiate empiric antibiotics based on clinical presentation 1
3. Drain any abscess if identified 6

Special Considerations

• Long-term indwelling catheters (particularly suprapubic catheters) increase risk for squamous cell carcinoma at the catheter site 3, 4, 7
• Patients with spinal cord injury are at increased risk for bladder malignancy and require vigilant monitoring 4
• Retrovesical masses in men often require exploratory laparotomy and histopathological examination for definitive diagnosis 6
• Testicular microlithiasis without a solid mass does not require further evaluation unless other risk factors are present 1

Follow-up Recommendations

• For patients with urinary retention who successfully void after catheter removal, inform them about increased risk for recurrent retention 2
• For indeterminate masses with normal tumor markers, consider repeat imaging in 6-8 weeks 1
• For patients requiring long-term catheterization, regular follow-up is essential to assess for complications including infection, stone formation, and malignancy 2, 4