What is the next step in managing testicular stones (testicular microlithiasis)?

Management of Testicular Microlithiasis

Testicular microlithiasis in the absence of solid mass and risk factors for developing germ cell tumor does not require further evaluation beyond routine testicular self-examination. 1

Definition and Diagnosis

• Testicular microlithiasis (TM) is characterized by multiple small echogenic non-shadowing foci (>5) in the testis on ultrasound examination 1, 2
• TM represents calcium deposits within the seminiferous tubules and has a reported prevalence ranging from 0.6% to 9% in the general population 2

Risk Assessment

Low-Risk Patients (No Further Evaluation Required):

• Isolated testicular microlithiasis with no associated risk factors 1, 3
• Normal physical examination with no palpable testicular mass 1
• Normal serum tumor markers (AFP, hCG, LDH) 1

High-Risk Patients (Requiring Follow-up):

• Personal history of germ cell tumor 3
• Family history of testicular cancer 3
• History of cryptorchidism (undescended testis) 3
• Prior orchidopexy 3
• Testicular atrophy (volume <12 ml) 1, 3
• Presence of a solid testicular mass 1
• Known germ cell neoplasia in situ (GCNIS) 4

Management Algorithm

For Low-Risk Patients:

1. No routine follow-up ultrasound is recommended 1, 3
2. Patient education on regular testicular self-examination 2
3. Standard age-appropriate urological care 1

For High-Risk Patients:

1. Annual ultrasound follow-up until age 55 3
2. Regular testicular self-examination 2
3. Consider serum tumor markers if clinical suspicion arises 1

For Patients with TM and Concurrent Testicular Mass:

1. Immediate referral to specialist center 3
2. Obtain serum tumor markers (AFP, hCG, LDH) 1
3. Radical inguinal orchiectomy is typically indicated for solid testicular masses 1

Special Considerations

• The association between TM and testicular cancer remains controversial, with reported associations ranging from 6-46% 2, 5
• More recent studies suggest both TM and testicular germ cell tumors may result from a common underlying tubular degeneration rather than TM being premalignant itself 2
• Testicular biopsy is not routinely recommended for isolated TM without other risk factors 2, 3
• In patients with TM in an undescended testis, orchidopexy or orchiectomy may be considered depending on age and other factors 6

Common Pitfalls to Avoid

• Overdiagnosis and unnecessary follow-up imaging in patients with isolated TM without risk factors 1, 3
• Failure to recognize high-risk patients who do require surveillance 3
• Performing testicular biopsy for isolated TM without other risk factors 2
• Neglecting patient education about testicular self-examination 2

The management of testicular microlithiasis has evolved toward a more conservative approach, with current guidelines recommending against routine follow-up for isolated TM without risk factors 1, 3. This approach helps reduce unnecessary procedures, anxiety, and healthcare costs while maintaining patient safety.