Management of Painless Testicular Enlargement Present for 1 Year
For painless testicular enlargement present for 1 year, ultrasound evaluation is essential to differentiate between benign conditions like hydrocele or varicocele and potentially malignant masses, followed by appropriate management based on the specific diagnosis.
Initial Evaluation
- Testicular ultrasound is the primary diagnostic tool to confirm the presence of a testicular mass and determine whether it is intra- or extratesticular 1
- Complete blood count, creatinine, electrolytes, and liver enzymes should be obtained if an intratesticular mass is identified 1
- Serum tumor markers (AFP, β-HCG, LDH) should be measured if a testicular mass is suspected, as they contribute to diagnosis and staging 1
Management Based on Ultrasound Findings
For Hydrocele
- Most reactive hydroceles are self-limiting and will resolve as any underlying inflammatory condition improves 2
- Conservative management with observation is recommended as the initial approach 2
- Supportive measures include bed rest, scrotal elevation, and analgesics for pain control if there is discomfort 2
- Surgical intervention (hydrocelectomy) is only indicated for persistent symptomatic hydroceles that cause significant discomfort or cosmetic concerns 3
For Varicocele
- Varicoceles are generally asymptomatic but may be associated with reduced fertility 3
- Indications for treatment include ipsilateral testicular atrophy, large varicocele, or pain 4
- Microsurgical subinguinal varicocelectomy is considered safe and effective with lower complication rates compared to other techniques 4
- It remains uncertain if surgical or radiologic treatment of varicoceles in subfertile men improves the rate of live births 3
For Intratesticular Mass
- Inguinal orchiectomy is considered the primary treatment for most patients who present with a suspicious testicular mass 1
- Further management is dictated by histology (seminoma vs. nonseminoma) and stage 1
- In patients of reproductive age, sperm banking must be discussed before any therapeutic intervention that may compromise fertility 1
Special Considerations
- Biopsy may be considered if a suspicious intratesticular abnormality, such as a hypoechoic mass or macrocalcification, is identified on ultrasound 1
- If microcalcifications without any other abnormality are observed, testicular biopsy is not necessary 1
- An open inguinal biopsy of the contralateral testis is not routinely performed but can be considered when a cryptorchid testis or marked atrophy is present 1
- Painless testicular enlargement in prepubertal boys with signs of precocious puberty should raise suspicion for hormone-secreting tumors such as Leydig cell tumors 5
Follow-up Recommendations
- For hydroceles: follow-up ultrasound is recommended if the hydrocele persists despite resolution of any primary inflammation 2
- For varicoceles: post-surgical follow-up should assess for complications such as hydrocele formation, which occurs in approximately 1% of microsurgical cases 4
- For testicular masses treated with orchiectomy: follow-up depends on histology and stage, with specific protocols for seminoma and nonseminoma 1
Common Pitfalls to Avoid
- Assuming all painless scrotal masses are benign; testicular cancer often presents as a unilateral, painless mass discovered incidentally 3
- Delaying evaluation of persistent testicular enlargement; a delay in diagnosis correlates with a higher stage at presentation for testicular cancer 1
- Failing to consider acquired cryptorchidism in boys 5-10 years of age, which can present as an apparent testicular mass 6
- Performing scrotal approach for suspected testicular tumors, as this is associated with a higher local recurrence rate 1