What is the initial step in managing a 25-year-old male with a painless scrotal mass?

Management of a Painless Scrotal Mass in a 25-Year-Old Male

The initial step in managing a 25-year-old male with a painless scrotal mass should be a scrotal ultrasound with Doppler. 1

Rationale for Scrotal Ultrasound as First Step

• Scrotal ultrasound with Doppler is the most appropriate initial imaging study for evaluating a scrotal mass, as it can differentiate between intratesticular and extratesticular masses 1, 2
• A solid mass in the testis identified by physical exam or imaging should be managed as a malignant neoplasm until proven otherwise 1
• Ultrasound can determine whether the mass is cystic, solid, or complex, which helps narrow the differential diagnosis 3, 2
• Scrotal ultrasound has high sensitivity and specificity for detecting testicular pathology and is considered the gold standard for initial evaluation 1, 4

Why Other Options Are Not Appropriate Initial Steps

• Fine-needle aspiration and cytology (option A):

  • Not recommended as an initial step as it may spread tumor cells if the mass is malignant 1
  • Could potentially compromise staging if the mass is malignant 1

• Abdominal computed tomography scan (option B):

  • Should only be performed after ultrasound confirms a testicular mass suspicious for malignancy 1
  • CT is not routinely used as an initial imaging modality for scrotal masses 1

• Observation and repeat examination in 2 weeks (option C):

  • Not appropriate for a solid testicular mass as it could delay diagnosis of a potential malignancy 1
  • A painless solid testicular mass is pathognomonic for testicular tumor and requires prompt evaluation 1

• Orchiectomy (option E):

  • While radical inguinal orchiectomy is the standard treatment for suspicious testicular masses, it should only be performed after proper evaluation with ultrasound and serum tumor markers 1
  • Proceeding directly to orchiectomy without imaging could lead to unnecessary surgery if the mass is benign or extratesticular 2, 4

Proper Diagnostic Algorithm for a Painless Scrotal Mass

1. Scrotal ultrasound with Doppler to characterize the mass (intratesticular vs. extratesticular, solid vs. cystic) 1
2. Serum tumor markers (alpha-fetoprotein, human chorionic gonadotropin, lactate dehydrogenase) should be drawn prior to any treatment 1
3. Counseling about risks of hypogonadism and infertility, with offer of sperm banking when appropriate 1
4. If ultrasound confirms an intratesticular solid mass suspicious for malignancy, proceed with radical inguinal orchiectomy 1
5. Further management depends on histology and staging 1

Important Clinical Considerations

• Extratesticular masses are usually benign, whereas intratesticular masses are generally malignant until proven otherwise 2, 4
• In patients with normal serum tumor markers and indeterminate findings on ultrasound, repeat imaging in 6-8 weeks may be appropriate 1
• MRI should not be used as the initial evaluation of a testicular lesion suspicious for neoplasm 1
• Testicular microlithiasis in the absence of solid mass and risk factors does not require further evaluation 1