What is the appropriate evaluation and management for a 46-year-old male with bilateral swollen testicles?

Bilateral Testicular Swelling in a 46-Year-Old Male

A 46-year-old man with bilateral testicular swelling requires urgent evaluation with testicular ultrasound and serum tumor markers (AFP, β-HCG, LDH) to rule out bilateral testicular malignancy, followed by assessment for infectious/inflammatory causes if imaging and markers are negative.

Immediate Diagnostic Workup

The evaluation must begin with testicular ultrasound to confirm the presence of intratesticular masses, assess testicular volume, and rule out malignancy 1, 2. This imaging is critical because bilateral testicular pathology in an adult raises serious concerns for:

• Testicular cancer (particularly if solid masses are present) 1
• Testicular atrophy (if volume <12 ml bilaterally) 2
• Infectious/inflammatory processes (epididymo-orchitis) 3, 4

Obtain serum tumor markers immediately: AFP, β-HCG, and LDH 1, 2. These markers are essential for:

• Diagnosing germ cell tumors (elevated in >90% of nonseminomatous tumors) 1
• Staging and prognosis if malignancy is present 1
• Note: β-HCG can be falsely elevated with hypogonadism or marijuana use 1

Additional blood work should include: 2

• Complete blood count, creatinine, electrolytes, liver enzymes 1
• Total testosterone, LH, and FSH (to assess for hypogonadism and testicular function) 2
• Urinalysis (to evaluate for infection) 3

Clinical Assessment Priorities

Physical examination must determine: 3, 5

• Whether testes are palpable and their position in the scrotum
• Presence of tenderness, firmness, or masses
• Testicular size and consistency
• Associated inguinal or abdominal findings

Key historical features to elicit:

• Onset (acute vs. gradual) and duration of swelling 3
• Presence of pain, fever, or systemic symptoms 3, 4
• History of cryptorchidism (increases testicular cancer risk) 2
• Previous testicular trauma or infections 3
• Sexual history (relevant for infectious epididymitis) 4

Differential Diagnosis and Management Algorithm

If Solid Masses Present on Ultrasound:

Testicular cancer must be assumed until proven otherwise 1. Even bilateral presentation, though rare, requires:

• Immediate urology referral for consideration of inguinal orchiectomy 1
• Sperm banking discussion before any surgical intervention 1, 2
• Chest radiograph and abdominopelvic CT for staging if malignancy confirmed 1

If Testicular Atrophy Identified (Volume <12 ml):

This warrants comprehensive evaluation 2:

• Assess hormone levels (testosterone, LH, FSH) to determine if hypogonadism is present 2
• Consider increased testicular cancer risk, particularly with history of cryptorchidism 2
• Regular monitoring and patient education on self-examination 2
• Organ-preserving approaches when possible if bilateral atrophy 2

If Infectious/Inflammatory Pattern:

Epididymo-orchitis is the most common cause of acute scrotum in adult men 4:

• In men over 35 years: E. coli, Pseudomonas, and gram-positive cocci are most common pathogens 4
• Antimicrobials effective against urinary tract pathogens are first-line 4
• Supportive care with scrotal elevation and NSAIDs 3

If Torsion Suspected (Though Rare Bilaterally):

Testicular torsion is a surgical emergency 3, 6:

• Bilateral torsion is extremely rare but catastrophic if missed
• Doppler ultrasound showing absent or decreased blood flow requires immediate surgical exploration 4, 6
• Do not delay surgery for imaging if clinical suspicion is high 6

Critical Pitfalls to Avoid

• Never dismiss bilateral testicular swelling as benign without imaging and tumor markers 1, 2
• Do not fail to discuss fertility preservation before definitive treatment 1, 2
• Avoid overlooking increased testicular cancer risk in patients with atrophic testes or cryptorchidism history 2
• Do not perform scrotal ultrasound alone without serum tumor markers when masses are suspected 1

Follow-Up Considerations

If malignancy is ruled out and atrophy or other benign pathology identified: 2

• Regular monitoring of hormone levels and testicular volume
• Long-term surveillance for hypogonadism and late malignancy development
• Patient education on testicular self-examination