What is the treatment for echogenic calcification in the testicle?

Management of Echogenic Testicular Calcifications

Isolated testicular microlithiasis (echogenic calcifications) without a solid mass or risk factors requires no treatment—only routine testicular self-examination is recommended. 1, 2

Distinguishing Microlithiasis from Concerning Lesions

The critical first step is determining whether you're dealing with benign microlithiasis versus a potentially malignant lesion:

Testicular Microlithiasis (Benign)

• Defined as >5 small echogenic non-shadowing foci scattered throughout the testis 1
• Does NOT confer increased malignancy risk in isolation and requires no further evaluation 1, 2
• Present in 5.6% of healthy males aged 17-35 years (14.1% in African Americans)—far more common than testicular cancer 3

Concerning Calcifications Requiring Biopsy

• Macrocalcifications (large, focal calcifications with acoustic shadowing) 1
• Central or focal calcifications associated with a hypoechoic mass 1
• Any solid mass component with vascular flow on Doppler 1

Management Algorithm

For Isolated Microlithiasis (No Mass, No Risk Factors)

• No routine follow-up ultrasound 2
• No serum tumor markers (AFP, hCG, LDH) required 2
• Teach testicular self-examination 2, 4, 3
• Standard age-appropriate urological care 2

For Microlithiasis WITH Risk Factors

Consider more aggressive surveillance if any of the following are present:

• Cryptorchidism (undescended testis) 1, 4
• Contralateral testicular tumor or personal history of testicular cancer 1, 4
• Family history of testicular cancer 1
• Testicular atrophy (volume <12 ml) 2, 5
• Germ Cell Neoplasia In Situ (GCNIS) 1

For these high-risk patients: Consider serum tumor markers and closer clinical follow-up 2

For Suspicious Lesions (Macrocalcifications or Associated Mass)

If ultrasound shows:

• Hypoechoic mass with vascular flow → Highly suggestive of malignancy 1
• Macrocalcifications or focal/central calcifications → Consider biopsy 1, 6

Management pathway:

1. Obtain serum tumor markers (AFP, hCG, LDH) BEFORE any intervention 1, 7
2. Counsel about fertility preservation and offer sperm banking 1, 7
3. Radical inguinal orchiectomy is the standard treatment for solid testicular masses 2, 7
4. If findings are indeterminate with normal tumor markers: Repeat ultrasound in 6-8 weeks 1

Critical Pitfalls to Avoid

• Do NOT perform routine surveillance ultrasounds or tumor markers for isolated microlithiasis without risk factors—this leads to overdiagnosis, unnecessary anxiety, and cost without improving outcomes 2, 4, 3
• Do NOT use MRI as initial evaluation 1
• Do NOT approach testicular masses through the scrotum—always use inguinal approach to prevent tumor seeding 7
• Do NOT confuse microlithiasis (multiple tiny non-shadowing foci) with macrocalcifications (large focal calcifications with shadowing)—the latter warrant biopsy consideration 1, 6

Key Distinction in the Evidence

While older literature suggested concern about microlithiasis and cancer risk, the 2019 AUA guidelines definitively state that microlithiasis alone does NOT increase cancer risk 1. The association seen in some studies reflects selection bias—microlithiasis was found during workup of patients who already had tumors or risk factors 3, 8. The majority of men with testicular microlithiasis will never develop cancer 3.