Recommended Workup for Left Testicular Pain and Hematuria in Post-Orchiectomy Patient
Given the recent negative imaging (PET CT, CT CAP, ultrasound) and normal tumor markers, the priority is to evaluate non-malignant causes of left testicular pain and hematuria, while maintaining vigilance for late recurrence or new primary testicular pathology.
Immediate Diagnostic Steps
Urinalysis and Urine Studies
- Obtain urinalysis with microscopy and urine culture to evaluate the hematuria, as this may represent urinary tract infection, nephrolithiasis, or other genitourinary pathology unrelated to testicular cancer 1.
- Consider urine cytology if microscopic hematuria persists and infection is excluded, particularly given the patient's age and cancer history 1.
Repeat Scrotal Ultrasound with Doppler
- Perform high-frequency (>10 MHz) scrotal ultrasound with Doppler evaluation of the remaining left testicle, even though April 2025 imaging was negative 1, 2.
- The sonographer should document testicular volume (atrophy defined as <12 mL), echogenicity patterns, presence of any hypoechoic masses or macrocalcifications, and perfusion abnormalities 3, 2.
- Pain persisting for several months warrants repeat imaging to exclude interval development of pathology, as up to 50-80% of small non-palpable masses may be benign, but solid intratesticular masses require aggressive evaluation 1.
Repeat Serum Tumor Markers
- Redraw AFP, β-HCG, and LDH despite recent normal values, as these should be measured when clinical suspicion changes 1.
- While normal markers do not exclude disease (sensitivity limitations), rising levels would indicate recurrence or new disease 1, 4.
Additional Considerations for Persistent Pain
Evaluate for Non-Malignant Causes
- Assess for epididymitis, orchitis, or chronic epididymo-orchitis through clinical examination and ultrasound findings of increased vascularity or epididymal enlargement 2.
- Consider testicular torsion variants or chronic testicular pain syndrome if imaging remains negative 1.
Right Inguinal Pain Evaluation
- Evaluate the right inguinal area for hernia, lymphadenopathy, or spermatic cord pathology with physical examination and potentially dedicated inguinal ultrasound 2.
- Given history of right orchiectomy, consider surgical site complications or nerve entrapment 1.
Surveillance Protocol Considerations
Risk Assessment for Contralateral Disease
- Assess risk factors for contralateral testicular cancer: testicular atrophy (<12 mL volume), history of cryptorchidism, or family history 3, 2.
- Men with testicular atrophy have an 11.9-fold higher cancer risk, warranting heightened surveillance 3.
Imaging Follow-up
- If current workup is negative, repeat scrotal ultrasound in 6-8 weeks for any indeterminate findings or persistent symptoms 1.
- Continue standard post-orchiectomy surveillance with CT chest/abdomen/pelvis as per stage-appropriate protocols 1.
Critical Pitfalls to Avoid
- Never perform scrotal approach biopsy if a solid mass is identified; inguinal exploration is mandatory 1, 2.
- Do not dismiss persistent testicular pain in a cancer survivor, as 12-20% of clinical stage I patients have occult metastatic disease, though this patient's recent negative imaging is reassuring 1.
- Do not attribute all symptoms to cancer recurrence without excluding common benign causes like infection, stones, or chronic pain syndromes 1.
Hematuria-Specific Workup
- Complete upper tract imaging with CT urography or renal ultrasound if hematuria persists after excluding infection 1.
- Consider cystoscopy if risk factors for bladder pathology exist (age >35, smoking history, occupational exposures) 1.
- Hematuria may be unrelated to testicular pathology and requires independent evaluation 1.