Management of Hypospadias with Testicular Mass
A patient presenting with both hypospadias and a testicular mass requires immediate evaluation of the testicular mass as a malignant neoplasm until proven otherwise, while recognizing that hypospadias itself is a risk factor for testicular cancer and associated anomalies. 1
Immediate Diagnostic Workup
Priority 1: Evaluate the Testicular Mass
Obtain scrotal ultrasound with Doppler immediately to characterize the testicular mass, as any solid intratesticular mass must be managed as malignant until proven otherwise. 1
Draw serum tumor markers (AFP, hCG, LDH) before any intervention, including orchiectomy, as these are essential for diagnosis, staging, and monitoring. 1
The presence of hypospadias significantly increases the clinical concern, as men with cryptorchidism (commonly associated with hypospadias) have a 3.6-7.4 times higher risk of testicular cancer than the general population. 1
Priority 2: Assess for Associated Anomalies
Screen for cryptorchidism and other urogenital anomalies, as the frequency of associated anomalies increases with the severity of hypospadias, particularly in posterior (penoscrotal, scrotal, or perineal) forms. 2, 3
Consider screening for urinary tract anomalies in patients with posterior hypospadias, as these patients have higher rates of associated structural abnormalities. 2
Infertile males and those with testicular dysgenesis (which may accompany severe hypospadias) have significantly elevated risk of testicular cancer (pooled OR 1.91). 1
Management Algorithm Based on Ultrasound Findings
If Solid Intratesticular Mass Identified:
Proceed directly to radical inguinal orchiectomy without delay, as this is both diagnostic and therapeutic. 1, 4
Counsel about fertility preservation and offer sperm banking before orchiectomy, especially given the baseline fertility concerns associated with hypospadias and potential need for contralateral testicular dysfunction. 1
Never perform scrotal biopsy or scrotal incision for suspected malignancy—only inguinal orchiectomy is appropriate to prevent tumor seeding and local recurrence. 5, 4
The hypospadias repair should be deferred until after oncologic management is complete and the patient is in remission, as cancer treatment takes absolute priority for mortality reduction. 1
If Indeterminate Findings on Ultrasound:
Repeat imaging in 6-8 weeks if STM are normal and findings are indeterminate, though maintain high suspicion given the increased baseline risk. 1
Up to 50-80% of non-palpable masses <2 cm may be benign, but the presence of hypospadias lowers this threshold for intervention. 1
Timing of Hypospadias Repair
Defer hypospadias repair until testicular malignancy is definitively excluded or treated, as cancer management supersedes reconstructive surgery for mortality considerations. 1
If no malignancy is found, the ideal age for hypospadias repair in a healthy child is between 6-12 months of age, with most cases repairable in a single operation. 2, 6
For severe posterior hypospadias (penoscrotal, scrotal, or perineal), more sophisticated multi-stage procedures may be required, but these should only proceed after cancer clearance. 7, 3, 6
Critical Pitfalls to Avoid
Never delay evaluation of a testicular mass to address hypospadias first—the mass takes absolute priority as delay in testicular cancer diagnosis correlates with higher stage at presentation and worse mortality. 1, 4
Do not assume the testicular mass is benign simply because the patient has hypospadias; in fact, the association increases cancer risk. 1
Never use MRI as the initial evaluation of a testicular lesion—ultrasound with Doppler is the mandatory first-line imaging. 1
Avoid performing orchidopexy for undescended testes (if present) before ruling out malignancy, as cryptorchid testes have 2-6% lifetime risk of testicular tumor. 1
Long-term Considerations
Men with hypospadias, particularly severe forms, may have bilateral testicular dysfunction even if only one testis appears abnormal, affecting both fertility and hormone production. 1
Regular testicular self-examination should be encouraged lifelong, as the cancer risk remains elevated even after successful hypospadias repair. 1
Patients with posterior hypospadias should be counseled about potential fertility challenges independent of cancer treatment, with paternity rates of 35-53% in bilateral cryptorchidism cases. 1