What is the management and treatment for bilateral testicular swelling that has reduced?

Management of Bilateral Testicular Swelling That Has Reduced

The priority is to rule out testicular malignancy through scrotal ultrasound and serum tumor markers (AFP, β-HCG, LDH), even though the swelling has reduced, because delay in diagnosis of testicular cancer correlates with higher stage at presentation and worse outcomes. 1, 2

Immediate Diagnostic Workup

Mandatory Imaging

• Obtain scrotal ultrasound with Doppler immediately to characterize any residual testicular abnormalities, assess testicular volume, and detect any solid masses that may have been masked by the swelling 1, 2
• Ultrasound has nearly 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing intratesticular from extratesticular processes 2
• Look specifically for testicular atrophy (volume <12 ml), non-homogeneous testicular architecture, microcalcifications, or any solid masses 1

Essential Laboratory Tests

• Draw serum tumor markers (AFP, β-HCG, LDH) before any intervention, as these are critical for staging and monitoring even if imaging appears benign 1, 2
• Measure total testosterone, LH, and FSH to assess testicular function, particularly important given bilateral involvement 2, 3
• Elevated AFP always indicates non-seminomatous histology, even if pathology suggests otherwise 2

Risk Stratification Based on Clinical Context

High-Risk Features Requiring Urgent Action

• Any solid intratesticular mass identified on ultrasound mandates radical inguinal orchiectomy, as this is both diagnostic and therapeutic 2, 4
• Testicular atrophy (volume <12 ml) in patients under age 40 carries a 34% risk of testicular intraepithelial neoplasia (TIN) 1
• History of cryptorchidism increases testicular cancer risk 3.6-7.4 times above baseline 1, 3

Moderate-Risk Features Requiring Close Surveillance

• Testicular microcalcifications without mass increase cancer prevalence approximately 18-fold 1
• Non-homogeneous testicular architecture suggests testicular dysgenesis and impaired spermatogenesis 1
• Infertile men have a pooled odds ratio of 1.91 for testicular cancer compared to fertile men 1

Management Algorithm Based on Findings

If Solid Mass Detected

1. Proceed directly to radical inguinal orchiectomy through inguinal incision—never use scrotal approach as this increases local recurrence rates 1, 2
2. Offer sperm banking before surgery if post-pubertal, as fertility may be compromised 1, 2, 3
3. Resect tumor-bearing testis with spermatic cord at the level of the internal inguinal ring 1, 2
4. Repeat tumor markers 7 days post-orchiectomy to determine half-life kinetics (HCG: 24-36 hours; AFP: 5-7 days) 1, 2
5. Obtain chest CT and abdominopelvic CT for staging 1

If Testicular Atrophy Without Mass

• Consider contralateral testicular biopsy to exclude TIN, particularly if volume <12 ml and age <40 years 1
• If bilateral atrophy with normal contralateral testis function, surveillance with regular self-examination is appropriate 1, 3
• If bilateral atrophy with biochemical hypogonadism, consider orchidopexy (if undescended) or hormone replacement 1, 3

If Benign Findings (Hydrocele, Epididymitis Resolution)

• Continue surveillance with repeat ultrasound in 3-6 months to ensure stability 1
• Teach testicular self-examination given the initial presentation 1, 3
• Monitor hormone levels if testicular atrophy is present 3

Critical Pitfalls to Avoid

• Never dismiss reduced swelling as reassuring without imaging and tumor markers, as testicular cancer can present with intermittent swelling 1, 2
• Never perform scrotal biopsy or scrotal incision if malignancy is suspected—only inguinal approach is appropriate 1, 2
• Never delay obtaining tumor markers before any surgical intervention, as this information is essential for staging 1, 2
• Never assume bilateral involvement is benign—lymphoma, bilateral germ cell tumors, and metachronous tumors occur in 2-3% of testicular cancer patients 1, 5
• Never treat post-pubertal adolescents with pediatric protocols if malignancy is found—they require adult treatment algorithms 2

Special Considerations for Bilateral Involvement

• Bilateral testicular swelling raises concern for lymphoma, which can present with painless bilateral enlargement and shows a characteristic "striated pattern" on ultrasound 5
• Synchronous bilateral testicular tumors occur in 2-3% of cases and may require organ-preserving surgery if both testes are involved 1
• Systemic conditions (Crohn's disease, vasculitis) can cause bilateral scrotal swelling but should be diagnoses of exclusion after malignancy is ruled out 6

Long-Term Follow-Up

• Regular monitoring of hormone levels and testicular volume is necessary, particularly if atrophy is present 3
• Lifelong testicular self-examination should be taught given the elevated cancer risk 1, 3
• Monitor for late complications including hypogonadism and contralateral malignancy 1, 3