What is the next step in evaluating testicular atrophy without a clear causative event?

Evaluation of Testicular Atrophy Without Clear Causative Event

When testicular atrophy is documented on imaging without an obvious cause, the next step is immediate measurement of serum tumor markers (AFP, β-hCG, LDH) and consideration of contralateral testicular biopsy, as testicular atrophy itself is an independent risk factor for testicular cancer with an 11.9-fold increased risk. 1, 2

Initial Diagnostic Workup

Mandatory Laboratory Assessment

• Obtain serum tumor markers immediately: AFP, β-hCG, and LDH must be measured, as testicular atrophy increases testicular cancer risk regardless of the underlying cause 3, 1
• If tumor markers are elevated, repeat testing is required for precise staging before any intervention 3
• Complete metabolic panel and testosterone levels should be obtained to assess for occult hypogonadism that may have been subclinical 4

Imaging Confirmation

• Testicular ultrasound with Doppler evaluation is essential even if already performed, specifically looking for: 2
  • Hypoechoic masses or macrocalcifications (which warrant immediate urologic referral) 3, 2
  • Heterogeneous echogenicity patterns (associated with pathologic processes) 5
  • Perfusion abnormalities on color Doppler that may indicate underlying pathology 2
• Document bilateral testicular volumes using the formula π/6 × length × height × width, with atrophy defined as volume <12 mL 1

Risk Stratification and Biopsy Consideration

When to Perform Contralateral Testicular Biopsy

Contralateral testicular biopsy should be strongly considered when marked atrophy is present, particularly in the following scenarios: 3, 2

• Testicular volume <16 mL (increased risk of testicular intraepithelial neoplasia) 3
• Any suspicious ultrasound findings such as hypoechoic masses or macrocalcifications 3, 2
• History of cryptorchidism, even if previously corrected 3
• Family history of testicular cancer 1, 2

Surveillance Protocol if Initial Workup is Negative

If tumor markers are normal and ultrasound shows only atrophy without suspicious features: 6

• Clinical examination and tumor markers monthly for the first year 3
• Repeat ultrasound at 3,6,9,12, and 24 months 3
• Patient education on testicular self-examination to monitor for changes 6

Critical Pitfalls to Avoid

The "Idiopathic" Atrophy Trap

Do not accept "idiopathic" atrophy without excluding occult causes: 4

• Subclinical hypogonadism may have been present for years before becoming clinically apparent 4
• Prior minor trauma may not have been reported or remembered by the patient 7
• Varicocele-induced atrophy can be subtle and progressive 5

The Microlithiasis Misconception

• Testicular microlithiasis alone does not increase cancer risk in the absence of other risk factors and does not require additional follow-up beyond standard surveillance 6
• However, microlithiasis combined with atrophy warrants closer monitoring 6

When to Refer to Urology Immediately

Urgent urologic referral is mandatory if: 3, 2

• Any elevation in tumor markers is detected 3
• Suspicious masses or macrocalcifications are present on ultrasound 3, 2
• Heterogeneous echogenicity with reduced perfusion on Doppler 5
• Progressive atrophy documented on serial imaging 5

Long-Term Counseling

Patients must be counseled about two critical long-term risks: 3

• Increased testicular cancer risk: The relative risk is 2.75-8 fold higher with testicular atrophy, and this risk persists lifelong 3
• Potential subfertility: Atrophy is associated with reduced fertility potential, and sperm banking should be discussed if future fertility is desired 3