Are National Health Service (NHS) radiologists and sonographers required to report testicular atrophy?

Reporting Testicular Atrophy on Ultrasound in the NHS

Yes, NHS radiologists and sonographers should actively document and report testicular atrophy when identified on ultrasound, as it represents a clinically significant finding with major implications for cancer risk, fertility, and patient management.

Why Testicular Atrophy Must Be Reported

Testicular atrophy is a critical risk factor that demands documentation because men with testicular atrophy have an 11.9-fold higher risk of testicular cancer, particularly when associated with cryptorchidism, family history, or prior malignancy. 1, 2 This dramatic elevation in cancer risk makes atrophy identification essential for appropriate clinical decision-making and surveillance planning.

Clinical Significance Beyond Cancer Risk

• Fertility implications: Testicular atrophy is a critical factor in evaluating male fertility, especially in men presenting with oligozoospermia or azoospermia 1
• Surgical planning: In patients with cryptorchidism and marked contralateral testicular atrophy, documentation may warrant consideration of testicular biopsy to exclude testicular intraepithelial neoplasia (TIN) 3, 1
• Risk stratification: The highest risk for contralateral TIN (approximately 30%) occurs in men with testicular atrophy (volume <12 ml) who are under 40 years of age 3

Defining Testicular Atrophy

Testicular atrophy is objectively defined as testicular volume less than 12 ml, which serves as the established clinical threshold used internationally 1, 2. This is not a subjective assessment—it requires actual volumetric measurement.

Measurement Requirements

• Calculate volume using the ellipsoid formula: π/6 × length × height × width 2
• Measure both testes bilaterally to establish comparative volumes and calculate percentage difference 1
• Use the contralateral testis as an internal control to assess for true pathologic asymmetry 1
• Document associated findings: heterogeneous echogenicity, reduced vascularity on Doppler, or suspicious masses 1, 4

Professional Responsibilities

For Sonographers

Sonographers must actively measure and document testicular volumes bilaterally, calculate the percentage difference, and describe any associated findings. 1 This is not optional—it represents the objective data collection that enables proper radiologist interpretation.

• Perform Doppler evaluation even when grayscale appearance seems normal, as perfusion abnormalities may indicate underlying pathology 1
• Document suspicious findings such as hypoechoic masses or macrocalcifications that may be associated with atrophy 1
• Note heterogeneous echogenicity, which correlates with seminiferous tubule atrophy and sclerosis on histology 5 and predicts testicular atrophy development after torsion 6

For Radiologists

The radiologist's role is to interpret these objective measurements within the clinical context and explicitly state whether atrophy is present in the final report. 1, 2 While sonographers document measurements, radiologists must synthesize this information and communicate its clinical significance to referring physicians.

Clinical Contexts Requiring Heightened Attention

High-Risk Scenarios Where Atrophy Documentation Is Critical

• Cryptorchidism evaluation: Atrophy in undescended testis warrants contralateral testicular biopsy consideration 2
• Infertility workup: Atrophy assessment is fundamental in evaluating male fertility 2
• History of testicular cancer: Patients with prior cancer require careful contralateral testis assessment 1, 2
• Post-traumatic evaluation: Testicular atrophy occurs in 50% of patients following blunt scrotal trauma 7
• Post-torsion follow-up: 54% of patients develop atrophy after testicular salvage, typically evident by 14 months 6

Common Pitfalls to Avoid

Do not assume that "normal-appearing" echogenicity excludes atrophy—volume measurement is mandatory, as homogeneous but reduced-volume testes still represent pathologic atrophy 7. Three cases in one trauma series showed homogeneous appearance despite significant volume reduction.

Do not rely solely on visual estimation—subjective assessment underestimates the prevalence and severity of atrophy. The heterogeneous or mottled appearance seen in 14% of elderly men on ultrasound corresponds to extensive tubular sclerosis on histology 5, but volume measurement provides the objective threshold.

Do not omit Doppler assessment—reduced vascularity may be present even with normal grayscale appearance and indicates underlying pathology 1, 7.

Practical Algorithm for NHS Practice

1. Measure both testicular volumes using the ellipsoid formula on every testicular ultrasound
2. Calculate and document the percentage difference between sides
3. Flag volumes <12 ml as atrophic in the report
4. Perform color Doppler to assess perfusion, particularly if heterogeneous echogenicity is present
5. Document associated findings: heterogeneity, masses, calcifications, or reduced flow
6. State explicitly in the report whether atrophy is present and its severity
7. Recommend clinical correlation with tumor markers (AFP, β-HCG) if any suspicious features are present 3