What are the diagnostic steps and treatment options for a painful testicular mass?

Painful Testicular Mass: Diagnostic and Treatment Approach

A painful testicular mass requires immediate testicular ultrasound with high-frequency probe (>10 MHz) and color Doppler to differentiate surgical emergencies (torsion, malignancy) from medical conditions (epididymitis), followed by urgent urologic consultation if an intratesticular mass or torsion is identified. 1

Immediate Diagnostic Steps

Serum Tumor Markers (Before Any Intervention)

• Draw AFP, β-HCG, and LDH immediately before any surgical intervention, as these are essential for diagnosis, staging, and monitoring 1
• These markers support the diagnosis even when pain is the presenting symptom 1
• Normal markers do not exclude germ cell tumors, particularly seminomas which have low marker sensitivity 1

Testicular Ultrasound with Doppler

• Use high-frequency probe (>10 MHz) with color Doppler assessment to evaluate blood flow patterns 1
• The examination must distinguish intratesticular from extratesticular masses, as this fundamentally changes management 2
• Look for the "whirlpool sign" if torsion is suspected 2
• Ultrasound has nearly 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing location 2

Additional Laboratory Work

• Obtain complete blood count, creatinine, electrolytes, and liver enzymes if an intratesticular mass is identified 1

Management Algorithm Based on Findings

If Testicular Torsion is Suspected Clinically

• Proceed immediately to surgical exploration within 6 hours of symptom onset to achieve >90% salvage rates 2
• Do not delay surgery for imaging if clinical suspicion is high 2
• Pain does not exclude torsion—the testis may detorse spontaneously creating intermittent symptoms 2

If Intratesticular Mass is Identified on Ultrasound

• Perform radical inguinal orchiectomy without delay, as this is both diagnostic and therapeutic 1
• The orchiectomy must be performed through an inguinal incision at the level of the internal inguinal ring 1
• In experienced centers only, consider frozen section analysis intra-operatively for small tumors to potentially allow organ-sparing surgery 1
• Organ-preserving surgery may be feasible only in highly experienced centers for synchronous bilateral tumors, tumor in a solitary testis, or contralateral atrophic testis 1

If Epididymitis is Diagnosed

• Treat with antibiotics targeting Chlamydia trachomatis, Neisseria gonorrhoeae, or enteric bacteria based on age and risk factors 3, 4
• Provide analgesics and scrotal support 3

Post-Orchiectomy Management

• Repeat tumor markers minimum 7 days after orchiectomy to determine half-life kinetics (AFP half-life 5-7 days, β-HCG half-life 1-3 days) 1
• Follow markers until normalization 1
• Persistent or increasing markers after orchiectomy indicate metastatic disease 1
• Obtain CT scan of chest, abdomen, and pelvis for staging 1

Critical Pitfalls to Avoid

Never Perform Scrotal Approach for Suspected Malignancy

• Any scrotal violation for biopsy or open surgery must be strongly avoided 1, 5
• Only inguinal orchiectomy is appropriate, as scrotal approach is associated with higher local recurrence rates 2, 5

Do Not Rely on Physical Examination Alone

• The Prehn sign has poor sensitivity and specificity for differentiating epididymitis from torsion 2
• Pain does not exclude malignancy—27% of testicular cancer patients present with scrotal pain 1

Do Not Delay for Life-Threatening Presentations

• In advanced, rapidly progressive disease requiring urgent chemotherapy, diagnosis may be based on typical clinical picture and marker elevation alone without orchiectomy 1
• Immediate chemotherapy takes priority over orchiectomy only when the patient is very sick with high tumor markers 1

Fertility Preservation

• Discuss sperm banking before orchiectomy in reproductive-age men 2, 5
• Determine total testosterone, LH, and FSH before operation if fertility is a concern 1

Special Considerations for Contralateral Testis

• Note the size and any structural alterations of the contralateral testis on ultrasound 1
• Routine biopsy of the contralateral testis is not indicated by the majority of experts 1
• Highest risk (∼30%) of contralateral testicular intraepithelial neoplasia occurs in men with testicular atrophy (volume <12 ml), age <40 years, and patients with extragonadal germ cell tumors 1