What is the management approach for testicular atrophy identified on ultrasound?

Management of Testicular Atrophy Identified on Ultrasound

When testicular atrophy is identified on ultrasound, the primary management priority is to determine the underlying etiology through contralateral testis biopsy if risk factors are present (age <30 years, testicular volume <12 mL), obtain serum tumor markers (AFP, β-HCG, LDH), and establish whether active surveillance or intervention is required based on the clinical context. 1

Initial Diagnostic Workup

Determine the Clinical Context

• Identify the cause of atrophy: Review patient history for prior testicular torsion, mumps orchitis, scrotal trauma, cryptorchidism, or previous inguinal hernia repair, as these are established causes of testicular atrophy 2, 3, 4, 5
• Measure testicular volume precisely: Document the degree of atrophy by comparing volume to the contralateral testis using ultrasound measurements or Prader orchidometer; atrophy is defined as >50% volume reduction compared to the contralateral side 2
• Assess ultrasound characteristics: Evaluate echogenicity (heterogeneous vs homogeneous), vascularity on color Doppler, and presence of any focal lesions or microcalcifications 5, 6

Mandatory Laboratory Assessment

• Obtain serum tumor markers before any intervention: Measure AFP, β-HCG, and LDH, as testicular atrophy increases the risk of germ cell neoplasia in situ (GCNIS) and testicular cancer 1
• Check endocrine function: Assess testosterone, LH, and FSH levels to evaluate for testicular dysfunction, particularly if bilateral atrophy or single remaining testis 1

Risk Stratification and Biopsy Indications

High-Risk Features Requiring Contralateral Testis Biopsy

The European Society for Medical Oncology and European Association of Urology recommend contralateral testis biopsy in patients with testicular atrophy (<12 mL volume) and young age (<30 years) to exclude GCNIS. 1

• Perform open inguinal biopsy (never scrotal approach) in patients meeting these criteria: testicular volume <12 mL, age <30 years, history of cryptorchidism, or suspicious ultrasound findings (hypoechoic mass, macrocalcifications) 1
• Do not biopsy for isolated microcalcifications without other abnormalities, as this does not require tissue diagnosis 1

Additional Surveillance Considerations

• If suspicious intratesticular abnormality is identified (hypoechoic mass, focal lesion), proceed directly to radical inguinal orchiectomy rather than biopsy, as any solid intratesticular mass must be managed as malignant until proven otherwise 1, 7

Management Algorithm Based on Findings

For Isolated Testicular Atrophy Without Suspicious Lesions

• Implement annual clinical examination with testicular palpation and assessment for new masses 1
• Consider surveillance ultrasound every 1-2 years if high-risk features present (cryptorchidism history, age <30 years, volume <12 mL) 1, 6
• Counsel on fertility preservation: Discuss sperm banking if reproductive potential is a concern, particularly if bilateral atrophy or single testis 1

For Atrophy With Suspicious Ultrasound Features

• Proceed to radical inguinal orchiectomy if any solid intratesticular mass or suspicious lesion is identified, regardless of tumor marker levels 1, 7
• Never delay surgical intervention for additional imaging if malignancy is suspected 1, 7
• Obtain staging CT chest/abdomen/pelvis after orchiectomy if germ cell tumor is confirmed on pathology 1

Critical Pitfalls to Avoid

• Never perform scrotal biopsy or scrotal incision for suspected malignancy; only inguinal approach is appropriate to prevent local recurrence and altered lymphatic drainage 1, 7
• Do not assume atrophy is benign without proper risk stratification, as atrophic testes have increased malignancy risk, particularly in patients with cryptorchidism history 1
• Avoid relying solely on tumor markers to exclude malignancy, as normal levels do not exclude the presence of disease due to low sensitivity 1
• Do not delay evaluation if new symptoms develop (pain, enlargement), as testicular cancer can develop in atrophic testes 1, 7

Long-Term Follow-Up Protocol

For Patients With Confirmed Benign Atrophy

• Clinical examination annually for at least 5 years, with lifelong testicular self-examination education 1
• Monitor endocrine function if bilateral atrophy or single testis, checking testosterone levels periodically 1
• Repeat ultrasound if any change in symptoms or physical examination findings 1, 6

Special Populations

• Patients with history of cryptorchidism or testicular maldescent: Maintain heightened surveillance indefinitely, as cancer risk remains elevated even after orchiopexy 1
• Young patients (<30 years) with severe atrophy (<12 mL): Consider contralateral biopsy even if asymptomatic, given GCNIS risk 1