What is the best approach to manage a painless right testicle swelling in an elderly male with hypertension (HTN), hyperlipidemia (HLD), chronic kidney disease (CKD), and aortic stenosis?

Management of Painless Right Testicular Swelling in an Elderly Male

Urgent testicular ultrasound with Doppler is mandatory to rule out testicular malignancy, which must be the primary concern in any painless testicular mass regardless of age or comorbidities. 1, 2

Immediate Diagnostic Workup

First-Line Imaging

• Scrotal ultrasound with Doppler is the gold standard (96-100% sensitivity, 84-95% specificity) to differentiate intratesticular from extratesticular masses and to rule out malignancy 2
• The ultrasound must assess:
  • Testicular parenchymal architecture for hypoechoic masses, macrocalcifications, or non-homogeneous patterns suggesting malignancy 2
  • Color Doppler flow patterns to exclude torsion or inflammatory processes 2
  • Contralateral testis evaluation (standard practice) 2

Laboratory Evaluation if Intratesticular Mass Identified

• Serum tumor markers before any intervention: AFP, β-HCG, and LDH for diagnosis, staging, and monitoring 1
• Complete blood count, creatinine, electrolytes, and liver enzymes 1

Management Based on Ultrasound Findings

If Intratesticular Mass (Presumed Malignancy)

Radical inguinal orchiectomy is the primary treatment for any suspicious intratesticular mass—this serves as both diagnostic and therapeutic intervention 1

Critical steps before surgery:

• Discuss and offer sperm cryopreservation (even in elderly patients if reproductive potential exists) 1
• Early clamping of spermatic cord during orchiectomy to prevent hematogenous dissemination 1

Never perform scrotal incision or biopsy when testicular malignancy is suspected—this violates lymphatic drainage pathways and may require subsequent hemiscrotectomy 2

If Extratesticular Pathology (Hydrocele, Epididymal Cyst)

• Manage conservatively or with hydrocelectomy if symptomatic 2
• However, ultrasound is still essential because hydrocele can mask underlying testicular malignancy 2

Special Considerations for This Patient's Comorbidities

Chronic Kidney Disease Impact

• CKD does not contraindicate surgical intervention for testicular cancer 1
• However, contrast-enhanced CT staging may require adjustment based on renal function 1
• Post-operative management and potential chemotherapy dosing will need renal adjustment 1

Aortic Stenosis Considerations

• Severe AS increases perioperative risk but should not discourage necessary cancer surgery 3, 4
• Multidisciplinary heart-kidney team involvement is ideal for surgical planning 3
• Orchiectomy is typically a lower-risk procedure than valve replacement, making cancer treatment feasible even with significant AS 4

Hypertension Management During Workup

• Continue current antihypertensive regimen (target <140/90 mmHg in elderly with CKD) 5
• Avoid overaggressive BP lowering (diastolic >65 mmHg) in elderly patients 5

Post-Orchiectomy Staging (If Malignancy Confirmed)

• Chest radiography and abdominal/pelvic CT scans to evaluate retroperitoneal lymph nodes 1
• Repeat tumor markers post-orchiectomy to evaluate normalization 1
• Further management depends on histology (seminoma vs. non-seminoma) and stage 1

Common Pitfalls to Avoid

1. Delaying evaluation: Delay in diagnosis correlates with higher stage at presentation for testicular cancer 1
2. Assuming age excludes malignancy: While testicular cancer is more common in younger men, it can occur at any age and painless masses are highly suspicious 5, 1
3. Treating empirically as infection: A trial of antibiotics is only appropriate for painful testicular swelling with signs of infection, not painless swelling 6
4. Using comorbidities as reason to defer workup: CKD, HTN, HLD, and AS are manageable and should not prevent cancer diagnosis and treatment 3, 4