What is the appropriate evaluation and treatment for a young to middle-aged adult with swollen lymph nodes in the testicles, potentially with a history of testicular trauma, infections, or cancer?

Evaluation and Management of Swollen Testicular Lymph Nodes

Any palpable testicular mass or swelling requires immediate scrotal ultrasound with Duplex Doppler to differentiate between intratesticular and extratesticular pathology, as 90% of intratesticular masses are malignant and require urgent urologic referral. 1, 2, 3

Critical First Step: Clarify the Anatomic Location

The term "swollen lymph nodes in the testicles" requires anatomic clarification, as lymph nodes do not exist within the testicles themselves. The testicular lymphatic drainage follows the spermatic cord to retroperitoneal lymph nodes (para-aortic and paracaval regions), not to intratesticular structures. 4 What you are likely evaluating is either:

• Intratesticular mass (within the testis itself)
• Extratesticular mass (epididymal cyst, hydrocele, varicocele)
• Retroperitoneal lymphadenopathy (enlarged lymph nodes from testicular cancer metastasis)

Immediate Diagnostic Workup

Imaging

• Order scrotal ultrasound with Duplex Doppler immediately as the mandatory first-line test, which has nearly 100% sensitivity for detecting intratesticular masses and 98-100% accuracy for distinguishing intratesticular from extratesticular processes. 1, 2
• Use a high-frequency linear array transducer (12-17 MHz) with both grayscale and color/power Doppler evaluation of both testicles. 2
• The contralateral testicle serves as an internal control for comparison. 2

Laboratory Tests

• Obtain serum tumor markers before any surgical intervention: alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (β-HCG), and lactate dehydrogenase (LDH). 5, 6
• These markers are essential for diagnosis, staging, prognosis, and post-treatment monitoring. 4, 5

Management Algorithm Based on Ultrasound Findings

If Intratesticular Mass Identified

Proceed directly to radical inguinal orchiectomy - this is both diagnostic and therapeutic, with early clamping of the spermatic cord to prevent hematogenous dissemination. 4, 5, 6

Critical pitfall to avoid: Never perform scrotal biopsy or scrotal incision for suspected malignancy, as this alters lymphatic drainage patterns and increases local recurrence rates. Only inguinal orchiectomy is appropriate. 4, 1

Pre-Orchiectomy Considerations

• Discuss and offer sperm cryopreservation to all patients of reproductive age before orchiectomy, as treatment may compromise fertility. 4, 5
• Obtain complete blood count, creatinine, electrolytes, and liver enzymes if an intratesticular mass is confirmed. 5

Post-Orchiectomy Staging

• Obtain chest radiography and abdominal/pelvic CT scans to evaluate retroperitoneal lymph nodes and distant metastases. 5
• Repeat tumor markers post-orchiectomy to evaluate normalization and guide adjuvant treatment. 5
• Testicular cancer metastasizes via lymphatics to retroperitoneal nodes: left testicular tumors drain to left para-aortic nodes below the left renal vein, while right testicular tumors drain to paracaval, precaval, and interaortocaval groups. 4

If Extratesticular Mass Identified

• Epididymal cysts/spermatoceles (most common finding, 27% of scrotal masses): benign, require no intervention unless symptomatic. 3
• Hydrocele (11% of scrotal masses): if patient is aged 20-40 with hydrocele, refer for urgent ultrasound to exclude underlying testicular pathology. 3
• Varicocele: dilated veins that become more prominent when standing and less noticeable when lying down. 1

If Retroperitoneal Lymphadenopathy Without Palpable Testicular Mass

This represents a rare "burned-out" testicular tumor where the primary tumor has spontaneously regressed but metastases persist. 7

• Perform testicular ultrasound looking for echogenic calcifications or microlithiasis. 7
• Biopsy the retroperitoneal lesion to confirm germ cell tumor histology. 7
• Proceed with radical inguinal orchiectomy even if the testis appears normal on ultrasound. 7

Prognosis and Treatment Outcomes

• Stage I disease (70-75% of patients at diagnosis): 99% five-year survival. 6
• Stage II disease (20% at diagnosis, retroperitoneal lymph node involvement only): 92% five-year survival. 6
• Stage III disease (10% at diagnosis, widely metastatic): 85% five-year survival. 6

Treatment is guided by histology (seminoma vs. nonseminoma), clinical staging, and risk classification, often requiring a multidisciplinary team at high-volume centers. 6

Special Populations

Patients with Cryptorchidism History

• Contralateral testicular biopsy should be considered in patients with testicular volume <12 mL or history of cryptorchidism, as these are high-risk for contralateral germ cell neoplasia in situ (GCNIS). 4
• Cryptorchidism is a significant risk factor for testicular cancer and burned-out tumors. 6, 7

Elderly Patients

• In men over 60, consider testicular lymphoma as the most common testicular malignancy in this age group, which presents as unilateral painless scrotal swelling and has a poor prognosis despite treatment. 8
• Testicular lymphoma requires orchiectomy followed by R-CHOP chemotherapy with CNS prophylaxis and prophylactic contralateral testicular irradiation. 8

Common Clinical Pitfalls

• Do not delay evaluation: Delayed diagnosis correlates with higher stage at presentation and worse outcomes. 5
• Do not rely on pain absence: The most common presenting symptom of testicular cancer is a painless testicular mass. 6
• Do not use scrotal approach: Always use inguinal approach for suspected malignancy. 4
• Do not skip tumor markers: These must be obtained before orchiectomy for proper staging and monitoring. 5