What is the appropriate initial order for a patient presenting with a scrotal mass?

How to Write Orders for a Scrotal Mass

Order scrotal ultrasound with Doppler as the initial and definitive imaging study for any patient presenting with a scrotal mass. 1

Initial Orders

The complete initial workup should include:

• Scrotal ultrasound with Doppler (this is the single required imaging study) 1
• Serum tumor markers (AFP, hCG, LDH) drawn before any intervention if a solid testicular mass is suspected 1
• No other imaging modalities (CT, MRI, nuclear scans) are indicated as initial studies 1

Why Ultrasound with Doppler is the Gold Standard

• Ultrasound achieves nearly 100% sensitivity for detecting intrascrotal masses 2, 3
• It differentiates intratesticular from extratesticular processes with 98-100% accuracy, which is critical since intratesticular lesions carry much higher malignancy risk 2, 3, 4
• The addition of Doppler significantly improves specificity by assessing vascularity and distinguishing solid masses from avascular hematomas 1
• Both the American College of Radiology and American Urological Association designate this as a Strong Recommendation (Evidence Level: Grade B) 1

Critical Management Principle

Any solid mass in the testis identified by physical exam or imaging must be managed as malignant until proven otherwise. 1, 4

• This is a Clinical Principle from the AUA guidelines that supersedes clinical judgment about benign appearance 1
• A painless solid testicular mass is pathognomonic for testicular tumor per the National Comprehensive Cancer Network 4

When to Order Serum Tumor Markers

Draw tumor markers (AFP, hCG, LDH) immediately if:

• Physical exam or ultrasound identifies a solid intratesticular mass 1
• The markers must be obtained before orchiectomy or any treatment to establish baseline values 1

Follow-Up Imaging Protocol

For indeterminate findings with normal tumor markers:

• Repeat ultrasound in 6-8 weeks rather than proceeding directly to surgery 1
• This approach is appropriate because 50-80% of non-palpable or incidentally detected masses <2 cm are benign 1

What NOT to Order

• Do not order MRI as initial evaluation (Moderate Recommendation against) 1
• Do not order CT abdomen/pelvis as initial imaging 1
• Do not order nuclear medicine scans as initial imaging 1

Common Pitfalls to Avoid

• Never assume a scrotal mass is benign without imaging confirmation, as ultrasound cannot definitively differentiate benign from malignant lesions based on appearance alone 2, 3
• Do not delay imaging for presumed inflammatory conditions, as this can miss testicular malignancies 3
• Do not rely on clinical examination alone, even experienced clinicians cannot reliably distinguish between various scrotal pathologies without imaging 2
• Do not forget to counsel about sperm banking before any definitive treatment in appropriate patients 1

Additional Considerations for Specific Presentations

For patients with trauma history:

• Ultrasound remains the first-line study and can detect testicular rupture, hematoma, and tunica albuginea disruption 1
• Doppler helps differentiate traumatic hematomas (avascular) from solid masses 1

For inflammatory presentations:

• Ultrasound with Doppler is particularly useful for diagnosing epididymitis and testicular abscess 1
• However, duplex ultrasound cannot definitively exclude malignancy in inflammatory-appearing lesions 1