What are the next steps for a patient with a scrotal ultrasound showing a hypoechoic mass?

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Last updated: April 16, 2025 • View editorial policy

From the Guidelines

The next steps after finding a hypoechoic mass on scrotal ultrasound should include prompt urological referral for further evaluation, as this finding raises concern for testicular cancer, and serum tumor markers including alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) should be obtained as these can help with diagnosis and serve as baseline measurements if cancer is confirmed 1.

Key Considerations

  • A hypoechoic mass on scrotal ultrasound is highly suggestive of malignancy, and any solid mass with vascular flow should be managed as a malignant neoplasm until proven otherwise 1.
  • The urologist will likely perform a physical examination and may order additional imaging such as color Doppler ultrasound to assess blood flow within the mass or CT scans of the abdomen/pelvis to check for lymph node involvement 2.
  • In most cases, the definitive management involves radical inguinal orchiectomy (surgical removal of the affected testicle through an inguinal incision) both for therapeutic and diagnostic purposes, as this approach is preferred over testicular biopsy which risks tumor spillage 1.
  • Patients should be counseled about the possibility of fertility preservation through sperm banking before any surgical intervention, especially if the mass is likely malignant and the patient desires future fertility 1, 2.

Diagnostic Approach

  • Scrotal ultrasound with Doppler should be obtained in patients with a unilateral or bilateral scrotal mass suspicious for neoplasm, as it is sensitive and has an important role in determining whether a mass is intra- or extratesticular 1.
  • MRI should not be used as the initial evaluation and diagnosis of a testicular lesion suspicious for neoplasm, and testicular microlithiasis in the absence of solid mass and risk factors for developing germ cell tumor (GCT) does not confer an increased risk of malignant neoplasm and does not require further evaluation 1.
  • The general consensus is that a sonographic detection of a solid or mixed cystic lesion mass requires additional imaging or surgical exploration, as differentiation between various subtypes of malignant testicular tumors on US could be challenging 3.

From the Research

Next Steps for Scrotal Ultrasound with Hypoechoic Mass

  • A hypoechoic mass found on scrotal ultrasound may require further evaluation to determine its nature and appropriate management, as suggested by 4, 5.
  • The presence of a hypoechoic mass may indicate a malignant or benign lesion, with associated findings such as microliths or hypoechoic regions surrounding the nodule being suggestive of malignant disease 5.
  • A formal workup, including serum tumor markers and prompt consultation with a urologist, may be necessary for testicular masses, as recommended by 4.
  • Scrotal ultrasound is a highly sensitive but nonspecific diagnostic technique, and surgical and pathological findings should be compared to preoperative scrotal ultrasonography results, as noted in 6.
  • The characterization of testicular lesions is primarily based on ultrasound examination, with the role of newer imaging modalities such as MRI, sonoelastography, and contrast-enhanced ultrasound evolving, as discussed in 5, 7.
  • Asymptomatic small testicular lesions found on ultrasound are mainly benign, but findings such as microliths or hypoechoic regions surrounding the nodules may indicate malignancy, and should be evaluated further, as suggested by 5.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.