Management of Testicular Microlithiasis in a 24-Year-Old Male
For a 24-year-old with isolated testicular microlithiasis and no additional risk factors, no further evaluation beyond routine testicular self-examination is required. 1
Risk Stratification is Critical
The management approach depends entirely on whether additional risk factors are present. The 2025 European Association of Urology guidelines emphasize that testicular microlithiasis (TM) in healthy, asymptomatic individuals carries a low risk of concurrent or long-term development of testicular germ cell tumors (TGCT). 2
Low-Risk Patient (Isolated TM)
If this 24-year-old has no additional risk factors, the following applies:
- No routine follow-up ultrasound is necessary 1
- Perform baseline serum tumor markers (AFP, β-HCG, LDH) to document normal values 1
- Teach and recommend monthly testicular self-examination 1, 3
- Provide standard age-appropriate urological care 1
High-Risk Patient (TM + Risk Factors)
The risk calculation changes dramatically if any of the following are present:
High-risk features that warrant closer surveillance include: 2
- Infertility or subfertility (18-fold increased odds of testicular cancer; pooled OR 18.11,95% CI 8.09-40.55) 2
- History of cryptorchidism/undescended testis (8.5-fold increased risk; RR 8.5,95% CI 4.5-16.1) 2
- Testicular atrophy (volume <12 ml) 1
- History of contralateral testicular cancer 2, 3
- Klinefelter syndrome 2
For high-risk patients, consider: 2
- Testicular biopsy may be offered to evaluate for germ cell neoplasia in situ (GCNIS) 2
- Serial tumor marker monitoring if clinical suspicion arises 1
- More intensive surveillance, though specific protocols remain controversial 3
Key Clinical Pitfall to Avoid
Do not over-investigate isolated testicular microlithiasis. The American Urological Association explicitly recommends against unnecessary follow-up imaging in patients with isolated TM without risk factors. 1 Older literature from the 1990s suggested TM was premalignant 4, but more recent evidence demonstrates that isolated TM without risk factors does not significantly increase cancer risk above the general population. 5
What to Document
For this 24-year-old, specifically assess and document:
- Fertility status (any history of infertility concerns or abnormal semen analysis)
- Testicular volume on ultrasound (atrophy defined as <12 ml) 1
- History of cryptorchidism 2
- Baseline tumor markers (AFP, β-HCG, LDH) 1
If a Solid Mass is Detected
Should ultrasound reveal a suspicious intratesticular mass or macrocalcification (not just microlithiasis), immediate management changes: 2