Management of Testicular Microlithiasis, Nephrolithiasis, and Gallbladder Polyp
Testicular Microlithiasis Management
For testicular microlithiasis without risk factors, routine ultrasound surveillance is not necessary—teach testicular self-examination only. 1
Classic testicular microlithiasis (≥5 microliths per image) carries higher malignancy risk (18%) than limited testicular microlithiasis (<5 microliths, 2% risk) at presentation. 1
In patients with isolated testicular microlithiasis and no risk factors (no cryptorchidism, testicular atrophy, infertility, contralateral testicular cancer, or Klinefelter syndrome), the risk of developing malignancy at short-term follow-up is low, questioning the need for routine ultrasound surveillance. 1
For high-risk patients (bilateral testicular microlithiasis, infertility, cryptorchidism, atrophic testes, or contralateral testicular cancer), consider testicular biopsy to rule out intratubular germ cell neoplasia (ITGCN). 2
Instruct all patients on monthly testicular self-examination regardless of risk category. 2, 3
Nephrolithiasis Management
Increase fluid intake to achieve at least 2 liters of urine output daily as first-line therapy for preventing recurrent kidney stones. 4, 5
Initial Dietary Modifications
Maintain normal dietary calcium intake of 1,000-1,200 mg/day rather than restricting it, as calcium restriction paradoxically increases oxalate absorption and stone risk. 5, 6
Reduce consumption of soft drinks acidified by phosphoric acid (colas), though drinks acidified by citric acid (fruit-flavored sodas) do not require restriction. 4
Limit sodium and animal protein intake. 4
Pharmacologic Therapy (If Fluid Therapy Fails)
If increased fluid intake fails to prevent stone recurrence, initiate monotherapy with thiazide diuretic, potassium citrate, or allopurinol—combination therapy offers no additional benefit over monotherapy. 4
Thiazide diuretics (hydrochlorothiazide 50 mg, chlorthalidone 25-50 mg, or indapamide 2.5 mg daily) reduce urinary calcium excretion. 4, 5
Potassium citrate (30-100 mEq/day) binds calcium and decreases urine acidity, particularly effective for hypocitraturia and uric acid stones. 4, 5, 6
Allopurinol decreases uric acid in urine, useful for hyperuricosuria. 4, 5
Monitoring Protocol
Obtain 24-hour urine collection within 6 months of treatment initiation measuring volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium, and creatinine. 5
Continue annual 24-hour urine collections to assess adherence and metabolic response. 5
Monitor for adverse effects: hypokalemia and glucose intolerance (thiazides), elevated liver enzymes (allopurinol), and hyperkalemia (potassium citrate). 5
Perform stone composition analysis whenever stone is retrieved, as stone type may change over time. 5
Gallbladder Polyp Management
The management algorithm depends on polyp size and presence of malignancy risk factors (age >60 years, primary sclerosing cholangitis, Asian ethnicity, sessile morphology). 7
Polyps ≥10 mm
- Proceed directly to cholecystectomy if the patient is fit for surgery, as malignancy risk is significant. 7
Polyps 6-9 mm
If one or more risk factors present: recommend cholecystectomy. 7
If no risk factors: perform ultrasound surveillance at 6 months, 1 year, and 2 years. 7
Polyps ≤5 mm
If risk factors present: perform ultrasound surveillance at 6 months, 1 year, and 2 years. 7
If no risk factors: no follow-up required. 7
During Surveillance
If polyp grows to ≥10 mm: recommend cholecystectomy. 7
If polyp grows ≥2 mm within 2 years: consider current size and risk factors through multidisciplinary discussion to determine whether to continue monitoring or proceed with cholecystectomy. 7
If polyp disappears: discontinue monitoring. 7
Discontinue follow-up after 2 years if no growth occurs. 7
Important Caveat
- For symptomatic patients with small polyps and no gallstones, cholecystectomy may be considered if no alternative cause for symptoms is identified, though counsel patients that symptoms may persist post-operatively. 7