What are the possible causes and treatments for an enlarged right testicle?

Enlarged Right Testicle: Diagnostic Approach and Management

Any enlarged testicle requires immediate scrotal ultrasound with Doppler to differentiate between benign and malignant causes, as any solid intratesticular mass must be managed as testicular cancer until proven otherwise. 1

Immediate Diagnostic Workup

First-Line Imaging

• Perform high-resolution scrotal ultrasound with color Doppler immediately as the mandatory first-line diagnostic test, which has nearly 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing intratesticular from extratesticular processes 2, 3
• The ultrasound must include both grayscale and color Doppler evaluation to assess blood flow patterns and determine whether any mass is intratesticular versus extratesticular, which fundamentally changes management 2, 3
• Power Doppler should be utilized due to its increased sensitivity to low-flow states 2

Laboratory Evaluation

• Obtain serum tumor markers (AFP, β-HCG, LDH) before any surgical intervention if an intratesticular mass is identified, as these are essential for diagnosis, staging, and monitoring 1, 4
• Order complete blood count, creatinine, electrolytes, and liver enzymes if an intratesticular mass is confirmed 1

Differential Diagnosis Based on Clinical Presentation

Painless Enlargement (Most Common Presentation)

• Testicular cancer - presents as unilateral painless mass, often discovered incidentally 5
• Hydrocele - fluid accumulation that can mask underlying testicular tumors and delay diagnosis 6
• Varicocele - dilated veins that become more prominent when standing, less noticeable when lying down 3
• Inguinal hernia - intermittent lump that appears/disappears with position changes or Valsalva maneuver 3

Painful or Intermittent Enlargement

• Intermittent testicular torsion - can present with intermittent pain and swelling during torsion episodes, requires urgent evaluation even if symptoms resolve 3
• Epididymitis/epididymo-orchitis - enlarged hypoechoic epididymis with increased blood flow on Doppler, may have fever and pyuria 2
• Tuberculous epididymitis - can masquerade as a scrotal tumor, though rare 7

Management Algorithm Based on Ultrasound Findings

If Intratesticular Mass Identified

Proceed directly to radical inguinal orchiectomy without delay, as this is both diagnostic and therapeutic 1, 4

Pre-Operative Steps:

• Discuss and offer sperm banking before orchiectomy in all patients of reproductive age, as this must be addressed before any therapeutic intervention 1, 4
• Ensure tumor markers are drawn before surgery 2
• Never perform scrotal biopsy or scrotal incision for suspected malignancy - only inguinal orchiectomy is appropriate, as scrotal approach is associated with higher local recurrence rates 2, 1

Surgical Technique:

• Radical orchiectomy must be performed through an inguinal incision with early clamping of the spermatic cord at the level of the internal inguinal ring to prevent hematogenous dissemination 2, 1
• Any scrotal violation should be strongly avoided 2

Post-Operative Management:

• Repeat tumor markers minimum 7 days after orchiectomy to evaluate normalization and determine half-life kinetics 2
• Obtain chest radiography and abdominal/pelvic CT scans for staging 1
• Further management depends on histology (seminoma vs. non-seminoma) and stage 1

If Extratesticular Mass or Benign Findings

• Hydrocele: Generally managed supportively, but do not assume the testicle is normal - hydroceles can mask underlying testicular tumors 5, 6
• Varicocele: Generally asymptomatic; surgical treatment uncertain benefit for fertility 5
• Epididymitis: Treat with appropriate antibiotics (covering C. trachomatis, N. gonorrhoeae, or enteric bacteria), analgesics, and scrotal support 5

If Torsion Suspected

• Immediate surgical exploration within 6 hours of symptom onset is necessary to achieve >90% salvage rates 2, 3
• Do not delay surgery for imaging if clinical suspicion is high 3
• Look for the "whirlpool sign" (spiral twist of spermatic cord) on ultrasound, which is the most specific sign of torsion 2

Critical Pitfalls to Avoid

• Never rely on physical examination alone when fluid (hydrocele) is present, as it can completely mask an underlying testicular tumor leading to delayed presentation of metastatic disease 6
• Never use the Prehn sign alone to differentiate epididymitis from torsion, as it has poor sensitivity and specificity 3
• Do not delay evaluation of persistent testicular enlargement - delay in diagnosis correlates with higher stage at presentation and worse outcomes 1, 4
• Never assume a mass is benign in high-risk patients (history of cryptorchidism, contralateral testicular cancer, family history) 4
• Do not forget that metastatic disease to the testicle can occur from colorectal cancer and other primaries, though rare 8

Special Considerations

• In patients with systemic symptoms (weight loss, weakness, anemia), consider that testicular cancer may present with metastatic disease, or that systemic conditions like sarcoidosis can mimic testicular malignancy 6, 9
• Patients with congenital anomalies (hypospadias, cryptorchidism) have 3.6-7.4 times higher risk of testicular cancer 4
• False-negative Doppler evaluations can occur with partial torsion and spontaneous detorsion 2