I've noticed an increase in my testicular size; what evaluation should I seek?

Evaluation of Increased Testicular Size

If you've noticed an increase in testicular size, you need an urgent scrotal ultrasound with Doppler to rule out testicular cancer, as any solid mass must be managed as malignant until proven otherwise. 1, 2

Immediate Clinical Assessment

Your evaluation should focus on these specific findings:

• Onset pattern: Sudden enlargement with severe pain suggests torsion requiring emergency surgery within 6-8 hours, while gradual painless enlargement raises concern for malignancy 1, 2
• Palpable characteristics: A hard, non-tender mass is highly suspicious for testicular cancer, while a soft, fluctuant swelling suggests hydrocele 1, 2
• Associated symptoms: Pain relieved by elevating the testicle (Prehn sign) suggests epididymitis rather than torsion 1
• Testicular size comparison: Normal adult testicular volume is approximately 15-25 mL; significant asymmetry (>2 mL difference) warrants investigation 1

Diagnostic Imaging Protocol

Scrotal ultrasound with color Doppler is the only appropriate initial imaging study 1, 2:

• This examination assesses testicular parenchyma, blood flow patterns, and characterizes any masses or fluid collections 2
• Normal testicular blood flow helps distinguish benign conditions from torsion 2
• Any solid hypoechoic mass with vascular flow is highly suggestive of malignancy 2
• Do not obtain CT or MRI as initial imaging—ultrasound is the definitive first-line study 1

Critical Management Decisions

If ultrasound identifies a solid testicular mass:

• Obtain serum tumor markers immediately (AFP, hCG, LDH) before any surgical intervention 2
• Radical inguinal orchiectomy is the standard treatment—a solid testicular mass must be managed as malignant until proven otherwise 2
• Discuss sperm banking before surgery if fertility preservation is desired 2
• Never perform a scrotal incision if malignancy cannot be excluded, as this violates oncologic principles 2

Common Pitfalls to Avoid

• Do not delay surgical exploration if torsion is suspected clinically, even with normal Doppler findings—false-negative rates reach 30% 2
• Do not perform ultrasound or other imaging for undescended testicles before specialist referral, as these studies rarely assist in decision-making 1
• Do not rely solely on physical examination to exclude serious pathology—palpation has limited sensitivity for detecting early testicular cancer 1, 2

Additional Considerations for Specific Scenarios

If you have a history of undescended testicles (cryptorchidism):

• You are at significantly increased risk for testicular cancer and should perform monthly self-examination 1
• Consider testicular biopsy if you have infertility, bilateral testicular microcalcification, or atrophic testes (<12 mL) 1

If the enlargement is bilateral with small, firm testicles:

• Check FSH, LH, and testosterone levels to evaluate for primary testicular failure 1
• Karyotype testing is indicated if FSH is elevated with testicular atrophy, as Klinefelter syndrome (47,XXY) is a common cause 1