In an adult male with a small right‑sided hydrocele and bilateral punctate testicular microlithiasis, what is the recommended management?

Management of Small Right Hydrocele with Bilateral Testicular Microlithiasis

For an adult male with isolated testicular microlithiasis and a small hydrocele, no intervention or routine surveillance is required beyond testicular self-examination, unless additional risk factors for testicular cancer are present. 1

Risk Stratification for Testicular Microlithiasis

The critical first step is determining whether this patient has high-risk features that would change management:

Low-risk patients (isolated testicular microlithiasis without additional risk factors):

• No routine follow-up ultrasound is recommended 1
• Standard age-appropriate urological care with testicular self-examination only 1
• The European Association of Urology confirms that testicular microlithiasis in healthy, asymptomatic individuals carries a low risk of testicular germ cell tumors 1

High-risk features that warrant closer surveillance include:

• Infertility or subfertility (18-fold increased odds of testicular cancer) 1
• History of cryptorchidism (8.5-fold increased risk) 1
• History of contralateral testicular cancer 1
• Klinefelter syndrome 1
• Testicular atrophy (volume <12 mL) 2
• Personal or family history of germ cell tumors 3

Initial Evaluation

Obtain baseline assessment to stratify risk:

• Serum tumor markers (AFP, hCG, LDH) for low-risk patients to establish baseline 1
• Document fertility status, including any history of infertility concerns or abnormal semen analysis 1
• Assess testicular volume on ultrasound—volumes <12 mL indicate atrophy and constitute a risk factor 2
• Document history of cryptorchidism 1

Management Algorithm

For Low-Risk Patients (No Additional Risk Factors):

• No routine follow-up ultrasound 1, 3
• Teach testicular self-examination 1
• Standard age-appropriate urological care 1
• Avoid overdiagnosis and unnecessary follow-up imaging 1

For High-Risk Patients (One or More Risk Factors Present):

• Annual ultrasound surveillance up to age 55 3
• Consider serum tumor markers if clinical suspicion arises 1
• Testicular biopsy may be offered to evaluate for germ cell neoplasia in situ (GCNIS) in highly selected cases 1

Management of the Hydrocele

Small hydroceles are typically managed conservatively:

• No intervention required unless symptomatic or enlarging
• The hydrocele itself does not increase cancer risk
• If a suspicious intratesticular mass or macrocalcification is detected during surveillance, obtain tumor markers before any intervention 1

Critical Pitfalls to Avoid

• Do not perform routine surveillance ultrasound in patients with isolated testicular microlithiasis without risk factors—this leads to overdiagnosis and patient anxiety 1
• Do not confuse microlithiasis with macrocalcifications—the latter require urgent evaluation for malignancy 1
• Be aware that microlithiasis is very common after chemotherapy and should not be construed as an abnormality in that context 4
• If a solid testicular mass is detected, radical inguinal orchiectomy is indicated, and sperm banking should be discussed before any therapeutic intervention 1

When to Escalate Care

Urgent specialist referral is indicated if:

• A testicular mass is found in association with microlithiasis 3
• Tumor markers become elevated 1
• Testicular volume decreases or other concerning features develop on surveillance 3