Urgent Scrotal Ultrasound with Doppler is Mandatory—This Patient Requires Immediate Imaging to Rule Out Testicular Malignancy
This 28-year-old male with a firm, movable scrotal mass must undergo scrotal ultrasound with Doppler imaging immediately, as any solid intratesticular mass must be managed as malignant until proven otherwise, and the current antibiotic treatment should not delay definitive diagnostic evaluation. 1, 2
Critical Next Steps
Immediate Diagnostic Workup
Order scrotal ultrasound with color Doppler imaging now—this is the mandatory first-line imaging modality with nearly 100% sensitivity for detecting intrascrotal masses and 98-100% accuracy for distinguishing intratesticular from extratesticular processes 1, 3, 4
The ultrasound must include both grayscale and color Doppler to assess blood flow patterns, evaluate testicular parenchymal architecture for hypoechoic masses or macrocalcifications, and determine if the mass is intra- or extratesticular 1, 3, 4
If an intratesticular mass is identified on ultrasound, immediately obtain serum tumor markers (AFP, β-HCG, LDH) before any surgical intervention, as these are essential for diagnosis, staging, and monitoring 2, 4
Why This Cannot Wait
The clinical presentation is concerning for several reasons:
A firm, movable mass in a young male raises significant concern for testicular malignancy, which is the most critical diagnosis to exclude 2, 5
The presence of redness and discharge suggests possible overlying skin infection or inflammation, but this does not exclude an underlying testicular mass that could be malignant 6, 7
Most extratesticular masses are benign, but intratesticular solid masses are malignant until proven otherwise 2, 6, 8
Management Algorithm Based on Ultrasound Findings
If Intratesticular Mass is Identified:
Urgent urology referral for radical inguinal orchiectomy—this is both diagnostic and therapeutic, with early clamping of the spermatic cord to prevent hematogenous dissemination 2, 4
Discuss sperm banking before orchiectomy in this reproductive-age male, as this must be offered before any therapeutic intervention that may compromise fertility 2, 4
Obtain complete blood count, creatinine, electrolytes, and liver enzymes if an intratesticular mass is confirmed 2
If Extratesticular Mass or Benign Finding:
Continue current antibiotic therapy if epididymitis, epididymal cyst, or other benign extratesticular pathology is confirmed 6, 7
Manage conservatively for simple hydrocele, varicocele, or other benign findings 4, 5
Critical Pitfalls to Avoid
Never delay ultrasound imaging because the patient is already on antibiotics—the firm, movable nature of this mass requires definitive characterization regardless of concurrent infection treatment 1, 2
Never perform scrotal incision or biopsy if testicular malignancy is suspected—only inguinal orchiectomy is appropriate, as a scrotal approach violates lymphatic drainage pathways and is associated with higher local recurrence rates 2, 4
Do not assume this is simply an infection because of redness and discharge—these findings could represent overlying skin changes with an underlying testicular mass 7, 5
Never rely on physical examination alone to differentiate benign from malignant masses—ultrasound is essential for accurate diagnosis 1, 8
Regarding Current Treatment
The current antibiotic regimen (co-amoxiclav) and topical mupirocin are appropriate for treating any superficial skin infection or epididymitis, but these should not delay diagnostic imaging 5
Continue warm compresses and hygiene measures as adjunctive therapy while awaiting ultrasound results 5
Timing Considerations
Schedule the ultrasound within 24-48 hours maximum—while this does not appear to be an acute torsion (given the absence of pain and normal vital signs), the possibility of testicular malignancy requires prompt evaluation, as delays in diagnosis correlate with higher stage at presentation 2, 5