What is the appropriate evaluation and management for a palpable epididymal mass in a male patient?

Evaluation and Management of Epididymal Mass

Initial Diagnostic Approach

Scrotal ultrasound with or without Doppler is the definitive first-line imaging study for any palpable epididymal mass, regardless of clinical presentation. 1

Key Clinical Assessment Points

Before imaging, obtain focused clinical information:

• History of prior genital surgery, sexually transmitted infections, or systemic illnesses affecting testicular function 2
• History of vasectomy, trauma, or infection (increases likelihood of benign conditions like tubular ectasia or chronic epididymitis) 3
• Childhood cryptorchidism (raises concern for testicular pathology) 2
• Duration and character of symptoms (persistent tenderness or swelling mandates ultrasound evaluation) 4

Physical Examination Essentials

• Careful palpation to distinguish epididymal from testicular origin 2
• Assessment of mass consistency, mobility, and tenderness 2
• Bilateral examination of vas deferens and evaluation for varicocele 2

Ultrasound Findings and Interpretation

Critical Distinction: Intratesticular vs. Extratesticular

Ultrasound differentiates intratesticular from extratesticular processes with 98-100% accuracy, which is the most important prognostic factor. 1, 4

• Intratesticular masses carry high malignancy risk and require urgent urologic referral 4
• Extratesticular/epididymal masses are predominantly benign (75% of cases) 5

Common Epididymal Mass Patterns on Ultrasound

Cystic lesions:

• Spermatoceles appear as anechoic or hypoechoic cystic structures at the epididymal head 2
• Epididymal cysts have 93.8% diagnostic accuracy on ultrasound 6

Solid or complex lesions require more careful evaluation:

• Chronic epididymitis and tuberculous epididymitis can be difficult to differentiate sonographically 6
• Tuberculous epididymitis may show cold abscess, calcification, or sinus tract formation 6
• Adenomatoid tumors (most common benign epididymal tumor) appear as well-circumscribed solid masses 5

Role of Doppler Ultrasound

Color-power Doppler significantly improves specificity for characterizing epididymal lesions, particularly for inflammatory processes like epididymitis. 1

• Increased vascularity suggests inflammatory or neoplastic processes 1
• Avascular masses may represent hematomas or certain benign lesions 1

Management Algorithm

For Confirmed Epididymal (Extratesticular) Masses:

Simple cysts/spermatoceles:

• Observation is appropriate for asymptomatic lesions 2
• Surgical excision reserved for symptomatic cases

Solid or indeterminate epididymal masses:

• Surgical exploration with intraoperative frozen section is recommended 7, 5
• Organ-sparing epididymectomy is both diagnostic and therapeutic for most benign lesions 7, 5
• The threshold for surgical excision should be low, as it provides definitive diagnosis and is often curative 7

If Intratesticular Component Identified:

Immediate additional workup required:

• Serum tumor markers (AFP, β-hCG, LDH) before any intervention 1, 4
• Chest radiograph 1, 4
• Abdominopelvic CT if intratesticular mass confirmed 1
• Counsel regarding sperm banking before treatment 1, 4
• Inguinal orchiectomy is the primary treatment for suspicious intratesticular masses 1, 4

Advanced Imaging Considerations

MRI of the scrotum is not routinely indicated but may serve as a problem-solving tool when ultrasound findings are indeterminate. 1

• MRI can help distinguish intratesticular from extratesticular masses when ultrasound is equivocal 1
• CT and nuclear medicine scans have no role in initial evaluation of epididymal masses 1

Critical Pitfalls to Avoid

• Do not delay ultrasound for a trial of antibiotics if a discrete palpable mass is present 1, 4
• Do not perform radical orchiectomy for epididymal masses without intraoperative pathological consultation 5
• Do not assume all epididymal masses are benign—while 75% are benign, malignancy must be excluded 5
• Fine needle aspiration alone is inadequate for definitive diagnosis of solid epididymal masses 7