Clinical Inquiries
How should you further evaluate an adult with a testicular mass?
Barnhouse K, Powers A, Smith PC. J Fam Pract. 2007 Oct;56(10):851-3.
Evidence-based Answer
Perform a scrotal ultrasonography immediately to determine whether emergency surgery is necessary for patients with an exam or history that suggests testicular torsion or rupture (strength of recommendation [SOR]: B, based on cohort trials of patient oriented outcomes). In less urgent cases, ultrasound is also useful for verifying diagnoses made by physical exam, and to exclude conditions such as neoplasm, for which further workup is indicated (SOR: C, based on expert opinion).
In those cases in which ultrasound and clinical exam are inconclusive or conflicting, magnetic resonance imaging (MRI) can provide additional information to improve management and decrease unnecessary surgery (SOR: B, based on cohort trials of patient-oriented outcomes).
Evidence-based Summary
A wide variety of conditions can cause scrotal masses (see TABLE 1 for a list of causes of acute scrotal swelling and TABLE 2 for causes of nonacute swelling).1,2 Many just require that you reassure the patient; however, some conditions do need diagnostic testing to determine appropriate treatment. [TABLE 1: Causes of acute scrotal swelling1,2] [TABLE 2: Causes of nonacute scrotal swelling]Ultrasound is the best initial test
Testicular torsion and acute epididymoorchitis are the most common causes of an acute scrotum.3 Patients with an acute scrotum require an urgent ultrasound to exclude pathology that requires immediate surgery (TABLES 1 AND 2).1 Although clinical exam identifies almost all cases of torsion, a few cases are missed.4 In a study of 209 emergency scrotal explorations, clinical exam by general practitioners and surgeons correctly diagnosed only 92.5% and 94% of testicular torsion cases, respectively, compared with the surgical diagnosis.4 In another study, which used surgery as the diagnostic gold standard, color Doppler ultrasound had a sensitivity of 93.5% for the diagnosis of testicular torsion;5 this has led some to say the combination of both clinical exam and ultrasound should be used to determine the need for surgery.1 However, this combination has not been thoroughly evaluated by researchers, and the best evidence shows that physician exam is essentially the same as color Doppler ultrasound for diagnosing testicular torsion. If torsion cannot be reliably excluded, emergent surgical exploration is mandatory.4
For patients who have a nonacute scrotal mass, ultrasound is often indicated to distinguish intratesticular from extratesticular masses.1 Although testicular neoplasm is relatively rare, it is a concern for patients with non-painful masses. Fortunately, false-negative scrotal ultrasounds are rare. In a small study comparing clinical exam with ultrasound for diagnosis of testicular tumor, the negative predictive value of ultrasound was 100%.6
Although ultrasound has high sensitivity for detection of testicular neoplasm, it cannot differentiate benign from malignant tumors.2 Additionally, ultrasound sometimes fails to differentiate a neoplastic process from a complication of an infection such as an abscess. In those instances, a repeat ultrasound is suggested after antibiotic administration to ensure resolution of the mass.2 When ultrasound is inconclusive, MRI may be helpful
When clinical and ultrasound findings are inconclusive, MRI may help deter-mine a diagnosis. For example, MRI can help distinguish inflammation or abscess from neoplasm, thus preventing a patient from undergoing unnecessary surgical intervention.2,7 If testicular neoplasm cannot be excluded based on clinical and radiographic findings, surgery is indicated.1
Clinical Commentary
Acutely painful testicle? Involve a radiologist and urologist early on
Peter C. Smith, MD
Rose Family Medicine Residency, University of Colorado Health Sciences Center, Denver
One of the keys to managing testicular masses is to differentiate normal anatomical structures and benign peritesticular pathology (such as varicoceles and spermatoceles) from true testicular masses. Early in my career, after I counseled men to do testicular self-exams, they occasionally made return visits concerned about a mass. These were almost always the testicular appendix, the epididymis, or scrotal inclusion cysts. I now describe these findings as a routine part of my counseling. Given the devastating consequences of a missed or delayed diagnosis of torsion, infarction, and cancer, I always make 2 phone calls early on when a patient has an acutely painful testicle or a true testicular mass: I call the radiologist and the urologist. These 2 phone calls can substantially reduce the risk of diagnostic delay.
Recommendations from Others
Few current evidence-based recommendations exist on the approach to patients with scrotal masses. The National Collaborating Centre for Primary Care (UK) suggests an urgent ultrasound when a scrotal mass does not transilluminate or when the examiner cannot distinguish the body of the testis.8
References
- Micallef M, Torreggiani WC, Hurley M, Dinsmore WW, Hogan B. The ultrasound investigation of scrotal swelling. Int J STD AIDS 2000;11:297–302.
- Eyre RC. Evaluation of nonacute scrotal pathology in adults. In: Rose BD, ed. UpToDate [online database]. Version 14.1. Waltham, Mass: UpToDate; 2006.
- Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996;78:623–627.
- Andipa E, Liberopoulos K, Asvestis C. Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses. World J Urol 2004;22:382–391.
- van Dijk R, Doesburg WH, Verbeek AL, van der Schouw YT, Debruyne FM, Rosenbusch G. Ultrasonography versus clinical examination in evaluation of testicular tumors. J Clin Ultrasound 1994;22:179–182.