Diagnostic Approach and Management of Scrotal Lumps

Initial Evaluation

• The American College of Radiology recommends scrotal ultrasound with Doppler as the mandatory first-line imaging study to determine whether the lump is intratesticular or extratesticular 2, 1
• Any solid mass within the testis should be managed as malignant until proven otherwise, requiring urgent scrotal ultrasound and serum tumor markers (AFP, β-HCG, LDH) before any intervention 1

Risk Factors and Clinical Distinctions

• The American College of Radiology identifies risk factors to assess, including cryptorchidism (RR 3.18), hypospadias (RR 2.41), inguinal hernia (RR 1.37), testicular atrophy (<12 ml volume), and family history 2, 5
• Approximately 90% of intratesticular masses are malignant, most commonly germ cell tumors (seminoma 50%, non-seminoma 50%) 3, 4

Management Algorithm

• The American Urological Association recommends drawing serum tumor markers (AFP, β-HCG, LDH) before any intervention, including orchiectomy 4, 7, 1
• Scrotal ultrasound with Doppler (7.5 MHz transducer) should be obtained to characterize the mass and assess both testes 3, 4, 1
• Counsel about fertility preservation and offer sperm banking before any definitive treatment 7, 1

Post-Orchiectomy Staging

• Repeat tumor markers 7 days post-surgery to assess half-life kinetics 7, 9
• CT chest, abdomen, and pelvis for staging, as well as full blood count, renal function, and liver enzymes 7, 9

Critical Pitfalls to Avoid

• Never perform scrotal approach biopsy or surgery for suspected testicular tumors, as this violates lymphatic drainage patterns and increases recurrence 3, 4, 7, 1
• Do not delay evaluation of persistent testicular enlargement, as delay correlates with higher stage at presentation 8
• Always obtain tumor markers before orchiectomy, as they are essential for staging and monitoring 4, 7, 1