Management of Painless Testicular Enlargement

Initial Evaluation

The National Comprehensive Cancer Network recommends testicular ultrasound as the primary diagnostic tool to confirm the presence of a testicular mass and determine whether it is intra- or extratesticular 1, 2
Complete blood count, creatinine, electrolytes, and liver enzymes should be obtained if an intratesticular mass is identified, as recommended by the National Comprehensive Cancer Network 1, 3
Serum tumor markers (AFP, β-HCG, LDH) should be measured if a testicular mass is suspected, as they contribute to diagnosis and staging, according to the National Comprehensive Cancer Network and European Urology 1, 2

The National Comprehensive Cancer Network and European Urology recommend inguinal orchiectomy as the primary treatment for most patients who present with a suspicious testicular mass 1, 2, 3
Further management is dictated by histology (seminoma vs. nonseminoma) and stage, as outlined by the National Comprehensive Cancer Network 1, 3
In patients of reproductive age, sperm banking must be discussed before any therapeutic intervention that may compromise fertility, according to the National Comprehensive Cancer Network 1, 3

Biopsy may be considered if a suspicious intratesticular abnormality, such as a hypoechoic mass or macrocalcification, is identified on ultrasound, as recommended by the National Comprehensive Cancer Network 1, 4
If microcalcifications without any other abnormality are observed, testicular biopsy is not necessary, according to the National Comprehensive Cancer Network 1, 4
An open inguinal biopsy of the contralateral testis is not routinely performed but can be considered when a cryptorchid testis or marked atrophy is present, as outlined by the National Comprehensive Cancer Network 1, 3

For testicular masses treated with orchiectomy: follow-up depends on histology and stage, with specific protocols for seminoma and nonseminoma, as recommended by the National Comprehensive Cancer Network and Annals of Oncology 1, 5

Delaying evaluation of persistent testicular enlargement; a delay in diagnosis correlates with a higher stage at presentation for testicular cancer, according to the National Comprehensive Cancer Network 1, 3
Performing scrotal approach for suspected testicular tumors, as this is associated with a higher local recurrence rate, as reported by European Urology 2

The American Urological Association recommends obtaining alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) before any surgical intervention, including orchiectomy, for diagnostic, staging, and monitoring purposes 6
Doppler ultrasound is the diagnostic modality of choice for scrotal masses, although it may have technical limitations in very large masses 7
Any solid intratesticular mass should be managed as malignant until proven otherwise 6

The American Urological Association recommends orchiectomy as both diagnostic and therapeutic, with early clamping of the spermatic cord to prevent hematogenous dissemination 6

The American Urological Association recommends discussing and offering sperm cryopreservation before orchiectomy in all patients of reproductive age 6

Chest radiography and abdominal/pelvic computed tomography (CT) scans are recommended for staging, with CT scans evaluating retroperitoneal lymph nodes 8, 9
Tumor markers should be repeated post-orchiectomy to evaluate normalization and guide adjuvant treatment 8, 9

For seminoma, adjuvant treatment options include surveillance, carboplatin, or radiotherapy, depending on the clinical stage 8, 9
For non-seminoma, management depends on the stage and prognostic group, with options including surveillance, retroperitoneal lymph node dissection, or chemotherapy 6

Follow-up protocols depend on histology and stage, with specific protocols for seminoma and non-seminoma 8, 9
For residual masses >3 cm after chemotherapy, a PET scan is recommended (minimum 6 weeks post-chemotherapy) 8, 9