From the CLINICAL INQUIRIES Family Physicians Inquiries Network

Kathleen Barnhouse, MD How should you further evaluate University of North Carolina Department of Family Medicine, an adult with a testicular mass? Chapel Hill, NC Anne Powers, MSLS Duke University Medical Center Evidence-based answer Library, Durham, NC Perform a scrotal ultrasonography exclude conditions such as neoplasm, for immediately to determine whether which further workup is indicated (SOR: C, emergency surgery is necessary for based on expert opinion). patients with an exam or history that In those cases in which ultrasound suggests testicular torsion or rupture and clinical exam are inconclusive or (strength of recommendation [SOR]: confl icting, magnetic resonance imaging B, based on cohort trials of patient (MRI) can provide additional information oriented outcomes). In less urgent cases, to improve management and decrease ultrasound is also useful for verifying unnecessary surgery (SOR: B, based on diagnoses made by physical exam, and to cohort trials of patient-oriented outcomes). Clinical commentary Acutely painful testicle? Involve a inclusion cysts. I now describe these radiologist and urologist early on fi ndings as a routine part of my counseling. FAST TRACK One of the keys to managing testicular Given the devastating consequences of Perform a masses is to differentiate normal anatomical a missed or delayed diagnosis of torsion, structures and benign peritesticular infarction, and cancer, I always make 2 scrotal ultrasound pathology (such as varicoceles and phone calls early on when a patient has an immediately spermatoceles) from true testicular masses. acutely painful testicle or a true testicular to exclude any Early in my career, after I counseled men to mass: I call the radiologist and the urologist. pathology that do testicular self-exams, they occasionally These 2 phone calls can substantially made return visits concerned about a mass. reduce the risk of diagnostic delay. needs emergency These were almost always the testicular Peter C. Smith, MD surgery appendix, the epididymis, or scrotal Rose Family Medicine Residency, University of Colorado Health Sciences Center, Denver

❚ Evidence summary Ultrasound is the best initial test A wide variety of conditions can cause Testicular torsion and acute epididymo- scrotal masses (see TABLE 1 for a list orchitis are the most common causes of of causes of acute scrotal swelling and an acute scrotum.3 Patients with an acute TABLE 2 for causes of nonacute swell- scrotum require an urgent ultrasound to ing).1,2 Many just require that you re- exclude pathology that requires immedi- assure the patient; however, some con- ate surgery (TABLES 1 AND 2).1 Although ditions do need diagnostic testing to clinical exam identifi es almost all cases determine appropriate treatment. of torsion, a few cases are missed.4 In a

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8851_r1_JFP100751_r1_JFP1007 885151 99/21/07/21/07 110:18:230:18:23 AMAM TABLE 1 INQUIRIES Causes of acute scrotal swelling1,2

CONDITION CLINICAL PRESENTATION PHYSICAL EXAM/CLINICAL COMMENTS

Epididymitis • Severe swelling and pain • Edema, tenderness, erythema

CLINICAL • Positive urinalysis because it’s often associated with urinary tract infection or prostatitis • Can result in abscess formation

Testicular torsion • Severe pain sudden in • Usually occurs in post-pubertal and neonatal onset (except in neonates) age group • Often presents with an asymmetric high riding testis or transverse orientation of affected testis • Cremasteric refl ex usually absent • Not relieved with elevation • Surgical emergency

Trauma • Associated with wide • May result in testicular rupture or torsion, spectrum of injuries which are surgical emergencies

Torsion of • Gradual onset of pain • Usually pre-pubertal age group appendix testis • Cremasteric refl ex preserved • Tenderness often localized to anterosuperior testes • Surgery not required in majority of cases

Inguinal hernia • Pain and swelling • May hear bowel sounds on affected side

study of 209 emergency scrotal explora- Fortunately, false-negative scrotal ul- tions, clinical exam by general practitio- trasounds are rare. In a small study ners and surgeons correctly diagnosed comparing clinical exam with ultrasound only 92.5% and 94% of testicular tor- for diagnosis of testicular tumor, the FAST TRACK sion cases, respectively, compared with negative predictive value of ultrasound In nonacute cases, the surgical diagnosis.4 was 100%.6 In another study, which used surgery Although ultrasound has high sen- ultrasound can as the diagnostic gold standard, color Dop- sitivity for detection of testicular neo- help confi rm pler ultrasound had a sensitivity of 93.5% plasm, it cannot differentiate benign exam fi ndings for the diagnosis of testicular torsion;5 this from malignant tumors.2 Addition- and exclude has led some to say the combination of ally, ultrasound sometimes fails to dif- both clinical exam and ultrasound should ferentiate a neoplastic process from a neoplasms be used to determine the need for sur- complication of an infection such as gery.1 However, this combination has not an abscess. In those instances, a repeat been thoroughly evaluated by researchers, ultrasound is suggested after antibiotic and the best evidence shows that physi- administration to ensure resolution of cian exam is essentially the same as color the mass.2 Doppler ultrasound for diagnosing testic- ular torsion. If torsion cannot be reliably When ultrasound is inconclusive, excluded, emergent surgical exploration is MRI may be helpful mandatory.4 When clinical and ultrasound fi ndings For patients who have a nonacute are inconclusive, MRI may help deter- scrotal mass, ultrasound is often indi- mine a diagnosis. For example, MRI cated to distinguish intratesticular from can help distinguish infl ammation or extratesticular masses.1 Although testicu- abscess from neoplasm, thus prevent- lar neoplasm is relatively rare, it is a con- ing a patient from undergoing unneces- cern for patients with non-painful masses. sary surgical intervention.2,7 If testicular

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TABLE 2 Causes of nonacute scrotal swelling1

CONDITION CLINICAL PRESENTATION PHYSICAL EXAM/CLINICAL COMMENTS

Hydrocele • Painless mass that may • Can be transilluminated increase in size throughout • Reactive hydrocele may be associated with the day testicular neoplasm, epididymitis, orchitis, or torsion

Testicular cyst • None • Benign incidental fi nding • Nonpalpable

Varicocele • Scrotal swelling secondary • Usually left-sided to dilation of spermatic • Described as a bag of worms superior to the testicle veins • Noticeable when standing or with • May present as infertility Valsalva maneuver • May present with pain if intratesticular

Spermatocele • If painful, relieved • Often an incidental fi nding on exam with elevation • Freely mobile • Usually located in epididymal head

Epidermoid • Painless mass • Found anywhere in epididymis cyst • Often surgically removed because it may be diffi cult to differentiate from malignancy

Primary • Solid mass • 10% present acutely with hemorrhage testicular • Classically painless but may • Most common malignancy in males tumor1,9 produce testicular discomfort between ages 18 and 40

Metastatic • Painless mass • Possible primary cancers include leukemia tumor lymphoma, melanoma, lung, prostate, kidney, GI tract FAST TRACK neoplasm cannot be excluded based on 3. Akin EA, Khati NJ, Hill MC. Ultrasound of the scro- If other fi ndings clinical and radiographic fi ndings, sur- tum. Ultrasound Q 2004; 20:181–200. gery is indicated.1 4. Watkin NA, Reiger NA, Moisey CU. Is the conserva- are inconclusive, tive management of the acute scrotum justifi ed on MRI can help clinical grounds? Br J Urol 1996; 78:623–627. Recommendations from others 5. Andipa E, Liberopoulos K, Asvestis C. Magnetic distinguish Few current evidence-based recommen- resonance imaging and ultrasound evaluation of infl ammation dations exist on the approach to patients penile and testicular masses. World J Urol 2004; with scrotal masses. The National Col- 22:382–391. from tumor laborating Centre for Primary Care (UK) 6. van Dijk R, Doesburg WH, Verbeek AL, van der Schouw YT, Debruyne FM, Rosenbusch G. Ultra- suggests an urgent ultrasound when a sonography versus clinical examination in evalua- scrotal mass does not transilluminate or tion of testicular tumors. J Clin Ultrasound 1994; when the examiner cannot distinguish 22:179–182. the body of the testis.8 ■ 7. Muglia V, Tucci S Jr, Elias J Jr, Trad CS, Bilbey J, Cooperberg PL. Magnetic resonance imaging of scrotal diseases: when it makes the difference. References Urology 2002; 59:419–423. 1. Micallef M, Torreggiani WC, Hurley M, Dinsmore WW, Hogan B. The ultrasound investigation of scro- 8. National Collaborating Centre for Primary Care. Re- tal swelling. Int J STD AIDS 2000; 11:297–302. ferral guidelines for suspected cancer. London: Na- tional Institute for Health and Clinical Excellence; 2. Eyre RC. Evaluation of nonacute scrotal pathology in adults. In: Rose BD, ed. UpToDate [online da- June 2005. NICE Clinical Guideline 27. Available at tabase]. Version 14.1. Waltham, Mass: UpToDate; www.nice.org.uk/page.aspx?o=261649. Accessed 2006. on August 29, 2007.

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