The new england journal of medicine Case Records of the Massachusetts General Hospital Founded by Richard C. Cabot Eric S. Rosenberg, M.D., Editor Virginia M. Pierce, M.D., David M. Dudzinski, M.D., Meridale V. Baggett, M.D., Dennis C. Sgroi, M.D., Jo-Anne O. Shepard, M.D., Associate Editors Allison R. Bond, M.D., Case Records Editorial Fellow Emily K. McDonald, Sally H. Ebeling, Production Editors Case 10-2018: An 84-Year-Old Man with Painless Unilateral Testicular Swelling Ryan W. Thompson, M.D., HeiShun Yu, M.D., Douglas M. Dahl, M.D., Rocio M. Hurtado, M.D., and Dipti P. Sajed, M.D., Ph.D.​​ Presentation of Case Dr. Michael S. Abers (Medicine): An 84-year-old man was evaluated at this hospital From the Departments of Medicine (R.W.T.), because of painless right testicular swelling. Radiology (H.Y.), Urology (D.M.D.), and Pathology (D.P.S.), Massachusetts Gen- The patient had been in his usual state of health until 6 weeks before this eral Hospital, and the Departments of evaluation, when he noted while showering that the right testicle was approxi- Medicine (R.W.T., R.M.H.), Radiology mately 3 times larger than the left testicle. The testicle was soft and nontender on (H.Y.), Urology (D.M.D.), and Pathology (D.P.S.), Harvard Medical School — both palpation, and the enlargement had not been present the previous day. in Boston. The next day, the patient was evaluated at a local urgent care clinic. He re- N Engl J Med 2018;378:1233-40. ported no trauma, heavy lifting, recent sexual intercourse, testicular or scrotal DOI: 10.1056/NEJMcpc1712224 pain, abdominal or back pain, skin changes or rash, obstructive urinary symp- Copyright © 2018 Massachusetts Medical Society. toms, hematuria or dysuria, or discharge. He had no constitutional symptoms, such as fever, night sweats, or weight loss. On examination, the right testicle had a large, soft, mobile posterior mass; the left testicle was normal. A presumptive diagnosis of a hydrocele was made, and the patient was advised to use scrotal support and, if pain occurred, to take nonsteroidal antiinflammatory drugs. Tes- ticular ultrasonography was scheduled for the following day. Dr. HeiShun Yu: The next day, ultrasonography (Fig. 1) revealed marked asym- metric enlargement and hypervascularity of the right testicle. A hypoechoic region in the mediastinum testis was most likely related to edema due to infection or inflammation. The epididymis was also enlarged and hypervascular. An associ- ated complex hydrocele, with septations and internal debris, was present on the right side. These findings were compatible with right epididymo-orchitis. The left testicle had normal echotexture and no focal lesion. There was an incidental left varicocele. Dr. Abers: A 10-day course of oral levofloxacin was prescribed. Six weeks later, at a follow-up visit with his primary care physician, the patient reported persistent testicular swelling. He noted that there had been a mild decrease in the swelling after he had completed the levofloxacin course but that the testicle continued to n engl j med 378;13 nejm.org March 29, 2018 1233 The New England Journal of Medicine Downloaded from nejm.org by MARK LITWIN on April 10, 2018. For personal use only. No other uses without permission. Copyright © 2018 Massachusetts Medical Society. All rights reserved. The new england journal of medicine A B C D Figure 1. Initial Ultrasound Images. A transverse ultrasound image of the scrotum shows asymmetric enlargement and edema of the right testicle (Panel A, arrow), and a corresponding color Doppler image shows asymmetric hypervascularity of the right testicle (Panel B, arrow). A sagittal ultrasound image of the right hemiscrotum shows enlargement of the right epididymis (Panel C, arrow), and a corresponding color Doppler image shows diffuse hypervascularity of the right testicle and epididymis (Panel D). enlarge thereafter, causing inconvenience owing of age. He was a retired health care professional; to its bulk and the pressure in the right groin, he reported that he had had at least one negative which made it difficult for him to sit and to flex tuberculin skin test in the past. More than 40 his upper leg. There were no additional symp- years earlier, he had smoked cigarettes for 5 years; toms, such as pain or fever. he did not consume alcohol or use illicit drugs. The patient had long-standing benign pros- He had traveled to Canada, Western Europe, and tatic hypertrophy with associated nocturia, as the Caribbean in the past. His mother had died well as Raynaud’s phenomenon, mild normo- in her 70s after a stroke, his father had lived cytic anemia, peptic ulcer disease, colonic diver- beyond 90 years of age, a brother had prostatic ticulosis, hypercholesterolemia, hearing loss, and hypertrophy, and a sister had multiple sclerosis. cataracts. An episode of syncope had occurred There was no family history of cancer. after exercise on a hot and humid day 3 years On examination, the patient appeared well. The earlier, and he had undergone left inguinal herni- temperature was 36.3°C, the heart rate 54 beats orrhaphy with mesh placement 13 years earlier. per minute, the blood pressure 119/64 mm Hg, Medications were aspirin, omeprazole, tamsulo- and the oxygen saturation 98% while he was sin, finasteride, nifedipine as needed for symp- breathing ambient air. The weight was 72.3 kg, toms of Raynaud’s phenomenon, and pravastatin. and the body-mass index (the weight in kilograms The patient had no known allergies. He per- divided by the square of the height in meters) formed aerobic exercise daily. He was married, 28.3. A firm, nontender right scrotal mass (7 cm had no children, and had immigrated to the in diameter) was located in the posterior region, United States from Turkey when he was 20 years protruding superiorly to the external inguinal 1234 n engl j med 378;13 nejm.org March 29, 2018 The New England Journal of Medicine Downloaded from nejm.org by MARK LITWIN on April 10, 2018. For personal use only. No other uses without permission. Copyright © 2018 Massachusetts Medical Society. All rights reserved. Case Records of the Massachusetts General Hospital ring. The mass transmitted light on transillumi- of testicular loss due to torsion or systemic nation. The scrotal skin was normal, with no spread of infection, they are unlikely diagnoses erythema or peau d’orange (orange peel) changes. in this case, given the patient’s gradual onset The left testicle had changes consistent with a of symptoms and the absence of pain on pre- varicocele. The prostate was small and benign sentation. on palpation. There was no inguinal lymphade- nopathy. The remainder of the examination was Hernia and Hydrocele normal. Urinalysis showed yellow, clear urine, Common causes of painless testicular enlarge- with a specific gravity of 1.011 (reference range, ment in elderly men include hydrocele, varico- 1.001 to 1.035), a pH of 6.0 (reference range, 5.0 cele, and inguinoscrotal hernia. Assessment for to 9.0), and no evidence of leukocyte esterase or a hernia can easily be performed on physical occult blood. A culture of the urine was sterile. examination. Although this patient had previ- Dr. Yu: Repeat testicular ultrasonography (Fig. 2) ously undergone a left inguinal hernia repair, a revealed further enlargement of the right testi- hernia on the right side was a consideration. cle. The right testicular volume was approximate- However, the transmission of light on transillu- ly 33 ml; it had been approximately 19 ml on an mination rendered a diagnosis of inguinoscrotal image obtained 6 weeks earlier. The hypoechoic hernia unlikely and confirmed the presence of region in the right mediastinum testis had in- fluid inside the scrotum, a finding consistent creased in size. The right testicular parenchyma with a hydrocele. Therefore, hydrocele was the and epididymis remained hypervascular. Multi- leading consideration on the patient’s initial ex- ple new nonspecific hypoechoic areas were scat- tered throughout the remaining testicular paren- chyma. The left testicle was normal. A Dr. Abers: A diagnostic procedure was per- formed. Differential Diagnosis Dr. Ryan W. Thompson: This 84-year-old man pre- sented with a 6-week history of painless swell- ing of the right testicle. In formulating a differ- ential diagnosis, the two key considerations are establishing the most worrisome or “can’t miss” diagnoses and establishing the most likely diag- B nostic possibilities according to age and epide- miologic and other features of the patient’s pre- sentation. In an 84-year-old man with unilateral testicular swelling, with a solid testicular mass in the absence of systemic inflammatory symp- toms that would be suggestive of acute infection, my initial impression is cancer. In fact, such a clinical presentation in an older man would be considered cancer until proven otherwise. Figure 2. Additional Ultrasound Images. Two additional considerations in narrowing Repeat ultrasonography was performed approximately the differential diagnosis are the degree of pain 6 weeks after the first ultrasound examination, at the and the pace of onset. Causes of testicular en- time of the current evaluation. A transverse ultrasound largement that develop suddenly and often in- image of the scrotum shows persistent asymmetric en- largement of the right testicle and worsening edema in volve considerable pain include testicular torsion the mediastinum testis (Panel A, arrow), and a corre- and acute testicular infections, such as epididy- sponding color Doppler image shows persistent hyper- mitis and orchitis. Although these diagnoses fall vascularity of the right testicle (Panel B, arrow). into the “can’t miss” category because of the risk n engl j med 378;13 nejm.org March 29, 2018 1235 The New England Journal of Medicine Downloaded from nejm.org by MARK LITWIN on April 10, 2018.