A 20-year-old male finds a mass in his scrotum. The first step in evaluating this mass is
The first step in evaluating a scrotal mass is to determine whether the mass is in the testis or outside it. Most solid masses arising from within the testis are malignant. Palpation of the scrotal mass and transillumination (holding a flashlight directly against the posterior wall of the scrotum) will distinguish testicular lesions from other masses within the scrotum, such as hydrocele. Ultrasonography will confirm a solid testicular mass. The tumor markers b-HCG and a-fetoprotein are not used in the initial evaluation of a scrotal mass, but may be impoant when a solid mass suggestive of testicular carcinoma is found. b-HCG or AFP will be elevated in about 70% of patients with disseminated nonseminomatous testicular cancer. Seminomas are usually associated with normal tumor cell markers. Choriocarcinomas produce b-HCG. Endodermal sinus tumors or embryonal cell carcinomas are often associated with elevated AFP levels. The lymphatic drainage of the testis is into the periaoic nodes, not to the inguinal nodes. The periaoic nodes must be assessed radiographically, usually by CT scanning, if a testicular neoplasm is strongly suspected.
Palpation and transillumination
HCG and a-fetoprotein
Scrotal ultrasonography
Evaluation for inguinal adenopathy