A 35-year-old man comes to the office for evaluation of an enlarged testicle. His partner first noticed the enlargement 2 weeks ago. The patient feels well and has had no fever, dysuria, urethral discharge, or scrotal trauma. He has a history of HIV infection and has been on antiretroviral therapy for 2 years. His most recent CD4 count was 550/mm³, and he has never had an HIV-related infection. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 72/min. No lymphadenopathy is present. The lungs are clear to auscultation, and heart sounds are normal. The abdomen is soft, nontender, and nondistended with no masses or hepatosplenomegaly. Testicular examination reveals a diffusely enlarged and hard right testicle with no distinct nodules and negative transillumination. The left testis is normal. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bfd6_ab9b_8f63_2b2b85e0c38a_MD0005_00 This patient has a firm, uniformly enlarged testicle that does not transilluminate, raising concern for testicular cancer. Testicular cancer is the most common solid tumor in men age 15-35. Risk is greatest in those with cryptorchidism, but individuals with HIV are at slightly elevated risk. Most patients have painless, unilateral testicular enlargement. Examination usually reveals a firm, hard testicle, with or without nodules, that does not transilluminate. The initial test of choice for evaluating a testicular mass is bilateral scrotal ultrasound. If ultrasound reveals a solid lesion, further work-up with serum tumor markers (eg, alpha-fetoprotein, β-hCG) and screening CT scans is typically required. Most patients then undergo radical inguinal orchiectomy to establish a tissue diagnosis. Radical orchiectomy plus chemotherapy is usually curative; 5-year survival rates are approximately 95%. (Choice A) Varicocele is a common condition of young men that can be treated with venous embolization. Although varicocele can cause testicular enlargement and does not transilluminate, it feels like a bag of worms on examination (unlike cancer, which is typically hard and firm). (Choice B) Patients with suspected testicular cancer who receive trans-scrotal biopsy are at increased risk for lymphatic spread and recurrence. As such, radical orchiectomy is preferred for both tissue diagnosis and treatment. However, scrotal ultrasound should be performed prior to either invasive procedure in order to determine if the mass is solid or cystic. (Choices C and E) Infectious epididymo-orchitis can be treated with a dose of intramuscular ceftriaxone and 10 days of doxycycline. Diagnosis is typically confirmed with urinalysis and urine testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Although infectious epididymo-orchitis can cause testicular enlargement, most cases are very painful and accompanied by scrotal wall erythema. Educational objective: Scrotal ultrasound is the initial test of choice for evaluating a testicular mass. If ultrasound shows a solid mass, further workup with serum tumor markers and screening CT scans is required. Patients with suspected testicular cancer then usually require radical inguinal orchiectomy for both tissue diagnosis and initial treatment. References: Ultrasound of the scrotum. (http://www.ncbi.nlm.nih.gov/pubmed/15602220)

A 35-Year-Old Man Comes to the Office for Evaluation of an Enlarged