An 18-year-old man comes to the office due to a mass in his left scrotum. He has no other symptoms. The patient plays basketball regularly but does not recall any recent trauma to the testicle. He is sexually active with 2 partners and does not use condoms. Vital signs are within normal limits. Physical examination shows a left intrascrotal nodule that is difficult to distinguish from the left testis. The mass is nontender, does not change in size upon supine positioning, and does not transilluminate. There is no inguinal lymphadenopathy. Which of the following is the most likely diagnosis?

Question

An 18-year-old man comes to the office due to a mass in his left scrotum.  He has no other symptoms.  The patient plays basketball regularly but does not recall any recent trauma to the testicle.  He is sexually active with 2 partners and does not use condoms.  Vital signs are within normal limits.  Physical examination shows a left intrascrotal nodule that is difficult to distinguish from the left testis.  The mass is nontender, does not change in size upon supine positioning, and does not transilluminate.  There is no inguinal lymphadenopathy.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_39a5_536f_9249_cd35f5146959_MD0001_00 The presence of a painless, solid testicular mass should always be considered testicular cancer until proven otherwise. Most cases present with a nodule or solid swelling in one testicle, which is often initially noticed by a partner or after a minor trauma. Bimanual examination of scrotal contents generally reveals a firm, hard, or fixed nodule within the tunica albuginea (fibrous covering of testes) that is ovoid in shape and painless to palpation. Because light does not penetrate solid tumors, testicular cancer does not transilluminate (unlike fluid-filled hydroceles) (Choice B). Bilateral scrotal ultrasound and serum tumor markers (eg, alpha-fetoprotein, beta human chorionic growth hormone) are usually obtained next to aid diagnosis. Most testicular tumors arise in young men (age 15-35) and are derived from a pluripotent testicular germ cell; these testicular germ cell tumors are generally curable with surgery and (when needed) chemotherapy. (Choice A) Epididymitis is common in young, sexually active men and is usually due to a sexually transmitted infection (eg, Chlamydia trachomatis, Neisseria gonorrhoeae). However, most cases are quite painful, and careful examination usually shows swelling adjacent to, rather than within, the testis. (Choice C) Syphilitic gummas are a manifestation of tertiary syphilis that can develop many years after initial infection in untreated patients. They generally present with painless, white-gray lesions on the skin that may ulcerate; testicular gummas (syphilitic orchitis) are rare and usually associated with pain and fever. (Choice E) Testicular hematoma usually occurs after scrotal trauma and generally presents with significant testicular pain and tenderness to palpation. (Choice F) Varicoceles are due to venous dilation in the pampiniform plexus. They can present with painless testicular swelling but characteristically feel like a "bag of worms" on physical examination. Most decompress with recumbency and grow in size with standing. Educational objective: A painless, solid scrotal mass should be considered testicular cancer until proven otherwise. Examination generally reveals a solid, firm, or fixed nodule in the tunica albuginea that is ovoid in shape and painless to palpation. Testicular tumors do not transilluminate.

An 18-Year-Old Man Comes to the Office Due to a Mass