A solid intratesticular mass in a young man is a germ cell tumour until proven otherwise; ultrasound confirms it is intratesticular, characterises it and looks at the other testis — CT then stages the retroperitoneum.
Orient first
- Extratesticular masses are usually benign; intratesticular solid masses are usually malignant.
- Seminoma: homogeneous, hypoechoic; non-seminomatous tumours: heterogeneous, cystic areas, calcification.
- Benign mimics: epidermoid cyst (onion-ring), tubular ectasia of the rete testis, segmental infarction, orchitis, Leydig cell tumour.
Acquire the study
- High-frequency linear probe (≥ 10 MHz), both testes in transverse and longitudinal planes, colour Doppler; staging CT of chest, abdomen and pelvis if malignant.
The manoeuvre
- Confirm the mass is inside the tunica albuginea (intratesticular) in two orthogonal planes.
- Size in mm, echotexture, cystic parts, calcification.
- Colour Doppler: internal vascularity (tumour) vs avascular (epidermoid, infarct, haematoma).
- Contralateral testis: microlithiasis, a synchronous lesion.
- Report: recommend tumour markers and staging CT (retroperitoneal nodes at the renal hilum).
What confirms it
- A solid, vascular intratesticular mass — orchidectomy provides the histology.
What licenses you to exclude it
- An avascular lesion with an onion-ring pattern (epidermoid) or a wedge-shaped avascular area (infarct) can be benign — say so and recommend follow-up.
The classic misread
- Calling a focal orchitis a tumour — orchitis is hypervascular, tender and resolves on follow-up.
- Staging only the pelvis — testicular tumours drain to the para-aortic nodes at the renal hila.