Incidental Non-Palpable Testicular Lesions: Management According to EFSUMB/WFUMB
Problem Context
The widespread use of high-frequency probes has led to an increase in the frequency of incidental non-palpable testicular lesions. Approaches to their management are systematized in the WFUMB position paper "Incidental Findings and How to Manage Them: Testis" (Lewicki A, Freeman S, Jedrzejczyk M et al., 2021) and in the EFSUMB guidelines on multiparametric scrotal ultrasound (Bertolotto et al.).
Simple Intratesticular Cyst
A simple (intratesticular) cyst is found in approximately 5–10% of men during scrotal ultrasound; the true frequency is likely higher due to the use of high-frequency probes. Most often, cysts are located in the mediastinum testis (rete testis).
The echographic criteria for a simple testicular cyst correspond to the general criteria for a simple cyst:
- anechoic content;
- thin smooth wall;
- clear contours;
- posterior enhancement;
- absence of internal inclusions, septations, parietal components;
- absence of vascularization on CDI/PDI.
Clinical Significance and Management
Isolated simple intratesticular cysts in men over 40 years old, meeting all criteria for a simple cyst, are considered benign; they have virtually no malignant potential. Tumor markers (AFP, hCG, LDH) are typically unchanged in the typical presentation.
In the presence of atypical features (heterogeneous content, septations, solid/parietal component), a differential diagnosis should be considered, including cystic teratoma. Specific threshold values and monitoring algorithms for non-palpable lesions are not detailed in the provided fragments [refer to WFUMB Position Paper, 2021].
Role of Multiparametric Ultrasound
For the differential diagnosis of non-palpable testicular lesions, EFSUMB recommends a multiparametric approach. In addition to grayscale mode and CDI/PDI, the following are used:
- contrast-enhanced ultrasound (CEUS) — according to EFSUMB Guidelines on CEUS in non-hepatic applications;
- elastography — qualitative and strain ratio elastography have diagnostic value in the differential diagnosis of non-palpable testicular lesions (Pozza C et al., 2016).
Frequently asked questions
How common is a simple testicular cyst?
Approximately 5–10% of men during scrotal ultrasound; the true frequency is likely higher due to the use of high-frequency probes.
What criteria define a simple intratesticular cyst?
Anechoic content, thin smooth wall, clear contours, posterior enhancement, absence of internal inclusions and septations, absence of vascularization on CDI/PDI.
Are tumor markers needed for a typical simple cyst?
In a typical presentation, AFP, hCG, and LDH are usually unchanged. Isolated simple cysts in men over 40 are considered benign.
What methods are used for the differential diagnosis of non-palpable lesions?
Multiparametric ultrasound according to EFSUMB: grayscale mode, CDI/PDI, CEUS, and elastography (qualitative and strain ratio).
What is important to remember about an atypical cyst?
Consider the differential diagnosis, including cystic teratoma (heterogeneous content, septations) — oncological vigilance is required.