Is it Nuts to Think About Sparing the Testicles?

The testi-monial

On my ultrasound list today, patient X, returning for a follow-up, was recounting his ‘close shave’ from losing one of his testicles after a suspected lump was detected during an ultrasound examination at his local hospital when he had pain in the scrotum. He was initially listed for theatre for an orchiectomy and the patient was grateful that someone stopped that and referred him to us for a repeat scan, this time with an adjunct contrast-enhanced ultrasound, which showed the abnormality in his testicle was an infarct instead of a tumor (Figure 1), which improved on follow-up (Figure 2).

Figure 1: Grayscale (left) and contrast-enhanced ultrasound (right) of patient X’s right testicular focal abnormality. Contrast-enhanced ultrasound showed no enhancement within the abnormality.
Figure 2: On follow-up contrast-enhanced ultrasound, it reduced in size and again showed no enhancement, supporting the diagnosis of a resolving infarct.

Incidentally detected testicular focal abnormality inevitably generates a great amount of anxiety, both for patients and doctors involved.


Ultrasound is good at picking up lesions. The problem is that, often, we do not know what they are, or what to do with them. While the old surgical dogma of ‘if in doubt, take it out’ does a good job in dealing with the uncertainty, it does appear to be an overly aggressive anxiety-relieving strategy, and not without consequence, as orchiectomy comes with associated endocrine, reproductive, and psychological impact.

It is worth noting that this problem is further exacerbated by the increased use of ultrasound for a variety of indications, which led to an increasing number of incidentally detected small focal testicular lesions. Many incidentally detected lesions are benign.

Even with the most beneficial of intentions, is scrotal ultrasound causing harm?

What could we do?

Which test tickles your fancy?

Although a variety of tools have been at the clinician’s disposal, the preoperative diagnoses of testicular masses remain uncertain in many cases. Tumor markers are often not raised in patients with malignant testicular tumors. MRI is considered a second-line tool for the characterization of focal testicular lesions; high cost, long study time, lack of standardization, and expertise are some of the drawbacks.

In most cases, ultrasound remains the primary diagnostic test to facilitate decision-making. Lack of flow on color Doppler (CD) increases the probability of a benign lesion but must be interpreted with caution as a substantial proportion of malignant lesions show no detectible vascularity.1 Microflow techniques may increase sensitivity,2 but the evidence is lacking for its value in assessing small testicular lesions. Imaging with contrast-enhanced ultrasound (CEUS) and elastography provides additional information.3,4 CEUS is a particularly valuable technique. The unique value of CEUS is the unequivocal demonstration of the lack of vascularity likely to be encountered in benign lesions, such as an infarct,5 hematoma,6 or epidermoid cyst,7 allowing for “watchful waiting” with ultrasound.8 Contrast dynamics may help differentiate benign from malignant solid masses, but this technique is not yet sufficiently robust for routine clinical use.9 Strain elastography could potentially identify the “hard” lesion as more likely malignant and the “soft” lesion benign on strain elastography.10 Shear-wave elastography has been less extensively evaluated but may also show differences between benign and malignant testicular lesions.11

I am not advocating that these ultrasound techniques are entirely diagnostic, but I am certainly suggesting that when combined with clinical and laboratory information, ultrasound technology is available for a more accurate assessment of the risk of malignancy. This may facilitate more desirable testis-sparing management options, such as ultrasound surveillance or testis-sparing surgery (TSS), to be considered, and avoid unnecessary orchidectomies.  

It is not nuts to suggest sparing the testicles.

The ball’s in your court.


  1. Ma W, Sarasohn D, Zheng J, Vargas HA, Bach A. Causes of avascular hypoechoic testicular lesions detected at scrotal ultrasound: can they be considered benign? Am J Roentgenology 2017; 209:110–115.
  2. Lee YS, Kim MJ, Han SW, et al. Superb microvascular imaging for the detection of parenchymal perfusion in normal and undescended testes in young children. Eur J Radiol 2016; 85:649–656.
  3. Huang DY, Sidhu PS. Focal testicular lesions: colour Doppler ultrasound, contrast-enhanced ultrasound and tissue elastography as adjuvants to the diagnosis. Br J Radiol 2012; 85 Spec No 1:S41–S53.
  4. Huang DY, Pesapane F, Rafailidis V, et al. The role of multiparametric ultrasound in the diagnosis of paediatric scrotal pathology. Br J Radiol 2020; 93(1110):20200063.
  5. Zebari S, Huang DY, Wilkins CJ, Sidhu PS. Acute testicular segmental infarct following endovascular repair of a juxta-renal abdominal aortic aneurysm: case report and literature review. Urology 2019; 126:5–9.
  6. Yusuf GT, Rafailidis V, Moore S, et al. The role of contrast-enhanced ultrasound (CEUS) in the evaluation of scrotal trauma: a review. Insights Imaging 2020; 11:68.
  7. Patel K, Sellars ME, Clarke JL, Sidhu PS. Features of testicular epidermoid cysts on contrast-enhanced sonography and real-time tissue elastography. J Ultrasound Med 2012; 31:115–122.
  8. Shah A, Lung PF, Clarke JL, Sellars ME, Sidhu PS. Re: New ultrasound techniques for imaging of the indeterminate testicular lesion may avoid surgery completely. Clin Radiol 2010; 65:496–497.
  9. Pinto SPS, Huang DY, Dinesh AA, Sidhu PS, Ahmed K. A systematic review on the use of qualitative and quantitative contrast-enhanced ultrasound in diagnosing testicular abnormalities. Urology 2021; 154:16–23.
  10. Fang C, Huang DY, Sidhu PS. Elastography of focal testicular lesions: current concepts and utility. Ultrasonography 2019; 38:302–310.

Roy C, de Marini P, Labani A, Leyendecker P, Ohana M. Shear-wave elastography of the testicle: potential role of the stiffness value in various common testicular diseases. Clin Radiol 2020; 75:560 e9–e17.

Dr. Dean Huang, FRCR, EBIR, MD(Res), is a radiologist and the clinical lead of uroradiolgy at King’s College Hospital, London, UK. He completed his doctoral research on the clinical application of contrast-enhanced ultrasound for scrotal pathologies at King’s College London, UK.

Tweet him @DrDean_Huang

Interested in learning more about contrast-enhanced ultrasound? Check out the following posts from the Scan:

Pediatric Contrast-Enhanced Voiding Urosonography Tips

Contrast-enhanced voiding urosonography (ceVUS) is most commonly used to assess for vesicoureteral reflux (VUR) and anatomic abnormalities of the urethra. Like fluoroscopic voiding cystourethrography (VCUG) examinations, in ceVUS, contrast is administered into the urinary bladder, and images are obtained of the kidneys, ureters, bladder, and urethra during filling and voiding phases.

As a department, we have performed hundreds of ceVUS exams since we began clinical studies almost 7 years ago. I have learned to ask several questions before beginning each ceVUS to help the exam go smoothly.

Does the patient/family know what will happen during the ceVUS?

Ultrasound is a workhorse for pediatric imaging because of the inherent qualities of the modality: no ionizing radiation, patients in close proximity to family members, calm and darkened exam rooms, non-imposing equipment infrastructure, and (usually) the absence of sedation or anesthesia. Most of these attributes hold for ceVUS, but bladder catheterization changes the non-invasive use of US to an invasive examination. Even so, I have been amazed by the distances that families will travel to seek ceVUS in place of VCUG for their children.

Patient and family preparation is a vital first step for ceVUS. To best image the urethra and bladder base, the probe will be positioned on the lower abdomen, perineum, and over the genitals. Discussion of catheterization and probe positioning on the body in a manner appropriate for the child’s age is critical prior to beginning. Childlife specialists can help prepare the child and family as well as provide support and distraction techniques during the examination.

Right grade 3 vesicoureteral reflux in a 3-year-old girl. Sagittal dual display grayscale (on the left) and contrast mode (on the right) of the right kidney showing echogenic ultrasound contrast in the right renal collecting system with dilation of the renal pelvis and calyces.

How will the child void during the examination?

Prior to the voiding phase images during an examination on a young adult, the patient told us that she could not void in the supine position. Unprepared for that moment, we stretched the US unit power cord (and ourselves) to follow her into the adjoining restroom and image her kidneys while she sat on the commode.

A major benefit of ceVUS over VCUG is that the patient is not confined to voiding in a supine position when imaging with ultrasound. While a small percentage of children will not void during either a VCUG or ceVUS, making a plan for how they will void will set the patient up for success during the study. Absorbent pads, bedpans, urinals, training toddler seats, and full-size commodes are all options. When planned for, we often can still obtain urethral images while permitting the patient modesty through appropriate draping.

Which probe positions will be optimal for this patient?

Another benefit of ceVUS over VCUG is that the patient’s anatomy can be visualized even when there is no VUR. When obtaining pre-contrast images, you should start by determining the best window to visualize each kidney.

When VUR occurs, the kidney-ureter unit can be observed with probe positioning from the flank. This position may allow visualization of both the right and left refluxing unit in young children. A transperineal view may not only help to see the urethra but also the bladder base and ureteral insertions.

During VCUG, an imaging team may be accustomed to placing tape on the suprapubic region to secure the bladder catheter. However, US images cannot be obtained through tape. Anticipating the best view of the urethra will help avoid an inopportune tape placement, which will obscure visualization during voiding. In the bladder filling phase, the contrast is following through the catheter, which demarcates the entire course of the urethra. Practicing probe position from a suprapubic or transperineal window during bladder filling will help identify the best window to use when voiding begins. With these preliminaries in mind, we’ve had tremendous success with ceVUS at our institution.

Susan J. Back, MD, is a pediatric radiologist at Children’s Hospital of Philadelphia.

Interested in learning more about pediatric ultrasound? Check out the following posts from the Scan:

Ultrasound for Undescended Testicles: Tailoring Use

In the early 1980s, prenatal ultrasound imaging opened the curtains to a “real-time” view of fetal anatomy. What we saw helped limit invasive diagnosis and therapy to those that benefited our unborn patient, and taught us that patiently waiting until after delivery was often the best approach to abnormalities detected in the womb. In other words, wanting to know was no longer a good reason for pursuing an immediate answer; needing to know, to benefit the child, was the rule to follow.

So, let’s skip over 40 years of “boring” fetal diagnostics, genetic testing, treatment, surgeries, and other distractions and talk about the great mystery on everyone’s mind, the hunt for the impalpable testicle—or as I call it, “following the bouncing ball”.

Every fetal sonographer knows what a testicle nestled in the scrotum looks like and will often be required to quickly gloss over the classic image in order to avoid the unwelcome or undesired “reveal”. As depicted in the diagram below, imaging after 20 weeks may show the scrotum (B) and after 30 weeks (C) may show “ball in sac” if the rest of the child behaves. If, however, the testicle(s) are not cooperative, nobody panics.

Schematic of testicular descent under normal influences with abdominal (A) position; descent to the internal ring (B); scrotal descent with patent processus vaginalis (C); descent complete with complete regression of the gubernaculum and occlusion of processus vaginalis (D). CSL indicates cranial suspensory ligament; T, testosterone; AMH, anti-mullerian hormone; S, sertoli cells; L, leydig cells, INSL3, insulin-like factor 3; GFN, genitofemoral nerve.

But after birth, if one or both testicles fail to stare the waiting observer in the eye, or happily make themselves easily ballotable in their pocket, the alarms go off and rational processes falter. In this vacuum of clinical reason, the reflex order for an ultrasound (US) emerges and sadly obscures best care of both the child and parents. Why should you wait to order an US? Because I am a pediatric Urologist and I said so! If that answer doesn’t suffice, as it never has for me at home or office, let me try and explain.

Case 1

Both testicles are absent to examination at birth. Well, if a newborn of male appearance and yet unknown genotype has no testicles, that neonate is a girl until proven otherwise. Genetic testing will answer that and other potential questions of chromosomal gender.

The lone cry in the wilderness that ultrasound can “find” nonpalpable testes, ignores the literature that shows that in an examination, a specialist will feel the previously un-felt testicle in over 80% of children, which is equivalent to US success. Add to that the false-positive rate of 15% (generous here) where an immobile abdominal or clinically absent gonad is “found” in the groin on US and we are rapidly approaching the poster-child for unwarranted examinations. I do not deny the HUGE contribution of US to the work-up of ambiguous genitalia and intersex conditions, supplanting fluoroscopy and even MRI in many centers, but please do not confuse garden-variety “lost balls” with these more complex issues.

Case 2

The infant or child has one or no balls in their pocket on subsequent examination after birth. Referral to a specialist often comes after US, MRI, and even CT scans seeking to see “where” the ball has strayed along its path to the scrotum. MR and CT for this concern are unjustified as a result of their expense and risk exposure, so I will speak of them no further.

If we go back to our rule that imaging is done to help the child or parents, how does the pre-specialty referral US play out? If the US finds a testis, I would have found it anyway, but the US will not define whether it is retractile (normal with a reflex requiring observation, not surgery), or truly undescended, where surgery is warranted after 6 months of age.

If US fails to find a testicle, I will need to do surgery for certainty (US false negatives on intrabdominal gonad are 10%—again generous) as testicular cancer is possible in undescended testes at 5 times the rate of the general population and direct surgical inspection is as near to 100% certainty of whether a testicle exists or not, as one can get.

So, tell me, where’s the harm in noninvasive, nonpainful, nonionizing, inexpensive imaging. Well? I’m waiting. Never mind. Let me tell you.

Imagine you are a parent. Testicles are absent on US, where does your mind go? Testicles are in the inguinal canal, where does your mind go? Now remember, not because I say so; not because I am some gifted guy; but because of my training and experience, I eliminate the worry after 60 seconds in the office and reverse the concerns set in motion in over 90% of visits after imaging. I would say that’s a lot of “Google-worry-stress time” avoided, so, it is therefore worth foregoing US before the specialist exam.

Finally, in the worst-case scenario, US finds testicles, and, as a result, the primary care physician tells the parents it’s OK, and an infant is denied time-sensitive surgery to maximize testicular function and possibly decrease cancer risk simply because the “presence” was interpreted as “normal”. The US window to gonadal and urogenital anatomy is evolving and brilliant, with contrast-enhanced ultrasound (CEUS), molecular imaging, and elastography promising even more advances. Our common goal is to have our tools create better outcomes and minimize the potential for harm.

Robert Mevorach, MD, is Chief of Pediatric Urology at the University of South Alabama, Mobile, and is Secretary of the American Institute of Ultrasound in Medicine (AIUM) Urology Community (2021–2023).

Interested in learning more about urologic ultrasound? Check out the following resources from the AIUM: