# Situation: A nurse at the reproductive health clinic of a district hospital cares for adult men and women with gynecologic and reproductive tract problems. A 26-year-old man felt a lump during testicular self-examination 1 week ago. At the clinic the nurse finds a firm, painless mass in the right testis that does not transilluminate. The testis lies in its normal position, the cremasteric reflex is present, and he has no fever or urinary symptoms. What should the nurse advise?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629502  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse at the reproductive health clinic of a district hospital cares for adult men and women with gynecologic and reproductive tract problems.

A 26-year-old man felt a lump during testicular self-examination 1 week ago. At the clinic the nurse finds a firm, painless mass in the right testis that does not transilluminate. The testis lies in its normal position, the cremasteric reflex is present, and he has no fever or urinary symptoms. What should the nurse advise?

## 보기

1. Arrange prompt evaluation with a scrotal ultrasound **✔ 정답**
2. Go to the emergency department at once for detorsion
3. Arrange a needle biopsy of the mass through the scrotum
4. Recheck in 2 weeks, since painless swelling is usually a hydrocele

**정답: 1**

## 해설

A firm, painless testicular mass that does not transilluminate in a man aged 15 to 35 must be treated as possible testicular cancer. He needs prompt scrotal ultrasound and tumor markers; if cancer is confirmed, the testis is removed through an inguinal incision, because a scrotal biopsy can spread the tumor. A normally positioned testis with a present cremasteric reflex and no pain makes torsion unlikely, and a hydrocele would transilluminate.

## 심화 해설

A firm, painless testicular mass that does not transilluminate in a man aged 15–35 years must be managed as possible testicular cancer until proven otherwise. The correct first step is prompt evaluation with scrotal ultrasound, not emergency detorsion, needle biopsy, or delayed recheck.

Why the presentation points away from torsion and hydrocele

The physical findings in this scenario are deliberately selected to rule out the two most common alternative diagnoses. In testicular torsion, the testis is typically painful, elevated, and associated with loss of the cremasteric reflex. This patient has a normally positioned testis, a present cremasteric reflex, and no pain, making torsion very unlikely. A hydrocele characteristically transilluminates when a light is placed against the scrotum; this mass does not transilluminate, which argues against a simple fluid collection. The absence of fever and urinary symptoms also makes epididymitis or orchitis less likely.

Why scrotal ultrasound is the right next step

A painless, firm, non-transilluminating testicular mass in this age group is testicular cancer until proven otherwise, and scrotal ultrasound is the initial imaging study of choice. Ultrasound can distinguish an intratesticular solid mass—highly suspicious for germ cell tumor—from extratesticular lesions, cysts, or other benign findings. The American Urological Association guideline emphasizes early imaging and staging for suspected testicular cancer because early diagnosis is directly linked to excellent cure rates . One review notes that when diagnosed early, the cure rate approaches 99% .

Why needle biopsy through the scrotum is contraindicated

Watch out! A scrotal needle biopsy of a suspected testicular tumor can seed malignant cells along the needle tract and alter lymphatic drainage, potentially worsening prognosis. The standard approach when cancer is confirmed is radical inguinal orchiectomy, in which the entire testis and spermatic cord are removed through an inguinal incision. This avoids breaching the scrotal skin and preserves oncologic safety . The guideline supports surgical removal rather than biopsy when imaging and tumor markers strongly suggest malignancy .

Epidemiology and tumor markers in context

Testicular cancer is the most common solid malignancy among males aged 15–40 years in the US, with a mean age at diagnosis of 33 years . Between 90% and 95% of cases are germ cell tumors, categorized as seminomas or nonseminomatous germ cell tumors . Classical serum markers include alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase. Emerging biomarkers such as microRNA-371a-3p show sensitivity greater than 90% for detecting viable germ cell tumors, surpassing traditional markers in some settings . However, biomarker testing does not replace imaging; ultrasound remains the first-line diagnostic tool for a palpable mass.

Clinical decision summary

| Finding | Interpretation | Implication |
| --- | --- | --- |
| Firm, painless, non-transilluminating mass | Highly suspicious for testicular cancer | Prompt ultrasound and tumor markers |
| Normal testis position, cremasteric reflex present, no pain | Torsion unlikely | No need for emergency detorsion |
| No fever or urinary symptoms | Infection less likely | Antibiotics not indicated initially |
| Mass does not transilluminate | Hydrocele unlikely | Do not delay with observation |

The priority is to confirm or exclude malignancy with scrotal ultrasound, because early-stage testicular cancer has a cure rate approaching 99% when diagnosed promptly. Key point! A scrotal biopsy is avoided; if cancer is confirmed, removal is performed through an inguinal approach to prevent tumor seeding .

## 임상 시나리오

Painless Testicular Mass: Rule Out CancerFirm, non-transilluminating mass in a young man demands prompt imaging
A firm, painless testicular mass that does not transilluminate in a man aged 15–35 years is testicular cancer until proven otherwise. The first step is prompt scrotal ultrasound, not observation or biopsy.

Key negatives in this case rule out alternatives: present cremasteric reflex and normal testicular position make torsion unlikely; a non-transilluminating mass argues against hydrocele; absence of fever and urinary symptoms lowers suspicion for epididymitis or orchitis.

CautionNever perform needle biopsy through the scrotum for suspected testicular cancer; it can spread tumor. If cancer is confirmed, the testis is removed through an inguinal incision.

## 핵심 개념

- **Testicular torsion** — Twisting of the spermatic cord causing ischemia; presents with acute pain, elevated testis, and absent cremasteric reflex.
- **Hydrocele** — Fluid collection around the testis that typically transilluminates on scrotal examination.
- **Cremasteric reflex** — Contraction of the cremaster muscle causing testicular elevation; typically absent in testicular torsion.
- **Scrotal ultrasound** — Initial imaging for suspected testicular mass; distinguishes intratesticular solid lesions from benign findings.
- **Inguinal orchiectomy** — Surgical removal of the testis through an inguinal incision for confirmed testicular cancer; scrotal biopsy is avoided.

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