Testicular tumors in children almost always show up as a painless, firm lump inside the scrotum. Before puberty, a large share of these tumors turn out to be benign, which changes the whole surgical plan: when the ultrasound looks favorable and tumor markers are normal, surgeons now aim to remove the tumor and keep the testicle. A lump that persists for more than two weeks should be examined rather than watched. This article covers what parents notice first, how the diagnosis is made, when testis-sparing surgery is appropriate, and what follow-up looks like.
How common are testicular tumors in children?
Testicular tumors are rare in childhood. According to the joint 2021 guideline from the European Association of Urology and the European Society for Paediatric Urology, tumors of the testis in prepubertal boys account for roughly 1% to 2% of all solid tumors in children.
Because they are uncommon, they are also easy to mistake for something else. A scrotal swelling in a toddler is far more likely to be a hydrocele or a hernia, so a genuine tumor is sometimes treated as a benign scrotal condition for months before imaging is ordered.
Age matters more here than in almost any other urologic tumor. Incidence peaks twice: once in early childhood, around age two, and again after puberty. The two peaks differ in tumor biology, in the proportion that are malignant, and therefore in how aggressively they are treated. In a two-institution comparison published in BMC Cancer in 2024, the 135 pediatric patients had a mean age of 2.3 years, and their histologic distribution differed clearly from that of the adult group treated at the partner hospital. That study was retrospective and drawn from two centers, so the exact proportions should not be read as universal.
What are the symptoms parents usually notice?
The classic presentation is a painless scrotal mass. Young children rarely report it themselves. Most cases are found by a parent during a bath or a diaper change, or by a clinician during a routine examination.
Findings that warrant an appointment include:
- A firm lump felt within one testicle
- Painless enlargement of one testicle compared with the other
- A sensation of heaviness in the scrotum
- A dull ache in the testicle, scrotum, or groin
Size asymmetry alone is not necessarily abnormal. One testicle is often slightly larger than the other. What matters is a discrete mass, a change from what was there before, or asymmetry that keeps increasing.
When to go to the emergency room
Sudden, severe testicular pain is a different problem. It points toward testicular torsion – the spermatic cord twists and cuts off blood supply to the testicle – rather than a tumor. Torsion has to be treated surgically within hours to save the testicle, so acute pain belongs in an emergency department, not on a clinic waiting list.
Epididymitis, hydrocele, and inguinal hernia can all produce scrotal swelling that resembles a tumor. Physical examination combined with scrotal ultrasound separates these conditions in most cases.
Which tumor types occur in children?
| Tumor type | Typical features | Behavior |
| Teratoma | Common in early childhood; often well-circumscribed on ultrasound | Benign before puberty |
| Yolk sac tumor | Raised alpha-fetoprotein; the main malignant tumor of early childhood | Malignant |
| Epidermoid cyst | Characteristic layered “onion-ring” appearance on ultrasound | Benign |
| Sex cord-stromal tumors | Leydig cell, Sertoli cell, granulosa cell tumors; may cause hormonal signs | Usually benign |
| Gonadoblastoma | Occurs in children with disorders of sex development | Can transform into malignancy |
Two of these deserve extra comment. Sex cord-stromal tumors sometimes announce themselves hormonally rather than as a lump: early pubic hair, accelerated growth, or breast tissue development in a young boy can be the first clue, and the testicular mass is found afterward. Gonadoblastoma is different again – it is essentially a tumor of abnormal gonadal tissue, so its management is tied to the wider evaluation of the disorder of sex development.
Tumors that appear after puberty behave like adult testicular cancer. Statistics collected in infants and toddlers should not be applied to a 16-year-old with a testicular mass.
What the evidence says about benign versus malignant tumors
For decades, textbooks stated that yolk sac tumor was the most common testicular tumor in prepubertal boys. That figure came largely from tumor registries. Registries capture malignant cases reliably, but benign tumors are frequently never submitted, so the denominator was incomplete.
Series that report every consecutive tumor operated on at a single institution give a different picture, with benign lesions making up the majority of prepubertal cases. This is the reasoning behind the current shift toward organ preservation.
A multicenter study published in European Journal of Pediatrics in 2023 analyzed 487 teratomas in children under 12 years of age. The great majority were managed with testis-sparing surgery, and no recurrences were observed during follow-up. A single retrospective series does not settle a question on its own, but the direction of the evidence is consistent across recent reports: in the prepubertal age group, removing the whole testicle for what turns out to be a benign teratoma is now considered overtreatment.
How are testicular tumors in children diagnosed?
Diagnosis rests on two things: high-resolution scrotal ultrasound and age-adjusted tumor markers.
Ultrasound detects prepubertal testicular masses with a sensitivity approaching 100%. It also answers the questions that determine surgical planning – where the mass sits within the testicle, how much normal parenchyma remains, whether it is cystic or solid, and how vascular it is. A small, well-defined, partly cystic lesion in a two-year-old with normal markers is a very different proposition from a large, heterogeneous, hypervascular mass.
Alpha-fetoprotein (AFP) is a protein produced by yolk sac tumors and measured in a simple blood test. Its interpretation in young children requires care. Healthy infants have physiologically high AFP levels that fall gradually over the first several months of life, reaching adult ranges by roughly eight months. An AFP value that would be alarming in an adult may be entirely normal in a three-month-old, so results must be read against age-specific reference values. This is one of the most common sources of confusion when these children are first evaluated outside a pediatric center.
Human chorionic gonadotropin (hCG), an important marker in adult testicular cancer, has little diagnostic value in prepubertal testicular tumors and is not used to guide the initial decision.
Cross-sectional imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) is generally reserved for after the tissue diagnosis is known, when the histology indicates a need for staging. Scanning every child before surgery adds radiation and anesthesia without changing management in most cases.
Testis-sparing surgery versus orchiectomy
Whatever the final plan, the incision is made in the groin, not the scrotum. The inguinal approach allows the surgeon to control the spermatic cord and blood supply before handling the tumor, which avoids seeding the scrotal skin and lymphatics if the mass turns out to be malignant.
The 2021 EAU-ESPU guideline recommends partial orchiectomy – testis-sparing surgery – as the primary approach when the preoperative ultrasound appearance is consistent with a benign lesion and AFP is normal for age. During the operation, the excised tissue goes for frozen-section analysis, a rapid pathology check that tells the surgeon within minutes whether malignancy is present. A 20-year single-center experience with a systematic literature review, published in Pediatric Surgery International in 2021, likewise reported that testis-sparing surgery was safe in appropriately selected children.
| Testis-sparing surgery | Radical orchiectomy | |
| Typical candidate | Prepubertal child, benign ultrasound features, normal AFP | Elevated AFP, malignancy on frozen section, tumor filling the testis, postpubertal patient |
| Extent | Tumor removed, remaining testicular tissue preserved | Testicle and spermatic cord removed |
| Intraoperative check | Frozen section guides the decision | Frozen section may confirm before completion |
| Additional therapy | Rarely needed for benign lesions | May include chemotherapy or retroperitoneal lymph node dissection depending on final pathology |
If final pathology confirms a malignant tumor and imaging shows spread, treatment is extended. Depending on histology and stage, that can mean chemotherapy, retroperitoneal lymph node dissection, or, less often in this age group, radiotherapy. Those decisions are made by a pediatric oncology team rather than by the surgeon alone.
Cryptorchidism, risk factors, and self-examination
An undescended testicle, or cryptorchidism, is the best-established risk factor for testicular tumors. A systematic review and meta-analysis of observational studies published in European Journal of Pediatrics in 2023 found that later orchiopexy – the operation that brings the testicle into the scrotum – was associated with a higher risk of testicular cancer in adulthood. Because the pooled studies were observational, causation cannot be proven, but the finding supports current guidance to perform orchiopexy early rather than to wait.
Disorders of sex development also carry increased risk and are managed with a dedicated surveillance plan, which may include gonadal biopsy or removal in specific diagnoses.
Boys with a history of cryptorchidism should learn monthly testicular self-examination from adolescence onward. The examination takes a few minutes:
- Do it just after a warm bath or shower, when the scrotal skin is relaxed
- Stand up, and examine one testicle at a time
- Roll each testicle gently between the thumb and fingers of both hands, covering the whole surface
- Look for a firm lump, a change in size, or a change in the feel of the surface
Two normal findings are worth knowing in advance. One testicle is commonly a little larger than the other, and the epididymis – a cord-like structure along the upper and back surface – is supposed to be palpable. Mistaking the epididymis for a mass is a frequent reason for an urgent visit that turns out to be reassuring.
What follow-up looks like after treatment
Follow-up is not optional, even when everything looks favorable at surgery. Patient information from the Urology Care Foundation, the education arm of the American Urological Association, states that children without evidence of metastatic disease and with a normal AFP after surgery still need close monitoring for at least two years.
The schedule quoted there for a malignant yolk sac tumor after orchiectomy involves physical examination, chest imaging, and serum AFP every six weeks, with CT of the abdomen and pelvis every three months over two years. Intervals differ by histology, stage, and the surgery performed, and modern protocols increasingly limit repeat CT in children. The treating team sets the actual plan.
For a benign lesion removed with testis-sparing surgery, surveillance is lighter and typically consists of clinical examination and periodic ultrasound of the remaining tissue.
Frequently asked questions
Will my son still be able to father children?
Long-term fertility data after childhood orchiectomy are limited. In general, a single healthy testicle produces sperm normally after puberty, and paternity is expected in most cases. Where sperm production is impaired, assisted reproductive techniques remain an option. Boys treated with chemotherapy warrant a separate fertility discussion as they approach adolescence.
Can a tumor develop in the remaining testicle?
Registry data on prepubertal patients have not reported new tumors arising in the contralateral normal testicle. In adult testicular cancer, bilateral disease occurs in about 2% to 3%. Continued follow-up and self-examination remain sensible for that reason.
Will he look different afterward?
The scrotum itself is not opened during inguinal surgery, and the remaining testicle continues to grow, so a visible difference is usually minimal. A testicular prosthesis can be placed later if the young man wants one; this is typically done after puberty.
How long does recovery take?
Inguinal surgery is commonly performed as a day case. Most children return to school within a week and avoid contact sports for at least two weeks. Specific restrictions depend on the extent of the operation.
Is a testicular lump in a teenager treated the same way?
No. After puberty, testicular tumors resemble adult germ cell tumors, and the malignancy rate is substantially higher. Organ-sparing surgery is used far more selectively in this group, and radical orchiectomy remains the standard operation for most solid tumors.
Key takeaways
- A painless scrotal lump is the usual first sign of a testicular tumor in children, and any lump lasting more than two weeks should be examined.
- Sudden severe testicular pain is an emergency and suggests torsion rather than a tumor.
- Most prepubertal testicular tumors are benign, so testis-sparing surgery is the preferred first approach when the ultrasound appearance is favorable and age-adjusted AFP is normal.
- Cryptorchidism raises the risk of testicular cancer, which is one reason early orchiopexy and later self-examination are recommended.
If you have found a lump in your child’s scrotum, talk to your doctor, who can arrange an ultrasound and blood tests and refer you to a urologist.
References
- Stein R, Quaedackers J, Bhat NR, et al. EAU-ESPU pediatric urology guidelines on testicular tumors in prepubertal boys. J Pediatr Urol 2021;17:529-33.
- Bois JI, Vagni RL, de Badiola FI, et al. Testis-sparing surgery for testicular tumors in children: a 20 year single center experience and systematic review of the literature. Pediatr Surg Int 2021;37:607-16.
- Zhou G, Sun F, Yu X, et al. Clinical characteristics and long-term management of prepubertal testicular teratomas: a retrospective, multicenter study. Eur J Pediatr 2023;182:1823-8.
- Zhang K, Song J, Zhang Y, et al. Comparison of clinical characteristics of testicular tumor between children and adult population: a retrospective analysis. BMC Cancer 2024;24:1287.
- Florou M, Tsilidis KK, Siomou E, et al. Orchidopexy for congenital cryptorchidism in childhood and adolescence and testicular cancer in adults: an updated systematic review and meta-analysis of observational studies. Eur J Pediatr 2023;182:2499-507.
This article is intended as general medical information and does not replace individual diagnosis or treatment. If you have symptoms, please consult a qualified healthcare professional.
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