Multiparametric Ultrasound for Characterisation of Testicular Lesions: Beyond Orchiectomy

The increasing detection of small, non-palpable testicular lesions has challenged the traditional paradigm that every solid intratesticular mass should be managed by radical orchiectomy. Many incidental lesions, particularly in infertile men and in patients with negative tumour markers, are benign or non-neoplastic, making overtreatment a clinically relevant concern. In this setting, ultrasound has become central to a more conservative and individualised diagnostic strategy. By combining high-resolution grey-scale imaging with Doppler, microvascular imaging, CEUS and elastography, multiparametric ultrasound provides complementary information on lesion morphology, vascularity, stiffness and interval change. When integrated with clinical presentation, tumour markers, fertility status, syndromic background and patient history, these features can help characterise lesions and estimate the likelihood of malignancy in the appropriate clinical context. Although imaging cannot replace histology, it can refine pre-test probability, support active surveillance in selected low-risk lesions, guide testis-sparing surgery, and improve assessment of the operated testis. This review examines the role of multiparametric ultrasound in characterisation of focal testicular lesions across different clinical settings, including incidentalomas, acute scrotal pain, trauma, bilateral disease, heterogeneous parenchyma, genetic and endocrine syndromes, and the postoperative testis. A structured, context-sensitive imaging approach may help reduce unnecessary orchiectomy while preserving timely detection of malignant, persistent, recurrent or metachronous disease.