Symptoms and Diagnostic Imaging
At a Glance
Testicular adrenal rest tumors in people with congenital adrenal hyperplasia are often silent and are checked first with scrotal ultrasound. Masses in both testicles near the central gateway support this diagnosis, but a one-sided or rapidly growing mass needs urologic assessment to rule out cancer.
Because Adrenal Rest Tumors are benign and often do not cause pain, they can be difficult to detect without medical imaging. Identifying them early is key to managing their growth and protecting your reproductive health.
Symptoms of Testicular Adrenal Rest Tumors (TART)
In the early stages, TARTs are almost always asymptomatic, meaning they cause no noticeable symptoms and cannot be felt by a doctor [1][2].
As these tumors grow, a patient may notice:
- A Palpable Mass: A firm, often painless lump that can be felt within the scrotum [3].
- Testicular Enlargement or Heaviness: The testicle may feel heavier or look larger than the other [4].
- Aching or Discomfort: Some patients experience a dull ache or localized discomfort [5].
- Fertility Concerns: Difficulty conceiving or abnormal semen analysis is often a reason TARTs are first discovered in adults [6].
🚨 URGENT SAFETY WARNING
Not all pain is caused by a TART. Sudden, severe testicular pain, rapid swelling, a high-riding testicle, nausea/vomiting, or an acutely painful mass are signs of a medical emergency (such as testicular torsion or infection). Seek emergency medical care immediately. Do not assume these symptoms are just your CAH or a TART. Additionally, any new, rapidly growing, or unilateral (one-sided) mass must be evaluated promptly by a specialist to rule out testicular cancer.
Symptoms of Ovarian Adrenal Rest Tumors (OART)
OARTs are exceedingly rare. When they do occur, their symptoms overlap significantly with general CAH “breakthrough” symptoms (when the steroid dose isn’t effectively controlling the adrenals) or other common conditions like Polycystic Ovary Syndrome (PCOS). Symptoms that warrant broader evaluation include:
- Persistent Virilization: The development of male-pattern traits, such as a deepening voice or increased facial hair, that does not improve with medication [7][8].
- Menstrual Changes: Amenorrhea (the absence of periods) or very irregular cycles [7].
- Chronic Pelvic Pain: Though less common, some patients report persistent abdominal or pelvic discomfort [9].
Note: A normal scan plus these symptoms does NOT necessarily mean an occult OART is present. These are triggers for a comprehensive endocrine and gynecologic evaluation.
Diagnostic Imaging for TART
The preferred initial test for evaluating TART is a scrotal ultrasound [10][11]. Doctors interpret the scan alongside your clinical history and lab results. They look for specific features that suggest a mass is an adrenal rest tumor rather than cancer:
- Bilateral Presence: TARTs are frequently found in both testicles [12][13]. Testicular cancer is more likely to appear in only one testicle.
- Location: TARTs are almost always located near the mediastinum testis, the “gateway” area where vessels and tubes enter the testicle [12][14].
- Appearance and Blood Flow: On the screen, they typically appear hypoechoic (darker than the surrounding tissue) and often have visible blood flow on a Doppler ultrasound [12].
The Danger of Misdiagnosis
One of the greatest risks for males with CAH is that a TART can look similar to Leydig cell tumors or other types of testicular cancer on an ultrasound [15][16].
If a radiologist or urologist is not aware that you have CAH, they may strongly suspect cancer. A characteristic bilateral pattern near the mediastinum in a patient with known CAH strongly supports the diagnosis of TART and often allows doctors to avoid an unnecessary orchiectomy (surgical removal of the testicle) [17][2].
However, ultrasound and ACTH levels alone cannot 100% rule out cancer. High ACTH simply reflects CAH control, not the tumor itself. If a mass is unilateral, atypical, rapidly growing, or if cancer cannot be safely excluded, you will need an expert urology assessment. This may involve specialized blood tests (tumor markers like AFP or beta-hCG) ordered by a doctor, advanced imaging (MRI), or in carefully selected cases, a tissue-sparing diagnostic surgery or removal.
Why OARTs Are Frequently Missed
OARTs are much harder to find than TARTs. Standard ultrasounds and MRIs frequently come back “normal” or negative even when an OART is present, often because they grow in unusual spots like the ligaments surrounding the ovaries [9][18]. If your hormone levels are well-controlled but you still have severe symptoms (like a deepening voice or no periods), your doctor will evaluate for a variety of causes, which in very rare cases might include using advanced imaging to look for OART [18][8].
Screening Guidelines
Because TARTs can develop early and are often asymptomatic, many specialists recommend starting regular scrotal ultrasounds during puberty (or earlier if hormone control is difficult) [19][11]. The exact frequency should be individualized by your endocrinologist based on your CAH phenotype, biochemical control, and previous ultrasound findings [20].
Common questions in this guide
What symptoms can a testicular adrenal rest tumor cause?
What does an ultrasound typically show with a TART?
Can an ultrasound confirm that a testicular mass is a TART instead of cancer?
When should testicular pain or swelling be treated as an emergency?
Why might an ovarian adrenal rest tumor be missed on imaging?
How often should people with congenital adrenal hyperplasia be screened for TARTs?
One line in your results can change your plan.
In known CAH, a bilateral pattern near the mediastinum on scrotal ultrasound strongly supports TART; a one-sided or atypical mass needs urology assessment. We check your results against the latest research to help you prepare for what’s next.
Get notified when new evidence is published on adrenal rest tumor.
We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.
References
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This page explains symptoms and imaging patterns associated with adrenal rest tumors in people with congenital adrenal hyperplasia for informational purposes only; it does not constitute medical advice. A new, painful, one-sided, or rapidly growing testicular mass requires prompt medical assessment.