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Suspicious testicular lumps warrant urgent referral

How should patients with testicular lumpsbe examined?

What are the risk factors for testicular cancer?

What investigations should be carried out?

How should patients with testicular lumpsbe examined?

What are the risk factors for testicular cancer?

What investigations should be carried out?

Finding an unusual lump in the scrotum or testicle can be very distressing for patients and can also be a cause of anxiety for the doctor carrying out the examination.

Although less than 5% of testicular lumps are cancerous1 a systematic approach needs to be undertaken in all cases to rule out malignancy. Testicular lumps require careful clinical assessment and may need further investigations such as ultrasound.

Testicular cancer is responsible for 1-2% of all male cancers and accounts for <1% of all cancers. Testicular cancer rarely occurs before puberty and is most common in men aged 15-44 years.2 It most frequently occurs in men between 20 and 35 years of age. Approximately 90% of cases affect men under the age of 55. In 2005 the incidence of testicular cancer was around 7 per 100,000 in the UK. The ten-year survival rate for patients in England and Wales is 98%. Before 1970, only around 5% of patients with metastatic testicular cancer survived, but around 80% survive today.3,4

History

A detailed history covering presenting symptoms, duration of these symptoms and past history should be obtained. Patients should also be asked whether they have a history of cryptorchidism, mumps orchitis or any fertility problems as these may all increase the likelihood of testicular cancer.

41223594It is important to note any risk factors for testicular cancer (see table 1, left).

Presentation

The most common symptom of testicular cancer is a painless enlargement of the testis. Enlargement is usually gradual, and a sensation of heaviness is not unusual.

The usual presentation is a lump that has been found on self-examination or by the patient's partner. Pain is not always an associated symptom although 30 - 40% of patients with testicular cancer give a history of a dull ache and approximately 10% present with acute pain. Haemorrhage within the tumour occurs in around 5% of cases and may cause acute pain.

A history of acute onset of symptoms including fever, urethral discharge, frequency and dysurea may suggest an infective origin.

Gynaecomastia is the presenting symptom in around 5% of cases of testicular cancer and may be regarded as a systemic endocrine manifestation.

Metastatic symtoms
In around 10% of cases, testicular cancer presents with metastatic symptoms such as:
• A neck mass
• Chronic cough
• Dyspnoea
• Bony pain
• Anorexia
• Weight loss

Examination
Bimanual examination should be carried out for assessment of the lump. This should begin with the normal side to obtain a baseline for normal size, shape and consistency. A careful examination can enable the doctor to determine whether the lump is testicular or epididymal in origin.

Furthermore, characteristics of the lump can help determine the nature of the lesion, for example, a smooth, soft, round lump is more likely to be benign in origin. A trans-illumination test can provide vital information about the cystic origin of a lump such as an epididymal cyst or hydrocoele. Physical examination should also include palpation of the abdomen, examination of the neck for enlarged lymph nodes, examination of the chest for any gynaecomastia and auscultation of the chest for lung metastases. Approximately 1 to 3% of testicular tumours are bilateral occurring either simultaneously or successively.

Differential diagnosis
Any solid, firm, intratesticular mass must be considered as cancer until proven otherwise.

41223595In around 25% of patients an incorrect diagnosis is made at initial examination. Epididymo-orchitis, epididymitis and hydrocoele are commonly mistaken diagnoses in patients with testicular cancer.

Symptoms such as pyrexia, acute onset, and irritative urinary symptoms are suggestive of an infective origin. Around 5-10% of tumours are associated with a hydrocoele. If it is difficult to examine the testis because of the presence of a hydrocoele, ultrasound should be arranged and aspiration of the hydrocoele should be avoided. Ultrasound is useful to differentiate between primary and secondary hydrocoeles.

Trauma can lead to the formation of haematocoeles. Spermatocoeles are most commonly found in the region extending from the head of the epididymis and may appear after vasectomy. Varicocoeles, which are caused by engorgement of the pampiniform plexus of veins in the spermatic cord, should disappear when the patient lies down.

Investigations
Dipstick
A urine dipstick test should be performed to look for the presence of nitrites, leucocytes, and blood in all cases of suspected infection and the infection should be treated appropriately. Once the infection has been treated the patient should be reassessed to confirm that treatment has been successful. If the desired outcome has not been achieved the patient should undergo urgent investigation such as ultrasound.

Tumour markers
All patients with suspected testicular cancer should be investigated for the presence of tumour markers before referral. However if a patient has a normal result this does not rule out cancer. These markers have a vital role in the diagnosis and staging of the tumour and also in monitoring the response to treatment. There are several biochemical markers that are important in the management of testicular cancer (see table 3, attached).

Scrotal ultrasound
All patients with a suspicious scrotal or testicular lump should be referred urgently for ultrasound.

Ultrasound should be carried out to confirm the findings of the physical examination. It will provide vital information about the outline and echo pattern of the testicles. Any hypoechoic area within the testicle should give a high index of suspicion for cancer. Ultrasonography allows differentiation between primary and secondary hydrocoeles and may also be useful in identifying impalpable lesions.

Patients with confirmed testicular cancer need to have a staging CT scan of the abdomen, pelvis and chest to establish whether there are distant metastases or lymph node involvement.

Treatment
Primary treatment for all testicular tumours is inguinal orchidectomy with the aim of removing the testicle, epididymis and spermatic cord with their coverings. Orchidectomy is a curative procedure in around 80% of cases. Further treatment with chemotherapy, radiotherapy and retroperitoneal lymph node dissection may be necessary depending upon the histology and stage of the disease.

Conclusion
All men aged 20 to 55 should be encouraged to carry out self-examination and advised never to ignore any lump but consult their GP about any changes.

Although most testicular lumps are benign, it is essential to have any abnormality checked to reach the correct diagnosis and plan appropriate treatment if required.

The average delay in treatment from initial recognition of the lesion by the patient to radical orchidectomy ranges from 3 to 6 months. The length of delay correlates with the incidence of metastases.

Patients with suspected cancer should be counselled and have tumour markers checked. An urgent request for ultrasound should be made and the patient referred under national guidelines for referring patients with suspected cancer.5

Testicular lumps are a major reason for referral to urology services and many centres have developed a dedicated clinic to fast track assessment and treatment.

Useful information

Cancer Research UK
www.cancerresearchuk.org

Authors

Mr Amit Mevcha
MBBS MRCS
clinical research fellow

Mr David Gillatt
MB ChB ChM FRCS
consultant urological surgeon
Southmead Hospital, Bristol

Key points Table 1 Table 2

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