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What's the cause of this man's swollen testis?

When Dr Oliver Starr saw this hard, enlarged testis he thought he had seen his first case of testicular cancer. But was he right?

When Dr Oliver Starr saw this hard, enlarged testis he thought he had seen his first case of testicular cancer. But was he right?

The patient

This 59-year-old man was somewhat of a recluse and rarely came in to the surgery. When I met him he had an odd affect, lived alone and was not very forthcoming. He said his left testicle had grown painlessly large and hard over six weeks, but he didn't sound too certain and I wondered if the history was actually much longer. He reported no problems with his breathing and gave me no history of urinary infections or urethral discharge. His medical history included an aortic valve replacement and he was on lifelong warfarin.

First instinct

Examining him, the left testicle felt rock hard and

I could get above it. The right hemi-scrotum was normal. There were no bowel sounds when listening over his scrotum. I've never been particularly good at transillumination and didn't attempt it. His abdomen was soft, there were no supraclavicular lymph nodes and his lungs were clear. I was concerned that his shyness had stopped him presenting with a testicular tumour.

Differential diagnoses

• Testicular cancer

• Inguinal hernia

• Hydrocoele

• Orchitis

Testicular tumours can be benign or malignant. Of the malignant types, he was the right age range for lymphoma of the testis, which has a peak age of incidence of 60-70 years and comprises about 7% of testicular tumours.

The very firm feeling of his testis didn't fit with an inguinal hernia and his groin creases looked normal. There was no suggestion of reducibility on the examination.

A hydrocoele was a distinct possibility although the scrotum felt a little too firm for this and I would expect the history to be a lot longer.

Acute orchitis normally presents with a painful, swollen testicle and I was more accustomed to seeing this in young men. But chronic orchitis, which may follow repeated episodes of the acute form or tertiary syphilis, can give a painless enlargement of the testis.

On balance I thought I was dealing with a very tense hydrocoele or a longstanding tumour. I needed to find out quickly and ordered an urgent ultrasound, which was done nine days later.

Getting on the right track

The ultrasound showed a large hydrocoele on the left with no focal testicular lesions.

He wasn't at all keen on being referred and refused a Jabouley's procedure outright. But he wanted something to reduce the size. So under aseptic conditions I drained off 250ml of clear green fluid with a green needle and 50ml syringe. The underlying testicle felt completely normal. Three months later, it had barely recollected.

Dr Oliver Starr is a sessional GP in Hertfordshire

Swollen testis

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