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 2It 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.

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

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

Examination

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

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

Tumour markers

Scrotal 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

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.