Testicular Swellings

TESTICULAR SWELLINGs

INTRODUCTION:

A testicular swelling in a young adult is a cancer until proven otherwise.  Undescended testis (UDT) is a predisposing factor, even after orchidopexy.  Patients who have a history of undescended testis or testicular abnormalities e.g. atrophic testis from previous severe orchitis need to be taught TSE, testicular self examination to look out for the testicular masses.

The differential diagnoses of testicular swelling could include the following: Non-testicular swelling in the scrotum e.g. epididymal nodules, hydrocele and hernia. A hernia would usually extend into the inguinal region and is often reducible on lying down and there is a cough impulse.

INVESTIGATIONS:

To differentiate the swellings, investigations could include a scrotal ultrasound.  Urinalysis may help to point to infection as a cause of the epididymal or testicular swelling.  If a testicular swelling is confirmed, it is important to take blood for testicular tumour markers, namely, alpha fetoprotein, beta HCG and LDH. A chest x-ray can also be performed to see if there is any metastatic disease as the lung is a common site of metastasis from testicular cancer.

TREATMENT:

The initial treatment of testicular masses is surgical removal. It is important not to disturb the testicular swelling so as to prevent spread of the malignant cells.  It is considered a negligence to do an open biopsy of the testicular swelling through the scrotum as this will cause seedling of the malignant cells onto the scrotal skin.  The scrotal skin drains into the inguinal lymph nodes and the testicles drained into the paraaortic nodes.  Therefore, if the patient already has a scrotal testicular biopsy, subsequent radiotherapy will have to cove the inguinal lymph nodes as well as the paraaortic area!  The surgery is an inguinal incision so that the spermatic cord can be ligated early during the surgery and then testis is then mobilised up into the inguinal incision to be removed, a procedure known as inguinal radical orchidectomy.

Nowadays, testicular cancer is readily curable. The mainstay of treatment is the inguinal radical orchidectomy, followed by chemotherapy.  The type and dosage of chemotherapy depend on the extent of the disease. If the patient has a seminoma, they are also sensitive to radiotherapy as well.

Following surgery, the histopathology of the testicular tumour is important: either a teratoma or seminoma (the latter often referred to as non-teratoma).  The tumour marker should also be repeated, depending on the half-life of the tumour markers (few days to few weeks). It will be an indication that the patient has residual disease if the tumour markers remain elevated.  The tumour markers are also important to monitor during treatment. 

Testicular cancer spread to the regional lymph nodes, namely, paraaortic and subsequently to the mediastinum and chest. 

Fertility is often an issue in patients with testicular tumour.  Sperm banking has to be discussed with the patients pre surgery and chemotherapy, as the fertility is often markedly reduced, following treatment. 

Dr Clarence Lei Chang Moh, FRCS Urol

Consultant Urologist

email: clarencelei@gmail.com

10^th September 2013

Enclosures: Photographs of testicular mass preoperatively and testicular mass during radical inguinal orchidectomy.