OVERVIEW
Several diseases can effect the testicle and associated structures.
When pain or a mass develops in the testicle or scrotum, one should
be evaluated by a physician to rule out infection or, less commonly,
a tumor. In patients where pain persists, despite antibiotic therapy,
an ultrasound is usually recommended to rule out a tumor.
A varicocele is common in young men and usually seen in the left
scrotum. It is a dilation of the veins which drain the left testicle.
These veins may cause enlargement of the left scrotum and feel like
a bag of worms under the skin. In most instances, these are of no
clinical concern, however, they potentially can cause problems with
infertility and pain. In these instances, surgical correction is possible.
Occasionally, fluid will develop around the testicle and this condition
is known as a hydrocele. These are common in newborns and usually
spontaneously resolve within the first year of life. In the adult,
a hydrocele may develop after trauma or infection. A hydrocele may
need to be drained or surgically removed if it causes problems with
pain or discomfort.
Torsion of the testicle is a condition where the testicle twists
upon itself. When the testicle twists on itself, this will result
in blockage of the blood flow to the testicle and ultimately, testicular
death. This phenomenon usually is seen in boys up to age 16 years,
however, it can also occur in adults. It presents with a sudden onset
of excruciating testicular pain. If left untreated for more than eight
hours, the testicle is usually permanently damaged. If a patient is
seen within a few hours of the onset of pain then the testicle should
be surgically untwisted.
Infections in the epididymis are common. This condition is called
epididymitis. Epididymitis may be recurring and cause chronic pain
in the scrotum. The usual treatment is with antibiotics, however,
a prolonged course may be necessary in select individuals. In severe
cases that do not respond to medication, surgery may be necessary
to remove nerves going to the testicle or to actually remove the testicle
in an effort to relieve pain.
Cysts are very common on the epididymis. On ultrasound evaluation,
these can be differentiated from testicular tumors. No treatment is
necessary unless there is persistent pain.
CANCER OF THE TESTICLE: INCIDENCE
Testicular cancer is the most common malignancy in men between the
ages of 15 to 35 years. It, fortunately, is one of the most curable
cancers due to early diagnosis, new techniques for treatment and a
greater understanding of the nature history of the disease.
The probability that an American white male will get testicular in
his lifetime is approximately 0.2%. Most tumors occur in late adolescence
or early adulthood, however, tumors are also seen in infancy and in
patients over the age of 6o years. The incidence of testicular tumors
in African Americans is much less than that in American whites. There
does not appear to be a great genetic predisposition for testicular
cancer to develop in family members. Testicular cancer usually occurs
in one testicle, however, 2-3% of tumors can occur in both testicles,
either simultaneously or at a later date.
TYPES OF TESTICULAR CANCER
There are several different types of testicular cancers. The most
common type is seminoma, followed by embryonal carciroma, teratocarcinoma,
teratoma and pure carcinoma. The type of tumor determines its biological
behavior, thus, is important in making treatment recommendations.
It is not unusual to have multiple cell types in a given testicular
cancer (i.e. embryonal carcinoma and teratoma)
Some testicular tumors produce proteins, which can be detected in
the blood called tumor markers. The two most common tumor markers
produced by testicular cancer are alphafetoprotein(AFP) and human
chorionic gonadotropin(hCG). If testicular tumors are removed and
thereis persistent elevation of one of these tumor markers then one
has to assume that there is tumor remaining in the patient.
SIGNS AND SYMPTOMS
Most patients notice a mass or a pain or swelling in one testicle.
In about 10% of patients, acute pain is presenting symptom. In a small
percentage of patients, the first symptom are from metastases, including
neck mass, problems with breathing (cough or shortness of breath),
difficulty eating, abdominal pain, back pain or pain in the bones.
Five percent of patients may have swelling of breast due to a hormonal
affect from the tumor.
SCREENING AND DIAGNOSIS
On examination, one feels a mass within the testicle. It is not unusual
to have small lumps in the epididymis, which is a tube adjacent to
the testicle, which helpstransport sperm, however, any unusual mass
should be evaluated by physician. Other diseases that can both cause
swelling or tenderness in the testicles, includes infection, fluid
around testicles, hernia or testicular torsion (twisting of the testicle
or one of its parts). An ultrasound examination of the scrotum and
testicle is the most reliable technique to evaluate for testicular
tumors.
Early detection is important, so annual examination by a physician is recommended.
This is the best done in a warm shower and any suspicious areas examined
by a physician.
STAGING
Staging is a classification system for testicular tumors that helps in making recommendations for treatment.
Testicular tumors are staged using the TNM system. Tumors are staged
based on the findings at the surgery to remove the testicle including;
the microscopic examination, X-ray, CT scan and other studies as indicated.
