Testicular cancer

Testicular cancer is a tumour that grows from the tissue of the testicle itself. Among malignant tumours as a whole it is uncommon, yet in men between fifteen and forty-five it is one of the most frequent of all. It is also a cancer that doctors talk about differently from most others: even when it is found late and has already seeded into the lymph nodes or the lungs, the chances of a complete cure remain high. Both halves of that sentence matter equally. The first is needed so that a man of twenty-five does not shrug off a lump with "cancer happens to older people". The second is needed so that, having felt that lump, he sees a doctor the following week rather than a year later, when fear finally outweighs denial.

Who this concerns

Age works here the opposite way round from the rest of oncology. The peak falls in youth: teenagers, students, men in their early thirties. After fifty, testicular tumours become noticeably rarer. Anyone with testicles can develop one, whatever their way of life or occupation.

It is precisely because of the age group that this is worth knowing in advance. A young man rarely visits doctors, has no habit of being examined, and tends to put any change in his body down to a knock at the gym or to something that will settle by itself. Here that habit is expensive: testicular tumours grow quickly, and weeks and months count.

The second half of the news is better than the first. Testicular tumours respond well to treatment, both to surgery and to chemotherapy. Most men recover completely, go back to work, to sport and to family life, and many go on to have children. There is no sense at all in putting off an appointment for fear of hearing a sentence: the earlier treatment starts, the less of it is needed.

How to examine yourself

Self-examination takes a minute and needs no skill. Its purpose is not to make a diagnosis but to know what your testicles normally feel like, so that any change is obvious straight away.

The easiest time is after a warm shower or bath: the skin of the scrotum is relaxed and the testicle rolls easily between your fingers. In the cold the scrotum draws up and you will not feel anything properly.

• Examine one testicle at a time, standing up.
• Roll it gently between your thumb and fingers, covering the whole surface.
• Judge the consistency: a healthy testicle is smooth, even and firm, roughly like a peeled hard-boiled egg.
• Find the epididymis, the soft ridge running along the back and top of the testicle. It is normal anatomy, not a finding. It is what frightens most people.
• Compare one testicle with the other. A slight difference in size, and one hanging lower, is entirely usual.

Once a month is enough. Checking daily gives you nothing but anxiety: a change only shows up over a stretch of time.

What should make you suspicious

The commonest finding is a hard nodule within the body of the testicle, not in the soft ridge of the epididymis. It is usually firm, does not move separately from the testicular tissue, and does not hurt.

• A lump or nodule of any size, from a pea upwards.
• A testicle that has grown larger or changed shape.
• A change in consistency: part of the testicle, or all of it, feels distinctly harder.
• Heaviness in the scrotum, a dragging sensation.
• A dull ache low in the tummy, in the groin or in the lower back.
• Swelling or tenderness of the breast tissue: some testicular tumours produce hormones.
• Unexplained weight loss, a persistent cough, breathlessness.

The absence of pain rules nothing out. Most testicular tumours do not hurt at all, and that is exactly why men come late: the reasoning is "it doesn't hurt, so it can't be anything". A painless hard lump is a more worrying finding than a painful one. Pain more often speaks of inflammation, which is to say of the less dangerous possibilities.

What it more often turns out to be

Most scrotal findings are not tumours. That is worth knowing so as not to panic, but not as grounds for diagnosing yourself.

• Epididymal cyst: a smooth, mobile little sac above the testicle and separate from it.
• Varicocele: dilated veins that feel like a tangle of soft cords, almost always on the left, more obvious standing up and nearly gone when lying down.
• Hydrocele: fluid collected around the testicle, so the scrotum enlarges evenly and feels tense.
• Epididymitis and orchitis: inflammation of the epididymis or testicle, with pain, redness, swelling and sometimes fever and stinging on passing urine.
• An inguinal hernia descending into the scrotum.

On paper all of this is easy to tell apart from a tumour; under your fingers it very often is not. Telling them apart is the doctor's job, and the main tool is a scrotal ultrasound scan: it takes a few minutes, is painless, and shows exactly where the lesion sits and what it is made of. Do not cancel the appointment on the grounds that your finding "looks like a cyst".

Sudden severe pain does not wait until morning

There is one condition that is not a tumour but needs help within hours: testicular torsion. The spermatic cord twists on its own axis and pinches off the vessels supplying the testicle.

• Sudden, very severe pain in the testicle, often at night or in the early hours, sometimes after exertion and sometimes out of nowhere.
• Nausea and vomiting alongside the pain.
• The testicle sits pulled up, higher than usual or lying crosswise.
• Swelling and redness of the scrotum, with pain spreading to the groin and lower abdomen.

This is an emergency and it is counted in hours. Without a blood supply the testicular tissue dies: the sooner surgery is done, the likelier it is to be saved. Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single European number 112 works) or go straight to a hospital emergency department with a surgeon on site. Do not take a painkiller hoping to sleep it off, and do not wait for a morning appointment: the pain can ease for a while as the testicle continues to die. Torsion happens mainly in teenagers and young men, that is, at the same age as tumours.

What raises the risk

In most cases the reason a testicular tumour appears is never established. But several circumstances raise the odds, and men in those groups should be particularly consistent about self-examination.

• An undescended testicle in childhood, even if it was brought down surgically in good time. The risk applies to both testicles.
• Testicular cancer in a father or brother.
• A previous tumour in the other testicle.
• Disorders of genital development, such as hypospadias.
• Infertility and persistently poor semen quality.
• HIV infection.

Testicular tumours are distinctly commoner in men of European origin and less common in people of African or Asian origin, but that difference is statistical and protects nobody personally. It is worth naming what is not on the list as well: knocks and blows, cycling, tight underwear, sport, masturbation and an active sex life do not cause tumours. Injury sometimes plays a different part: because of it a man feels his testicle for the first time and finds a lump that was already there.

How it is investigated and what follows

It all starts with an examination and a scrotal ultrasound scan. Blood tests for tumour markers fill in the picture: these are substances produced by certain types of tumour, and their level later helps to track how treatment is going. If the suspicion holds, a CT scan is arranged to see whether the tumour has spread beyond the testicle.

A biopsy through the scrotal skin is not usually done when a tumour is suspected. The main operation is removal of the testicle together with the spermatic cord through an incision in the groin; it treats the disease and at the same time provides the tissue for an exact diagnosis. If a man wishes, a prosthesis can be fitted during the operation or later, indistinguishable from a testicle in appearance and to the touch.

After that, treatment depends on the type of tumour and how far it has spread: sometimes surgery is enough and only monitoring with regular blood tests and scans remains, and sometimes chemotherapy or radiotherapy is added. The remaining testicle is usually enough both to produce testosterone and to father a child. Follow-up afterwards runs for years and is not worth skipping: a relapse found early is treatable too.

Sperm is stored before treatment begins

This is the step most often forgotten, and afterwards there is no going back. Chemotherapy and radiotherapy can disturb sperm production temporarily or permanently, and surgery on the abdominal lymph nodes can affect ejaculation.

That is why sperm freezing is raised before the first dose, not after it. Producing a sample takes little time, samples are kept for years, and they can be used long after treatment is over. If fertility recovers on its own within a few years, the frozen sample simply will not be needed, and that is the best of the outcomes.

If treatment has been planned and nobody has mentioned storing sperm, ask about it yourself, before the course starts, even if you are not thinking about children at present. Plans change, and the chance to give a sample comes round only once.

Online consultation

Many men put off any conversation about their testicles out of embarrassment, and that is one reason consultations happen late. An online appointment works well as a first step: describing the finding, showing the results of tests already done and working out what to do next can all happen from home and without queuing.

During the consultation the doctor will go through exactly what you have felt and since when, explain which investigation you need in your case, help you read an ultrasound report or a marker result, and point you to the right specialist. A testicle cannot be palpated through a screen, so an examination and a scan will still be needed, but you will go to them knowing why.

An online consultation is not the route for sudden severe scrotal pain: that situation calls for an ambulance, not a message.

This material is for information only and does not replace medical advice.