Testicular/scrotal lump differential
Confirm diagnosis with scrotal ultrasound scan
- Testicular cancer
- Non tender (or even reduced sensation)
- Arising from testicle
- Hard without fluctuance or transillumination
- Irregular
- Age 15-40
- Hydrocele
- Tunica vaginalis is a membrane around each testicle
- Hydrocele is fluid built up inside this membrane
- Transilluminated by shining torch into the fluid
- It is soft, fluctuant and may be large
- It is irreducible and has no bowel sounds
- May indicated underlying testicular cancer
- May require surgical intervention
- Varicocele
- Soft “bag of worms”
- Swollen pampiniform venous plexus (testicular veins)
- Can cause dragging or soreness
- Usually harmless
- Epididymal cyst
- A cyst (sac of fluid)
- At the epididymis (at the top of the testicle)
- Soft, fluctuant lump at the top of the testicle
- Usually harmless
- Epididymo-orchitis
- Tender
- Generally swollen
- Inguinal Hernia
- Separate from testicle
- Soft
- Bowel sounds
- Reducible
- Testicular Torsion
- Extremely tender
- Abnormal lie
- Suggestive history
The right testicular vein arises from the inferior vena cava. The left testicular vein arises from the left renal vein. Therefore a unilateral left sided varicocele can indicate an obstruction of the left testicular vein, for example caused by a renal cell carcinoma. However, it is worth noting that NICE CKS recommend NOT routinely referring men with a left sided varicoceles for an ultrasound to investigate for renal tumours.
Testicular Cancers (Germ Cell Cancers)
- Seminoma (50%)
- Teratoma (50%)
- Rarely other types
Tumour Markers
- Alpha-fetoprotein may be raised in teratomas (not seminomas)
- Beta-hCG may be raised in teratomas and seminomas, but more often in teratomas
- Lactate dehydrogenase
Metastasis
- Lymphatics
- Lungs
- Liver
- Brain
Prognosis
- Good prognosis unless metastatic (>90% cure rate)
- Even metastatic disease is often curable
- Slightly better prognosis for seminomas
Treatment
- Orchidectomy (offer testicular prosthesis)
- Chemotherapy / radiotherapy based on staging
- Monitoring post treatment with tumour markers and imaging