Testicular mass

Testicular tumour

Testicular tumours represent only 1-2% of all tumours in men but are the second most common malignancy in males between the ages of 20 and 35 years. Almost all are germ cell tumours and are classified as either seminomas, nonseminomas or a mixture of the two. They classically present as painless unilateral scrotal swellings. On physical exam there is a firm, nontender, intratesticular mass that does not transilluminate. A scrotal ultrasound may be helpful if there is any question about the diagnosis.

If a testicular tumour is suspected a prompt urology consult is necessary as these can be rapidly growing tumours. The diagnosis must be made pathologically.

Once the diagnosis is confirmed the disease must be staged. Testicular tumours usually spread in an orderly fashion first seeding the retroperitoneal lymph nodes. A CT scan of the abdomen and pelvis can detect lymph nodes greater than 2 cm. A CXR is also needed to rule out more distant metastases. Tumour markers including alpha-fetoprotein and beta-HCG can also be helpful to detect residual tumour mass.

Treatment options differ depending on whether the primary tumour is a seminoma or a nonseminoma, with mixed tumours being treated as nonseminomas. Seminomas confined to the retroperitoneal lymph nodes (RPLN) are best treated with radiotherapy. Nonseminomas confined to the retroperitoneal lymph node should be treated surgically with a RPLN dissection. If the tumour has spread outside the RPLN or the retroperitoneal disease is very bulky then chemotherapy is needed regardless of whether the tumour is a seminoma or a nonseminoma.

Despite the aggressive treatment often required the results are excellent with a cure rate greater than 90%.

Hydrocoele

A hydrocoele is a collection of fluid surrounding the testicle contained within the tunica vaginalis.
There are 3 types of hydrocoeles: communicating, reactive and chronic.
- A communicating hydrocoele occurs in infancy.
- There is a communication between the peritoneal cavity and the hydrocoele sac through a patent processus vaginalis.
- On exam a sac of fluid can be felt surrounding the testicle on the affected side.
- It transilluminates and is nontender.
- The communicating hydrocoele is small and soft in the morning but large and tense in the evening because of the effect of gravity.

The processus vaginalis will close spontaneously in most patients during the first year of life allowing the hydrocoele to resolve. If the hydrocoele persists beyond one year of age surgical repair is recommended. An inguinal incision is used in order to correct the patent processus vaqinalis and reduce any accompanying hernia.

A reactive hydrocoele is one in which the fluid surrounding the testicle is secondary to a local abnormality.
Testicular tumour, trauma and epididymo-orchitis are common causes.
These hydrocoeles transilluminate but may be painful depending on the underlying abnormality.
Treatment of the primary problem is usually all that is needed.

In older men a chronic hydrocoele is more common. The cause is not known. Scrotal ultrasounds are recommended to rule out any underlying pathology. They do not need any treatment unless they become symptomatic.

Varicocoele

A varicocoele is a dilatation of the network of veins - the pampiniform plexus - draining each testicle. Varicocoeles are present in 15% of normal young males and are usually asymptomatic. However, they have been implicated as a cause of infertility.

The patient is best examined in the standing position to allow dilatation of the veins with gravity. The varicocoele feels like a bag of worms lying just superior to the testicle on the affected side. The degree of dilatation can be increased with the Valsalva maneuver. The varicocoele usually disappear when the patient lies flat. They are much more common on the left.

The exact cause of varicocoeles is unknown but it is believed to be due to the back flow of blood from the internal spermatic vein. Most are asymptornatic and unless fertility is in question no treatment is necessary.

If they become uncomfortable or fertility is a problem, they can be treated surgically. Different surgical approaches are available with differing recurrence and complication rates.

Spermatocoele

A spermatocoele is a cystic structure arising from the epididymis and containing spermatozoa. It is usually small (less than 1 cm) and asymptomatic. The patient will be unaware of its presence unless it becomes quite large.

On physical exam it lies just superior and posterior to the testis but is separate from it. If large enough it will transilluminates. If the diagnosis is in question a scrotal ultrasound will be helpful. No treatment is necessary unless it becomes large enough to bother the patient.

Epididymal Cyst

A epididymal cyst is similar to a spermatocoele except that it contains no sperm. The cause is unknown. The patient may notice the cyst as a painless swelling in the scrotum. These cyst may, however, become infected and cause some discomfort. The diagnosis can be confirmed with a scrotal ultrasound.

Asymptomatic cysts should be left alone. If they cause discomfort the patient can be given a trial of antibiotics like septra (2 tabs po bid). Attempts to excise bothersome cysts should only be used as a last resort. There are often multiple small cysts and surgical removal may result in the recurrence of another.