Pathophysiology
Whilst unlikely to present as acute testicular pain, malignancy is appropriate to consider within the context of testicular swellings, or swelling treated as epididymo-orchitis which does not respond to antibiotic therapy. Whilst patients will often present to primary care physicians with the associated symptoms or concerns, patients may present to the Emergency Department or be prompted by history and physical examination to divulge concerns that they have had.
Where appropriate, the opportunity to discuss regular self-examination of the testicles should be taken up with patients. In particular, patients should feel for changes in size, shape or for swellings, and be encouraged to discuss this with a primary care physician where indicated.
Differentials:
- Hydrocele
- Spermatocele
- Varicocele
- Hernia
- Acute causes e.g. torsion, trauma, epididymo-orchitis
- Testicular tumour
- Vasculitic diseases e.g. HSP, Kawasaki’s, Buerger’s disease
Malignancies will tend to not have associated pyrexia or urinary symptoms. Often painless, but they can present with a diffuse or acute pain, and with inflammation.
There are three important points to distinguish in assessing a mass:
- Is the mass distinguishable from the testis body – if so, treat as malignant, and investigate/refer accordingly
- Is the mass cystic – if so, it is likely a hydrocele (especially if transluminable)
- Is the mass intrascrotal (can you get above it?) – if not, likely a hernia
Learning Bite
Peak incidence of testicular malignancies is in the 25-35 year age range, who are also likely to be sexually active. Hence the importance of careful history and examination with re-attendances important to screen for malignancy.