Andrew Siegel MD 11/24/2018
This is the concluding segment of the “Big Ball” series of entries, which provide information about maladies of the male gonads.
Image below: testes cancer occupying entire testicle (pathology: seminoma)
Attribtion: Ed Uthman from Houston, TX, USA [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)%5D, via Wikimedia Commons
Most testes lumps, bumps and growths are benign and not problematic. Although cancer of the testicle is rare (< 9000 cases/ year in the USA), it is the most common solid cancer in young men age 15-40, with the greatest incidence in the late 20s, striking men at the peak of life. Notable men who are members of the testes cancer club include the following: Tour de France Champion Lance Armstrong; baseball player Scott Shoenweis; skater Scott Hamilton; MTV Host Tom Green; comedian Richard Belzer; sportswriter Robert Lipsyte; and Olympian Eric Shanteau. The great news is that it is a highly curable cancer, especially so when picked up in its earliest stages, and also potentially curable even at advanced stages.
Testes cancer has a predilection for occurring more commonly in Caucasian men as compared to African-American or Asian men and is seen more commonly in men with undescended testes and Klinefelter’s syndrome.
In its early phase, testes cancer causes a lump, irregularity, asymmetry, enlargement, heaviness or a dull ache of the testicle. It most often does not cause pain, so the absence of pain should not dissuade you from getting evaluated if you are concerned about something that does not feel right.
Note well: If you feel that there is a lump or bump in or on your testes that was not present previously, please see a urologist. You will never be chided for being a “hypochondriac” for getting checked out; it is truly better to be safe and cautious.
Testes cancer can also present with a sudden fluid collection around the testes, breast enlargement and/or tenderness, back pain and rarely shortness of breath, coughing up of blood or a lump in the neck.
The testicles have two functions, the manufacture of sperm (via germ cells) and the manufacture of testosterone (via Leydig cells). Most testes cancers (about 95%) are of germ cell origin. Germ cell cancers consist either of seminomas or non-seminomas. Non-seminomas include embryonal cell cancers, choriocarcinomas, yolk sac tumors and teratomas. Many testes cancers are mixed germ cell tumors consisting of several of the sub-types. 5% of testes cancers are of stromal cell origin, including Leydig or Sertoli cell tumors.
If a patient complains of an abnormality of the testes, the first step is a careful physical examination, usually followed by an ultrasound of the scrotum. The ultrasound will confirm if the mass is solid versus cystic (fluid-filled) and determine its precise location and size. If the mass is suspicious for a malignancy, blood tests—known as tumor markers—consisting of alpha-feto protein (AFP), human chorionic gonadotropin (B-HCG) and lactate dehydrogenase (LDH) are routinely obtained.
An outpatient surgical procedure is necessary to remove the diseased testicle along with the spermatic cord that contains the blood and lymphatic supply of the testicle. This is accomplished via a relatively small groin incision. A pathologist examines the testes microscopically and determines the precise diagnosis. At the time of surgery, some men will elect to have a testicular prosthesis implanted, whereas others are not concerned about an empty scrotal sac on one side. Additional staging studies—repeat tumor markers after testes removal and computerized tomogram (CT) of the abdomen and pelvis as well as a chest x-ray—are often necessary to determine if there is any spread of the cancer to remote areas of the body.
Note: Stage I is confined to the testes; stage II to the regional lymph nodes (abdominal lymph nodes); stage III is distant spread.
Depending on the final pathology report and the staging studies, additional treatments may be required. At times chemotherapy is the treatment of choice, the go-to cocktail of medications often a combination of bleomycin, etoposide and cisplatinum (BEP). At other times, sampling of the abdominal lymph nodes is necessary (retroperitoneal lymph node dissection) and depending on the specific pathology, at other times, radiation therapy is necessary. In addition to the urologist, a medical oncologist and radiation oncologist often are involved with the treatment process.
The Sean Kimerling testicular cancer foundation is an awesome resource for learning more about this disease.
How to do a testes self-exam, a simple task that can be lifesaving
Since only 5% or so of men with testes cancer are diagnosed by a physician on routine physical exam and 95% are picked up in the followup of a testes abnormality noted by a man or his partner, it makes a lot of sense to learn how to do a good self exam.
Note: For most men, touching/manipulating/rearranging their nether parts is a natural and almost reflex activity that—supplemented with a little instruction, knowledge and direction—can be put to some practical clinical use. What follows is appropriate for the partner of the man in question. If your man is not willing to do self-exams, at a moment of intimacy do a “stealth” exam under the guise of affection—it just might be lifesaving. Several times in my career as a urologist, it was the man’s partner that was astute enough to recognize a problem that prompted the patient visit that determined the diagnosis of testicular cancer.
The goal of self-exam is to pick up an abnormality– in a very early and treatable stage–at a time when testes cancer is a localized issue that has not spread to the lymph nodes or lungs, which are common sites of metastasis.
Because sperm production requires that testes are kept cooler than core temperature, nature has conveniently designed men with testicles dangling from their mid-sections. There are no organs in the body—save female breasts—that are more external and easily accessible to examination. One of the great advantages of having one’s gonads located in such an accessible locale—conveniently “gift wrapped” in the scrotal satchel—is that it makes them so easy to examine. This is as opposed to the ovaries, which are internal and not amenable to ready inspection. This explains why early testes cancer diagnosis is a cinch as opposed to ovarian cancer, which most often presents at a more advanced stage.
The testicles can be examined anywhere, but a warm shower or bath is an ideal setting as the warm water tends to relax and thin the scrotal sac and allow the testes to descend to a position that is most accessible. Soapy skin will eliminate friction and allow the examining fingers to easily roll over the testicles.
The exam is best performed with the thumb in front and the remaining fingers behind the testicles. The four fingers immobilize and support the testicle and the thumb does the important work in examining the front, sides, top and bottom of the testicle; then the thumb immobilizes the front while the four fingers examine the back of the testes. When examining the back surface of the testicle, the index and middle fingers will do most of the work. The motion is a gentle rolling one, feeling the size, shape, and contour and checking for the presence of lumps and bumps.
Compare the two testes in terms of size, shape and consistency. Generally, the testicles feel firm, similar to the consistency of hard-boiled eggs, although this can vary between individuals and even in an individual. Lumps can vary in size from a kernel of rice to a large mass many times the size of the normal testes. The epididymis is a comet-shaped structure located above and behind the testes that is responsible for sperm storage and maturation. It has a head, a body and tail, and it is worthwhile running your fingers over this structure as well.
This exam should be done regularly—perhaps every couple of weeks or so—such that you get to know your (or your partner’s) anatomy to the extent that you will be attuned to a subtle change. Once you get in the habit of doing this on a regular basis, it will become second nature and virtually a subconscious activity that only takes a few moments.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.
Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:
MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food
These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.
Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx
New video on female pelvic floor exercises: Learn about your pelvic floor
Our Greatest Wealth Is Health 