Testicular Cancer - Treatment Options

Stage I seminomas are usually treated with surgical removal of the testicle and spermatic cord (radical inguinal orchiectomy) followed by radiation aimed at regional lymph nodes (inguinal and retroperitoneal lymph nodes). Because seminoma cells are very sensitive to radiation, moderate doses can be used, usually around 10 to 15 treatments. More than 95% of stage I seminomas can be cured this way.

The doctor may recommend radiation therapy even if CT scan results do not show that the cancer has spread to the nodes. This is because in approximately 20% of cases of testicular cancer of this type, cancerous cells have spread but were not detected during imaging studies. Radiation therapy is usually successful in destroying these hidden (occult) metastases.

Another approach to treating men with stage I seminomas is currently being evaluated. Instead of treating regional lymph nodes with radiation right after surgery, patients are followed closely with blood tests and regularly scheduled imaging studies for several years. If these tests do not find any spread beyond the testicle, no additional treatment is given. If spread is detected later, radiation or chemotherapy can still be used effectively. This approach is about as effective as immediate radiation therapy, particularly if the original testicular cancer was not larger than 6 cm (about 2 ½ inches) and if there is no evidence that the cancer has spread into lymphatic vessels or blood vessels.

A third approach that has proved as effective as radiation is to 1 or 2 courses of chemotherapy with the drug carboplatin.

One way doctors make a decision on whether or not to treat is based on the size of the tumor and whether it invades nearby blood vessels. If the tumor is larger than 4 centimeters (1.5 inches) or invades blood vessels, they will recommend treatment with either radiation or chemotherapy.

Stage I nonseminoma germ cell cancers are also highly curable (98%), but the standard approach is different from treatment of seminomas. As with seminomas, the initial treatment is radical inguinal orchiectomy. Then there are 3 options:

Retroperitoneal lymph node dissection. This has the advantage of a high cure rate and the disadvantages of major surgery with its complications and the possibility of the loss of ejaculation.

Careful observation with frequent (usually monthly) doctor visits and tests for several years. This has the advantage of no surgery or chemotherapy side effects. Its disadvantage is that the cancer can return and without careful watching can grow so large that it may not be curable. So far, this has not happened in men who saw their doctor for follow-ups as scheduled. About 80% of relapses occur in the first 12 months, and most of the rest in the next 12 months.

Immediate treatment with 2 cycles of chemotherapy. This option, used mainly for stage IB, also has a high cure rate but has the disadvantage of the side effects of chemotherapy (mostly the short-term effects, since 2 courses do not usually cause any long-term effects). Most doctors do not recommend this option because of the possible (but unlikely) long-term side effects of chemotherapy. If the tumor is stage IS, then full dose chemotherapy is recommended (i.e., if the testicle and its tumor have been removed but abnormal blood levels of tumor markers, such as HCG or AFP, persist without a rapid decline after surgery).
Doctors have learned that certain features of the tumor mean that the cancer might come back. These depend on the blood test results and the appearance of the cancer cells under the microscope. If these signs are present, doctors are less likely to recommend observation only.

Stage II Germ Cell Cancers

Stage II seminomas are classified as either "nonbulky" or "bulky," which refers to the size of the retroperitoneal lymph nodes. Nonbulky tumors are treated with radical inguinal orchiectomy followed by radiation to the regional (retroperitoneal) lymph nodes. Bulky tumors are treated with radical inguinal orchiectomy, followed by combination chemotherapy that includes 3 cycles of cisplatin, etoposide, and bleomycin. Usually higher doses of radiation are given for nonbulky stage II seminoma than for stage I seminoma. Radiotherapy is not used for bulky stage II seminoma. Chemotherapy is the best treatment for patients with this stage of seminoma.

At one time, lymph nodes in the center of the chest were treated with radiation, but this is no longer recommended.

Stage II nonseminoma germ cell tumors are also divided into "nonbulky" and "bulky." For nonbulky disease, radical inguinal orchiectomy is followed by retroperitoneal lymph node removal. About one fourth of these men will not have cancer in their lymph nodes even though their CT scan suggested they might. For the other three fourths who do have cancer in their lymph nodes, there are 2 options after surgery:

Observation. As for stage I testicular cancer, monthly visits are required with frequent testing. This is usually recommended for men who had cancer in fewer than 5 lymph nodes and whose lymph nodes were small (less than 1 inch).

Chemotherapy. For men with more cancer-involved lymph nodes or larger ones, or for those who want to avoid the intense observation period, chemotherapy is given. This usually consists of 2 courses of chemotherapy, most often with the drugs cisplatin and etoposide.

Men with bulky disease in their lymph nodes should, of course, have the testicular tumor removed surgically. For these men, the next step is not more surgery, but chemotherapy. Several regimens are used, but the most common contain etoposide, bleomycin, and cisplatin. These are given as 3 or 4 courses. Following this, a repeat CT scan is done to see if the retroperitoneal lymph nodes are still enlarged. If they are, a retroperitoneal lymph node dissection is performed. This surgery is a little more difficult for men who have had chemotherapy than for those who have not.

Finally, if the tumor markers are high after orchiectomy, chemotherapy is probably the first treatment and then surgery of the lymph nodes will be considered, depending on the results of CT and PET scans.

Stage III Germ Cell Cancers

Stage III seminomas are treated with orchiectomy followed by chemotherapy with a combination of drugs. The main regimens are the same as those used for stage II testicular cancers (usually etoposide, cisplatin, and bleomycin). This approach produces a cure in over 70% of cases.

Those who are not cured might consider enrolling in clinical trials of other chemotherapy agents (for more information, see Clinical Trials in this section). Patients whose cancer has metastasized to the brain usually receive chemotherapy plus radiation therapy aimed at the brain, although surgery for the brain tumor is another option.

Stage III nonseminomas usually receive the same treatment with chemotherapy and have similar survival rates as seminomas. Once chemotherapy is complete, the doctor looks for any cancer that remains. Sometimes a few tumors remain. These are most often in the lung or in the retroperitoneal lymph nodes. Removing these surgically may result in a cure.

If the tumor markers are very high then the usual chemotherapy programs may not be successful and a clinical trial of more aggressive therapy may be the best choice.

Recurrent Germ Cell Cancer

Treatment of recurrent germ cell cancer depends on the initial stage and treatment. Cancer that comes back in the retroperitoneal lymph nodes after orchiectomy alone was performed for early stage tumors can be treated by surgery if the recurrence is small. Depending on the results of the surgery, chemotherapy may be recommended.

If the recurring cancer in the retroperitoneal lymph nodes is extensive or if the cancer has returned elsewhere, then chemotherapy is recommended. This may be followed by surgery.

If a man’s cancer recurs after chemotherapy or if his treatment is no longer working, then he will be treated with different drugs, typically, ifosfamide, cisplatin, and either etoposide or vinblastine.

The treatment of recurrent disease with standard-dose chemotherapy has not been as effective as doctors would like. Therefore, many men whose disease comes back after chemotherapy receive high-dose chemotherapy followed by autologous blood stem cell transplantation. For men with recurrent disease, this may be a better option, rather than standard chemotherapy. (See Stem Cell Transplantation in this section for more information.)

In general, it is probably safest to seek a second opinion from a center of excellence, with extensive experience in the treatment of relapsed testicular cancer, before starting other treatments after chemotherapy is no longer working.

Sertoli Cell and Leydig Cell Tumors

Radical inguinal orchiectomy is usually recommended for Sertoli cell and Leydig cell tumors. Radiation therapy and chemotherapy are generally not effective in these rare types of testicle tumor. If metastasis beyond the testicle is suspected, retroperitoneal lymph nodes may be surgically removed

Adapted from: American Cancer Society, inc.

Testicular cancer

Testicular cancer occurs in the testicles (testes), which are located inside the scrotum, a loose bag of skin underneath the penis. The testicles produce male sex hormones and sperm for reproduction.

Compared with other types of cancer, testicular cancer is rare. But testicular cancer is the most common cancer in American males between the ages of 15 and 34. The cause of testicular cancer is unknown.

Testicular cancer is highly treatable, even when cancer has spread beyond the testicle. Depending on the type and stage of testicular cancer, you may receive one of several treatments, or a combination. Regular testicular self-examinations can help identify growths early, when the chance for successful treatment of testicular cancer is highest.

Signs and symptoms

Testicular cancer can result in a number of signs and symptoms. These may include:

A lump or enlargement in either testicle
A feeling of heaviness in the scrotum
A dull ache in the abdomen or groin
A sudden collection of fluid in the scrotum
Pain or discomfort in a testicle or the scrotum
Enlargement or tenderness of the breasts
Unexplained fatigue or a general feeling of not being well
Cancer usually affects only one testicle.

Causes

Nearly all testicular cancers begin in the germ cells — the cells in the testicles that produce immature sperm. What causes germ cells to become abnormal and develop into cancer isn't known.

Risk factors

Researchers don't know what causes testicular cancer. Risk factors may include:

An undescended testicle (cryptorchidism). The testes form in the abdominal area during fetal development and usually descend into the scrotum before birth. Men who have a testicle that never descended are at greater risk of testicular cancer than are other men are. The risk remains, even if the testicle has been surgically relocated to the scrotum. Still, the majority of men who develop testicular cancer don't have a history of undescended testicles.

Abnormal testicle development. Conditions that cause testicles to develop abnormally, such as Klinefelter's syndrome, may increase your risk of testicular cancer.

Family history. If other family members have had testicular cancer, you may have an increased risk.

Age. Testicular cancer affects teens and younger men, particularly those between ages 15 and 34. However, it can occur at any age.

Race. Testicular cancer is more common in white men than in black men. The reason for racial differences in the incidence of testicular cancer is unknown.

When to seek medical advice.

See your doctor if you detect any pain, swelling or lumps in your testicles or groin area, especially if these signs and symptoms last longer than two weeks. Make an appointment with your doctor even if a lump in your testicle isn't painful. Only a small percentage of testicular cancers are painful from the outset.

Screening and diagnosis

Most men discover testicular cancer themselves, either unintentionally or while doing a testicular self-examination to check for lumps. In other cases, your doctor may detect a lump during a routine physical exam.

To determine whether a lump is testicular cancer, your doctor may recommend:

Ultrasound. A testicular ultrasound test uses sound waves to create a picture of the scrotum. During an ultrasound you lie on your back with your legs spread. Your doctor then applies a clear gel to your scrotum. A hand-held probe is moved over your scrotum to make the ultrasound image.

An ultrasound test can help your doctor determine the nature of any testicular lumps, such as if the lumps are solid or fluid filled. Ultrasound also tells your doctor whether lumps are inside or outside of the testicle. Your doctor uses this information to determine whether a lump is likely to be testicular cancer.

Blood tests. Your doctor may order tests to determine the levels of tumor markers in your blood. Tumor markers are substances that occur normally in your blood, but the levels of these substances may be elevated in certain situations, including testicular cancer. A high level of a tumor marker in your blood doesn't mean you have cancer, but it may help your doctor in determining your diagnosis.

Surgery to remove a testicle (radical inguinal orchiectomy). If your doctor determines the lump on your testicle may be cancerous, he or she may recommend surgery to remove the testicle. Your testicle will be analyzed in a laboratory to determine if the lump is cancerous and, if so, what type of cancer.

In general, a biopsy or removal of the lump alone isn't used when testicular cancer is suspected. However, a biopsy may be an option in certain situations, for instance, if you have only one testicle.
Determining the type of cancer

Your doctor will have your extracted testicle analyzed to determine the type of the testicular cancer. The type of testicular cancer you have determines your treatment and your prognosis. In general, there are two types of testicular cancer:

Seminoma. Seminomas occur in all age groups, but if an older man develops testicular cancer it is more likely to be seminoma. Seminomas, in general, aren't as aggressive as nonseminomas, and are particularly sensitive to radiation therapy.

Nonseminoma. Nonseminoma tumors tend to develop earlier in life and grow and spread rapidly. Several different types of nonseminomatous tumors exist, including choriocarcinoma, embryonal carcinoma, teratoma and yolk sac tumor. Nonseminomatous tumors are sensitive to radiation therapy, but not as sensitive as seminomas. Chemotherapy is often very effective for nonseminomas, even if the cancer has spread.

Sometimes both types of cancer are present in a tumor. In that case, the cancer is treated as though it is nonseminoma.

Staging the cancer

Once your doctor confirms your diagnosis, the next step is to determine the extent (stage) of the cancer. To determine whether cancer has spread outside of your testicle, you may undergo:

Computerized tomography (CT). CT scans take a series of X-ray images of your abdomen. Your doctor uses CT scans to look for signs of cancer in your abdominal lymph nodes.

X-ray. An X-ray of your chest may determine whether cancer has spread to your lungs.

Blood tests. Blood tests to look for elevated tumor markers can help your doctor understand whether cancer likely remains in your body after your testicle is removed.

After these tests, your doctor assigns your testicular cancer a stage. The stage helps determine what treatments are best for you. The stages of testicular cancer are:

Stage I. Cancer is limited to the testis.
Stage II. Cancer has spread to the lymph nodes in the abdomen.
Stage III. Cancer has spread to other parts of the body. Testicular cancer most commonly spreads to the lungs, liver, bones and brain.

Complications

Testicular cancer treatment can cause infertility. Whether you'll experience infertility after cancer treatment depends on the extent of your cancer and what treatments you undergo. Many men with testicular cancer have decreased sperm production even before cancer treatment begins. Treatments that can cause infertility include:

Surgery. Surgery to remove one testicle (orchiectomy) won't cause infertility, and it won't affect your ability to have an erection. If your surgery involves removal of lymph nodes (retroperitoneal lymph node dissection) you may experience difficulty ejaculating if nerves are severed during surgery. Lymph node dissection won't affect your ability to get an erection. Surgery using a nerve-sparing technique reduces the chance that you'll have trouble ejaculating after treatment. Ask your surgeon whether this procedure may be appropriate for you.

Surgery to remove both testicles will leave you infertile. Also, your body will no longer be able to make testosterone, so your doctor will recommend testosterone replacement treatments.

Radiation therapy. Radiation therapy can interfere with sperm production, causing infertility. For some men, sperm production may be limited for a year or two, eventually returning as the treated area heals. For other men, infertility may be permanent after radiation therapy.

Chemotherapy. Certain chemotherapy drugs can cause infertility, while others won't. Ask your doctor about your particular chemotherapy drugs. In some cases, sperm production may come back with time. In other cases, infertility is permanent after chemotherapy.

Consider storing sperm in a sperm bank before you begin treatment — even if you've yet to consider having children or you think you won't want more children. In most cases, storing sperm now for later use is more successful than trying to restore fertility later if you decide you'd like to start a family. Sperm can be frozen (cryopreserved) for years in case you experience infertility after cancer treatment.

Treatment

The options you have for treating your testicular cancer depend on several factors, including the type and stage of your cancer, your overall health and your own preferences. Treatment options may include:

Surgery
Surgery to remove your testicle (radical inguinal orchiectomy) is the primary treatment for nearly all stages and types of testicular cancer. To remove your testicle, your surgeon makes an incision in your groin and extracts the entire testicle through the opening. A prosthetic, saline-filled testicle can be inserted if you choose. You'll receive anesthesia during surgery. All surgical procedures carry a risk of pain, bleeding and infection.

You may also have surgery to remove the lymph nodes in your groin (retroperitoneal lymph node dissection). Sometimes this is done at the same time as surgery to remove your testicle. In other cases it can be done later. Your lymph nodes are removed through a large incision in your abdomen. Your surgeon takes care to avoid severing nerves surrounding the lymph nodes, but in some cases severing the nerves may be unavoidable. Severed nerves can cause difficulty ejaculating, but won't prevent you from having an erection. A newer technique called nerve-sparing surgery may be an option.

In cases of early-stage testicular cancer, surgery may be the only treatment needed. Your doctor will give you a recommended schedule for follow-up appointments. At these appointments — typically every few months for the first few years and then less frequently after that — you'll undergo blood tests, CT scans and other procedures to check for signs that your cancer has returned. If you have a more advanced testicular cancer or if you're unable to adhere closely to the recommended follow-up schedule, your doctor may recommend other treatments after surgery.

Radiation therapy
Radiation therapy may be a treatment option if you have the seminoma type of testicular cancer. Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. During radiation therapy, you're positioned on a table and a large machine moves around you, aiming the energy beams at precise points on your body. Side effects may include fatigue, as well as skin redness and irritation in your abdominal and groin areas. You may experience infertility as a result of radiation therapy. However, as the treated area heals you may regain your fertility.

Chemotherapy
Chemotherapy treatment uses drugs to kill cancer cells. Chemotherapy drugs travel throughout your body to kill cancer cells that may have migrated from the original tumor. Your doctor might recommend chemotherapy after surgery. Chemotherapy may be used before or after lymph node removal. Side effects of chemotherapy depend on the drugs being used. Ask your doctor what to expect. Common side effects include fatigue, nausea, hair loss, infertility and an increased risk of infection.

Treatment for advanced or recurrent testicular cancer
If your cancer hasn't responded to other treatments or if your cancer has returned, you and your doctor may consider other treatments. You may consider enrolling in a clinical trial. These research studies give you a chance to try experimental treatments and procedures that are being developed for future use. Clinical trials aren't guaranteed to bring a cure, and side effects of new medications may not be known. Ask your doctor about clinical trials that are open to people with testicular cancer, as well as the possible risks and benefits of experimental treatments.

One treatment being studied for use in advanced testicular cancer is stem cell transplant. Before a stem cell transplant, you're given drugs that coax your body's bone marrow stem cells out of your bones and into your bloodstream. Then the stem cells are filtered from your blood and frozen for later use. You then undergo high doses of chemotherapy to kill any cancer cells in your body, which may also kill bone marrow cells. Your stored stem cells are thawed and put back into your body to replenish your bone marrow cells.

Prevention

There's no sure way to prevent testicular cancer. However, regularly self-examination may improve your chances of finding a tumor at its earliest stage. Beginning in your midteenage years, and continuing throughout your life, examine your testicles at least once a month.

A good time to examine your testicles is after a warm bath or shower. The heat from the water relaxes your scrotum, making it easier for you to find anything unusual.

To do this examination, follow these steps:

Stand in front of a mirror. Look for any swelling on the skin of the scrotum.

Examine each testicle with both hands. Place the index and middle fingers under the testicle while placing your thumbs on the top.

Gently roll the testicle between the thumbs and the fingers. Remember that the testicles are usually smooth, oval shaped and somewhat firm. It's normal for one testicle to be slightly larger than the other. Also, the cord leading upward from the top of the testicle (epididymis) is a normal part of the scrotum. By regularly performing this exam, you will become more familiar with your testicles and aware of any changes that might be of concern.

If you find a lump, call your doctor as soon as possible. Testicular cancer is highly treatable, especially when identified early.

Your doctor should also examine your testicles whenever you have a physical. If you have an undescended testicle, be sure to tell your doctor, who may refer you to a urologist for treatment or a more specialized exam.

Coping skills

Each man comes to terms with his testicular cancer and deals with the ensuing emotions in his own way. You may feel scared and unsure of your future after your diagnosis. While feelings of anxiety may never go away, you can create a plan to help you manage your emotions. Try to:

Learn all you can about testicular cancer. The more you know about your cancer and your treatment options, the more confident you'll feel as you make decisions about your treatment. Write down any questions that come to mind and ask them at your next doctor's appointment. Ask your doctor or other members of your health care team to recommend reputable sources of further information. Good places to start include the National Cancer Institute and the American Cancer Society. Each has a Web site and a telephone support line you can call for more information.

Take care of your body. Make healthy choices in your everyday life to help your body as you begin cancer treatment. Eat a healthy diet with a variety of fruits and vegetables. Get plenty of rest so that you wake each morning feeling refreshed. Eliminate unnecessary stress from your daily life so that you can concentrate on getting well. With your doctor's approval, find time for gentle exercise a few times each week. If you smoke, quit. Talk to your doctor about medications and other strategies to help you stop smoking.

Connect with other cancer survivors. Find other testicular cancer survivors in your community or online. Contact the American Cancer Society for a listing of support groups in your area.

Stay connected with your loved ones. Your family and friends are just as afraid for your health as you are. They want to help, so don't turn down their offers to assist with transportation to appointments or with errands. Close friends and family will listen when you need someone to talk to or provide a distraction when you're feeling blue.

Adapted from: Mayo Foundation for Medical Education and Research

Varicocele

A varicocele is an enlargement of the veins within the scrotum, the loose bag of skin that holds the testicles. A varicocele is similar to a varicose vein of the leg.

Up to one in five men have a varicocele. For males who are infertile, the figure is higher — about 40 percent. Varicoceles are the most common cause of low sperm production and decreased sperm quality, although not all varicoceles affect sperm production.

Most varicoceles develop over time. They usually occur in the left testicle, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles. Fortunately, most varicoceles are easy to diagnose and, if they cause symptoms, can be repaired surgically.

Signs and symptoms

A varicocele usually produces no symptoms. Rarely, it may cause pain that may worsen over the course of a day because of physical exertion and typically is relieved by lying on your back. Varicoceles can grow larger and become more noticeable over time.

Causes
The spermatic cord, which supplies blood to and returns blood from the testicle, houses the vas deferens, which carries sperm from the testicles. The pampiniform plexus is a group of veins within the scrotum and above the testicles. The pampiniform plexus drain blood from the testicles. Enlargement of these veins often occurs during puberty.

It's not certain what causes varicoceles, but many experts believe abnormal valves within the veins prevent normal blood flow. The resulting backup causes the veins to widen (dilate).

Risk factors

You're at greater risk for varicoceles between the ages of 15 and 25.

When to seek medical advice

Because of the lack of symptoms, a varicocele often is discovered during an evaluation of fertility or during a routine physical exam. However, if you experience pain or swelling in your scrotum, contact your doctor. A number of conditions can cause testicular pain, and some of the conditions require immediate treatment. Your doctor can determine which condition is causing your pain.

Screening and diagnosis

Your doctor will conduct a physical exam, which may reveal a twisted, nontender mass above your testicle. Some people have described the mass as feeling like a bag of worms. If it's large enough, your doctor will be able to feel it while you're standing up. If you have a smaller varicocele, your doctor may ask you to take a deep breath and hold it while you bear down (Valsalva maneuver). This helps your doctor detect abnormal enlargement of the veins.

If the physical exam is inconclusive, your doctor may order a scrotal ultrasound. This test, which uses high-frequency sound waves to create precise images of structures inside your body, may be used to ensure there isn't another reason for your symptoms. One such condition is a tumor that compresses the spermatic vein.

Complications

A varicocele may cause :

Shrinkage of the affected testicle (atrophy). The bulk of the testicle is made up of sperm-producing tubules. When damaged, as from varicocele, the testicle shrinks and softens. It's not clear what causes the testicle to shrink, but experts believe it has to do with the malfunctioning valves, which allow blood to pool in the veins. The result is increased pressure in the veins and exposure to toxins in the blood, which stays in place longer because of the pooling.

Infertility. It's not clear how varicoceles affect fertility. Some experts believe the testicular veins cool blood in the testicular artery, helping to maintain the proper temperature for optimal sperm production. By blocking venous blood flow, a varicocele may keep the temperature too high, affecting sperm formation and movement (motility).

Treatment

Varicoceles usually require no treatment. However, if you're infertile or your varicocele causes pain or testicular atrophy, you may want to undergo varicocele repair. Treatment is aimed at sealing off the affected vein to redirect the blood flow into normal veins.

Although varicoceles typically develop in adolescence, it's less clear whether you should have varicocele repair at that time. Indications for repairing a varicocele in adolescence include progressive testicular atrophy, pain or abnormal semen analysis results.

Varicocele repair presents relatively few risks. Increased fluid around the testicles (hydrocele) occurs in a small percent of cases. Recurrence of varicoceles is a risk, affecting perhaps one in 10 men who undergo repair. Repair methods include:

Open surgery. This most common form of treatment usually is done on an outpatient basis, under general or local anesthetic. The surgeon may approach the vein through your groin (transinguinal), abdomen (retroperitoneal) or below the groin (infrainguinal/infrapubic). Transinguinal surgery is most frequently used.

Recovery after surgical repair usually proceeds rapidly. Your doctor may advice you to return to normal activities that aren't strenuous after two days. As long as you're not uncomfortable, you can return to more strenuous normal activity, such as exercising, after two weeks. Pain resulting from this surgery usually is mild. Your doctor may prescribe pain medication for the first two days after surgery. After that, your doctor may advise you to take over-the-counter (OTC) painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Motrin, Advil, others) to relieve discomfort.

Your doctor may advise you not to have sexual intercourse for one week. It takes about 72 days for sperm to generate, so you'll have to wait three or four months after surgery to get a semen analysis to determine whether the varicocele repair was successful in restoring your fertility.

Laparoscopic surgery. With this approach, the surgeon makes a small incision in the abdomen and passes a tiny instrument through the incision to see and to repair the varicocele. However, this procedure, which requires general anesthetic, isn't used generally because it poses more risk while offering little advantage.

Percutaneous embolization. A radiologist inserts a tube into a vein in your groin or neck through which instruments can be passed. Viewing your enlarged veins on a monitor, the doctor releases coils or balloons to create a blockage in the testicular veins, which interrupts the blood flow and repairs the varicocele. This procedure uses sedation and may take several hours. Again, because of presenting greater risks than open surgery and offering little advantage, this procedure isn't widely used.

Self-care

If you have a varicocele that causes you minor discomfort but doesn't affect your fertility, you might try the following for pain relief:

Take OTC painkillers, such as acetaminophen (Tylenol, others) or ibuprofen (Motrin, Advil, others).

Wear an athletic supporter to relieve pressure.

Adapted from: Mayo foundation for Medical Education and Research

Testicular Trauma

Because the testicles are located within the scrotum, which hangs outside of the body, they do not have the protection of muscles and bones. This makes it easier for the testicles to be struck, hit, kicked or crushed. The following information should help explain why timely evaluation and proper management are critical for the best outcomes.

What happens under normal conditions?

As the producers of sperm and testosterone, the testicles are paired organs essential for every reproductive and sexual function enjoyed by men. But they are also prone to injuries that can leave damage to either the entire gland or essential parts of it.

Suspended in the scrotum, a skin pouch below the penis, each testicle is surrounded by the tunica albuginea, a tough, fibrous covering that often takes the hit of trauma to the gland. Like the shell of an egg, it can be easily "fractured" or shattered when confronted by a blunt or violent force.

But while this covering is injury-prone, other parts of the scrotal sac, most notably the adjacent epididymis, are also vulnerable. Lying along the backside of the testicle, this rubbery gland contains a single coiled tube formed by the merger of thousands of sperm-producing ducts, seminiferous tubules, originating inside the testicle.

Sperm stop briefly in the epididymis to mature before exiting in semen through the vas deferens, a tube that connects with the urethra. Unlike the vas, which is covered by a thick muscle wall, the epididymis has a coating that is both thin and fragile. As such, it puts the gland at higher risk for inflammation or injury.

What are the causes of testicular injury?

While testicular injuries can be from penetrating forces (e.g., stab wounds, gunshot wounds) or blunt forces (e.g., kick to the scrotum, baseball to the scrotum), they all have the potential of inflicting similar injuries: partial or complete ripping of the testicle as well as loss of the entire testicle. An injury sustained from a penetrating object such as a knife or bullet that punctures the scrotal sac, may cause a minor scrape to the skin or major impediment of the blood flow to the testicle itself. An injury can also be caused by a moving object — such as a kick or baseball to the groin — hitting the scrotal sac with a force so strong the energy causes injury.

What are the symptoms of testicular injury?

While trauma to the testicle or scrotal sac usually produces severe pain as a first symptom, it can also result in actual physical injury to any of its contents. When the testicle's hard covering is shattered or ripped, the blood flows from the injury, stretching the normally elastic scrotal sac until it is tense. While that collection of blood can trigger infection, there also may be additional fertility problems due to the ultimate loss of a testicle or immune system problems that affect the remaining testicle. In very severe cases of testicular injury, the entire testicle is ripped with either part of the testicle that cannot be saved or the entire testicle injured beyond repair.

Considerable pain not caused by a defect in the testicle's covering, may be due to epididymitis. Because the epididymis, the lengthy coil alongside the testicle, is a very thin-walled gland it easily becomes red and swollen either by infection or injury. If left untreated, the condition can lead to a loss of the testicle due to blockage of the blood supply to the testicle.

The symptoms mentioned above may indicate a very treatable, benign problem but they may also indicate testicular cancer. A substantial number of malignancies are discovered after minor injuries. But many men are not aware of the painless, solid lump, bulging from the smooth testicular covering, until they're injured in the groin and are examining themselves.

Do not make the mistake of many men who postpone medical care, thinking they are dealing with a simple bruise. This is a medical emergency! While testicular cancer caught early is generally curable, malignancies discovered late often require prolonged treatment involving surgery, radiation and chemotherapy.

Men who suffer anything more than a minor injury to the scrotum should seek an evaluation by a urologist. Reasons to seek medical care include:

swelling of the scrotal sac
any penetrating injury to the scrotal sac
prolonged pain in the scrotal sac
bruising and swelling of the scrotal sac
fevers after testicular injury
any other symptom that develops after injury to the scrotal sac

How are testicular injuries treated?

A urologist (particularly an expert in scrotal injury) can probably determine the extent of any injury to the testicle with a simple physical examination. After the urologist asks questions about how the injury occurred as well as other medical history questions, he will examine the contents of the scrotal sac. In doing so, the hard covering overlying the testicle can generally be easily felt as well as the narrow, soft epididymis. The structures that run into the testicle including the artery, vein and vas would then be felt to ensure that they are normal.

If everything appears normal, with no injury present, the urologist will probably prescribe pain medication such as acetaminophen or ibuprofen. A patient will also be advised to wear a jock strap, which provides good support for the scrotum.

If it is not clear that an injury has occurred, the urologist may request a scrotal ultrasound scan. Based on the same sonar sound waves that guide submarines, this device can safely and effectively image parts of the sac, including the testicle, epididymis and spermatic cord. More specialized versions can also track blood flow.

Although no imaging test is 100 percent perfect, ultrasound is an attractive alternative because it is easy to perform, uses no X-rays and clearly shows the physical structure of the scrotum. On rare occasions, the urologists may request an MRI, a more sophisticated imaging technique, if the ultrasound leaves more questions than answers.

If any imaging study reveals evidence of or suggests testicular injury, the usual course of action is an operation in which the urologists opens the scrotal sac and visually inspects as well as repairs any injury. Under anesthesia, an incision is made in the sac and the entire contents are examined. If a rip of the testicle has occurred and the testicle can be repaired (if it has good blood supply and the remaining testicle has sufficient covering available), the urologist will usually repair the defect with stitches and then close the scrotal sac skin. In some cases, the urologist will leave a drain in the scrotal sac to drain blood and other fluids. While it is removed in a few days, the patient can expect to wear a protective jock strap for several weeks.

On occasion, the injury is so severe that the testicle cannot be repaired. If this occurs, the urologist will remove the testicle. That does not mean the patient cannot father a child, however. If the patient's other testicle is normal, he should be able to impregnate his partner. Also, the patient's hormone levels should remain steady since only one testicle is required for either function

If the patient's physical examination and ultrasound suggest that the injury has caused epididymitis, he will probably be treated conservatively, placed on an anti-inflammatory medication (such as ibuprofen) and encouraged again to wear a jock strap. If necessary, the urologist may also prescribe an antibiotic. It generally takes six to eight weeks for the swelling to subside. The patient may have to have several follow-up visits with the urologist to chart his progress. Further, if conservative measures (medications and jock strap) do not work, surgery may be required and the testicle may have to be removed.

Frequently asked questions:

I have noticed pain in my scrotum and testicle but I do not remember any injury. What should I do?

There are many possible causes of scrotal or testicle pain including epididymitis, inflammation of the testicle and problems with other parts of the scrotum. Whatever the source, you should be examined by a urologist, a specialist trained in such problems.

I was hit by a knee during a basketball game and have since noticed a new lump in my scrotal sac. It does not hurt but should I do anything about it?

Like many young men, you are probably examining yourself for the first time now that you have had a sporting injury. There is a good chance that the lump or "new" mass you have just felt is a normal part of the anatomy (your epididymis). But it could be an injury or even testicular cancer. Any new lump should be checked immediately by a trained urologist. With his/her expertise, a urologist will ease your mind and point you to swift and accurate treatment.

I'm 55 years old and noticed a lump in my scrotum after being hit in the groin during pick-up game of baseball? Could this be testicular cancer or am I too old for that?

Testicular cancer can occur at any age, even though the most cases are between 15 and 35. Anyone with a new lump in the scrotum should see a urologist immediately. Often you will not need any further tests because the urologist can make a diagnosis with a physical examination. However, the urologist may also request an ultrasound. While some masses are not cancer (benign), many can be malignant. The good news, however, is that testicular cancer can be treated effectively (with initial surgical removal of the gland) if caught early. So do not be afraid to contact a urologist!

I noticed blood in my urine after being hit with a baseball. I do not feel any lumps. Should I still report this to my doctor?

Absolutely. Blood in the urine that is visible to the naked eye is almost always due to a urologic problem. You need to see a urologist immediately for evaluation to sort out the possibilities.

What can I do to prevent injury to my testicles?

There are many common-sense steps you can take to reduce your risk of testicular trauma. Wear a seat belt when driving a car. Make sure your clothes are tucked in and you are not exposing loose belts or other items to machinery that has exposed chains or belts. Wear a jock strap when playing sports. If the activity could produce severe contact (as in baseball, football or hockey) use a hard cup to reduce the risk. Finally, avoid any circumstances in which a moving object could hit your groin, particularly the scrotum.

Adapted from: American Urological Association Education and Research

Testicular Torsion

Sometimes, the tissue surrounding a testicle is not well attached to the scrotum. As a result, the testicle may become twisted around the spermatic cord resulting in the blood supply being cut off. The following information should help you better understand this potentially serious health hazard.

What happens under normal conditions?

The testicle (testis) receives its blood supply through the spermatic cord, which arises in the abdomen, courses through the inguinal canal and then enters the scrotum. This cord also includes the vas deferens, which transports sperm to the urethra. While there is more than one source of arterial blood to the testicle, they all enter the testicle via the spermatic cord. Interruption of this arterial route, therefore, will result in a complete cutoff of blood supply and demise of the testicle.

The testicles are organs suspended in a pouch-like skin sac — the scrotum — below the penis. By looking at the scrotum, both the right and left testicle should be approximately equal in size. An asymmetric enlargement, especially if acute, suggests an underlying pathologic condition on one side. Similarly, the skin color on both sides of the scrotum should be identical. Any change in color, especially redness or darkening, also suggests a problem. Finally, testicles are normally not painful and any pain or discomfort should alert the individual to seek medical attention, even if there is no swelling or skin color change.

What is testicular torsion?

Testicular torsion, or twisting of the testicle resulting in a strangulation of the blood supply, occurs in men whose tissue surrounding the testicle is not well attached to the scrotum. It is important to emphasize that testicular torsion is a medical emergency. The testicle will die (infarct) and diminish in size (atrophy) if the blood supply is not restored within approximately six hours. Restoration of the blood supply requires untwisting the cord (de-torsion).

Torsion is relatively rare, occurring in approximately one in 4,000 males under the age of 25. However, it can also occur in newborns and in older men.

What causes testicular torsion?

In most individuals a testicle cannot twist because the surrounding tissue is well attached to the scrotum. The term "bell clapper" deformity is often used to describe a congenital condition in those individuals, whose testes hang within the scrotum and can "swing" like a bell clapper in a bell, allowing for easy twisting. It must be emphasized that boys and men born with the "bell clapper" deformity have no attachments around either testicle, so that torsion can potentially occur on either side. Bilateral testicular torsion, however, is an exceedingly rare event.

What are the symptoms of testicular torsion?

The hallmark of testicular torsion is sudden, severe, one-sided testicular pain. Torsion can occur at any time, while sitting or standing, or may awaken an individual from sleep. Physical activity does not cause torsion, but it may occur during sports or physical exercise. There is often associated nausea and vomiting. Slow-onset testicular pain, over several hours or days, can represent torsion, but it is less common. Problems with urination, such as burning or frequency, are not normally associated with torsion. Torsion is not a painless event, except perhaps in the newborn.

Early in the process, there may be no scrotal swelling. However very shortly thereafter, there will be swelling and redness of the scrotal skin. Testicles that have died (infarcted), after many hours of torsion, cause the greatest scrotal changes. The scrotum will be very tender, reddened and swollen. Often the individual will not be able to find a comfortable position.

How is testicular torsion diagnosed?

Clinical evaluation by the urologist, consisting of medical history and physical examination, is often sufficient to diagnose torsion. Time is of the essence, so if the urologist cannot exclude torsion or suspects it, surgical intervention must be undertaken without further delay. There are X-ray tests which may be used, especially in those individuals whose examination and history may not be characteristic. Both ultrasound and nuclear medicine techniques can be used to assess blood flow to the testicle, and therefore, can also exclude or confirm torsion.

How is testicular torsion treated?

Ultimately, all individuals with torsion require surgery. The testicle can at times be manually untwisted in the emergency room, but whether this is successful or not, surgery should follow. At surgery, the affected testicle will be untwisted and then sutures placed around both testicles to prevent future torsion. Most often this is performed through the scrotum, although an inguinal approach may be used. Unfortunately, there are individuals whose testicles cannot be saved, because it has already infarcted. This is determined at surgery. These individuals will undergo removal of the affected testicle at the time of surgery and then placement of sutures around the remaining opposite testicle to prevent future torsion.

The testicles of newborns with torsion can rarely be salvaged by untwisting, because they are almost always infarcted. Neonatal torsion is, therefore, not the same sort of surgical emergency as torsion in older boys and men. On the other hand, there have been instances of the other non-involved testicle twisting shortly after birth, leaving the baby with no testicles. In addition, there have been great improvements in pediatric anesthesia and postoperative care of even the smallest newborns. Many pediatric urologists will therefore take a newborn to surgery within the first few hours or days of life to remove the affected testicle and to place sutures around the opposite testicle to prevent future torsion.

What can be expected after treatment for testicular torsion?

Whether the testicle is removed or not, scrotal exploration results in minimal and short-lived discomfort. Oral pain medication may be necessary for a few days. Most surgeons will allow the patient to return to work or school within a few days to a week. However, strenuous physical activity or exercise might be best avoided for several weeks. The sutures that are placed around the testicles are not perceived by the patient and are not bothersome. It would be very rare for torsion to recur after the placement of fixation sutures. Patients and families should be wary of any testicular pain or swelling, however, especially if there is only one remaining testicle. In that case they should seek medical attention immediately.

If the torted testicle is left in place, it still might diminish in size slightly, since there may have been some permanent damage during the hours that the testicle was twisted. It is not possible to predict in whom this will happen, except that testicles torted for the longest time, in general, may have more size reduction. In addition, if one testicle is removed, the opposite testicle may increase in size to greater than normal, which is known as compensatory hypertrophy. Torsion of the testicle cannot be prevented by changes in activity or by taking medication. Only fixation sutures placed around the testis at surgery will prevent future torsion.

Frequently asked questions:

How will my future fertility be affected after the loss of a testicle?

Only one functioning testicle is necessary for normal fertility potential and full masculinization. A single testicle will produce normal amounts of sperm and testosterone. While there has been some experimental evidence to suggest that mechanisms might exist to diminish fertility in these patients, they do not appear to be clinically relevant in the vast majority of men who have had torsion.

How will my lifestyle be impacted if I have lost a testicle or have a weakened testicle?

Patients who have lost a testicle or who have a weakened testicle should remain cautious about the remaining testicle. They should always wear protection when engaging in contact sports. They should always seek medical attention if they have any discomfort or notice anything abnormal in the scrotum or remaining testicle.

Should I consider a testicular prosthesis?

Testicular prostheses are manufactured to replace a lost testicle. The products available include a solid, soft silicone polymer and a saline-filled silicone, which have not yet achieved full FDA approval. Most often, these prostheses are inserted when the individual is fully grown and through puberty. Placement of a smaller prosthesis in a younger boy would necessitate a second surgery to replace it with an adult sized prosthesis. Surgery for placement of a prosthetic testicle is not done at the time of removal of the infarcted testis, but may be performed some months later. The decision to place a prosthesis is highly personal and should be discussed with the urologist.

Can a newborn have testicular torsion?

Yes, although neonatal (newborn) testicular torsion is even more rare than torsion in older individuals. It is diagnosed right after birth, and may relate to prolonged or difficult labor. The torsion most often occurs prior to delivery. Its exact cause is unknown and location of the twisting of the spermatic cord is in a different location, as compared to older boys and men. They usually present with a hard scrotal mass, with some darkening of the scrotal skin. Unlike older patients, these infants most often are comfortable, without irritability. The vast majority of these testes cannot be salvaged and are already dead tissue when the baby is born.

What other torsions can occur?

Torsion of the appendix epididymis or testis deserves special mention, because in younger, prepubescent boys it is far more common than torsion of the testicle itself. This may occur in older boys and men, but is much less common in that age group. As in testicular torsion, there are no predisposing factors or activities that cause these structures to twist, and it can occur at any time. The testicular appendages are embryologic remnants that have no function in men. They are located at the upper pole of the testicle and epididymis. They have their own small blood supply and they can also twist, resulting in infarction. These individuals also present with scrotal pain, followed by swelling and redness. However, the pain is most often less severe and can gradually worsen over several hours or days. At times this diagnosis will be determined at the time of surgery, since the history and clinical findings are so similar to testicular torsion. At other times, the urologist may be able to make this diagnosis on physical examination or through the use of radiographic means, such as ultrasound or nuclear medicine scan. If the diagnosis is certain and testicular torsion is excluded, surgery might be avoided in those instances, since the pain and swelling will subside after several days. If there is any doubt at all, though, surgery will be suggested to rule out testicular torsion.

Adapted from: American Urological Association Education and Research

Spermatoceles

The male reproductive tract is responsible for the production, maturation of sperm, and delivery of sperm. This tract is a complex and highly integrated entity. Sperm are produced in the testicles and then are transported through the genital ductal system to the penis and out of the urethra during ejaculation. Each component of the reproductive tract is highly specialized.

Abnormalities within the male reproductive tract may appear as scrotal masses. Masses may be of little significance or may represent life-threatening illnesses. It is necessary to follow a set course of action to determine the nature of the masses and the most appropriate treatment option. For example, testicular cancer is a source of great concern and uniformly requires prompt intervention. Other masses, such as varicoceles, can cause pain or impair reproductive function. Spermatoceles are benign and generally painless masses that grow at the top of the testicle. Thus, it is important for a patient to seek prompt medical attention when he identifies a scrotal mass or abnormality while performing testicular self examination. The following information will assist you when talking to a urologist about spermatoceles.

What is a spermatoceles?

Spermatocele, also known as a spermatic cyst, are typically painless, noncancerous (benign) cysts that grow from the epididymis near the top of the testicle. Spermatoceles are typically smooth and they are usually filled with a milky or clear colored fluid containing sperm. Over time, spermatoceles may remain stable in size or they may grow. If in fact the size becomes bothersome, or results in pain, then there are several treatment options to rectify the problem. Spermatoceles are generally no more than a nuisance rather than a serious medical condition.

What can cause spermatoceles?

The precise cause of spermatoceles is not known. While spermatoceles may form as a result of trauma or inflammation, these conditions are certainly not required for spermatocele formation. Others suggest that blockage of the efferent ducts and epididymis result in spermatocele formation. Additionally, in utero exposure to diethylstilbestrol (DES), a synthetic form of estrogen, has also been suggested as a possible cause.

How common are spermatoceles?

The precise incidence of spermatoceles is unknown, but an estimated 30 percent of all men have this condition. Incidence increases with age, with peak rates for the diagnosis of spermatoceles occurring in men in their forties and fifties. No racial or ethnic predispositions to spermatocele formation are known.

What are the symptoms of spermatoceles?

Men with spermatoceles usually have no symptoms. However, when associated symptoms are present, they may include scrotal heaviness and/or pain.

How are spermatoceles diagnosed?

Spermatoceles are typically discovered through a man's self-examination of his testicles or at the time of an evaluation by a physician. Light can be shined through a spermatocele (transillumination), indicating that the mass is not a solid tumor but more likely a benign cyst. Ultrasound examination remains a very reliable means of evaluation and is a relatively quick, noninvasive and inexpensive test. Other diagnostic imaging tests are not generally used although magnetic resonance imaging (MRI) can also be used as an adjunct in cases where scrotal ultrasound is inconclusive.

How are spermatoceles treated?

Since spermatoceles generally do not cause discomfort and often go unnoticed by patients, they rarely require treatment. Nevertheless, some affected individuals do experience significant associated symptoms, such as bothersome size or pain. When intervention is indicated, the available treatment options include:

Medical therapy: Oral analgesics or anti-inflammatory agents may be used to relieve pain associated with symptomatic spermatoceles. No other type of medical therapy is specifically indicated for the treatment of spermatoceles.

Surgical therapy: Spermatocelectomy involves surgical removal of the spermatocele from the adjoining epididymal tissue. The overall goal of surgical therapy is removal of the spermatocele with preservation of the continuity of the male reproductive tract.

Other therapies: Aspiration and sclerotherapy are two less commonly utilized approaches to treat spermatoceles. Aspiration involves puncture of the spermatocele with a needle and withdrawal of its contents into a syringe. Sclerotherapy is performed with subsequent injection of an irritating agent directly into the spermatocele sac to cause it to heal or scar closed, removing the spermatocele space and decreasing the odds of fluid reaccumulation. Although several reports describe the effectiveness and tolerability of these treatment options, they are generally not recommended. Spermatocele recurrence is a common complication with both approaches, and chemical epididymitis and pain are common complications with sclerotherapy. Furthermore, aspiration and sclerotherapy have limited applicability in men of reproductive age, due to the significant risk of epididymal damage potentially leading to obstruction and resultant subfertility.

What can be expected after surgical treatment?

Spermatocelectomy is typically performed as an outpatient procedure, under a variety of possible anesthetic agents. Patients are generally discharged home with a pressure dressing consisting of an athletic supporter filled with fluffy gauze. Ice packs are applied for two to three days to minimize swelling. Oral pain medications are generally used for one to two days postoperatively. Patients may shower 24 to 48 hours after surgery, and a follow-up visit is scheduled for one to two weeks after the procedure.

Potential complications of spermatocelectomy include fever, infection, bleeding (scrotal hematoma) and persistent pain. Furthermore, inadvertent epididymal obstruction may result, which can lead to subfertility or infertility. Therefore, intervention should be avoided in men who still desire children. These complications may potentially be minimized by use of meticulous surgical technique (including use of an operating microscope or optical magnification).

Frequently asked questions:

Do spermatoceles lead to testicular cancer?
Spermatoceles are benign epididymal lesions. They are separate and distinct from the testicle. Patients with spermatoceles do not have an identified increased risk of testicular cancer.

Are any medications available to cure my spermatocele or prevent the formation of additional ones?
Medications are available to treat associated discomfort or pain, but no medication will lead to resolution or prevention of spermatoceles.

How often should I perform scrotal self-exams?
These exams should be performed at least once per month. Your physician can instruct you in the specific technique. If you detect any suspicious changes, such as increasing size or unusual firmness of scrotal structures, contact your physician.

Adapted from: American Urological Association Education and Research

Scrotal masses

Scrotal masses are areas of fluid or solid material in, on or around your testicles. Although they may indicate a less serious or harmless condition, scrotal masses may also signal something as serious as cancer.

The location of the testicles in the scrotum, a loose bag of skin underneath your penis, keeps them at a temperature lower than that within your abdominal cavity. The lower temperature is needed for adequate sperm production.

The relatively exposed location of the testicles and scrotum makes them prone to injuries, but it also makes them easy to examine for the presence of scrotal masses.

Have your doctor check out any unusual lumps or swelling in, on or around your testicles. Treatment of scrotal masses depends on the cause.

Signs and symptoms

The testicles (testes) are located inside the scrotum, a loose bag of skin below your penis. They produce male hormones and sperm. Signs and symptoms of scrotal masses include:

A lump or swelling in the scrotum
Local pain or tenderness

Causes

Scrotal masses have various causes, including cysts, infection, inflammation, trauma, inguinal hernia and tumors. The tumors may be noncancerous (benign) or cancerous (malignant). Because of the possible seriousness of a scrotal mass, it's important to have a doctor check out any swelling or lumps. Specific causes of scrotal masses include:

Epididymitis. This infection in the tubular coil (epididymis) that collects sperm from the testes produces pain in the top and rear of the scrotum. Epididymitis is often caused by bacteria. The pain may be severe. Fever and swelling also are common.

Spermatic cyst (spermatocele). This common type of painless, benign cyst develops adjacent to the epididymis near the top of the testicle.

Hydrocele. This soft, usually painless swelling in the scrotum is a collection of watery fluid in the sheath that holds the testicle. Normally this sheath contains just enough fluid to lubricate the testicle. When your body produces too much fluid or can't absorb enough fluid, the excess liquid creates a hydrocele. Hydroceles are a common cause of scrotal swelling and may occur on one or both sides.

Hematocele. This type of scrotal mass is generally caused by trauma to the area. It results in blood collecting in the sheath that holds the testicle, and is usually painful.

Varicocele. Enlarged (varicose) veins cause this painless, benign source of scrotal swelling, more commonly on the left side. Blood backs up in the veins leading from the testicles because of a problem with valves inside the veins. The swelling is usually painless. The varicocele itself isn't serious, but it may contribute to infertility.

Orchitis. This inflammation of the testicle is often due to a bacterial infection or the mumps virus. It involves pain and swelling in the scrotum along with a feeling of added weight in the scrotum. Orchitis can permanently damage one or both testicles, resulting in diminished size of the testicle, inadequate hormone production and infertility.

Inguinal hernia. An inguinal (ING-gwih-nul) hernia develops when abdominal contents, usually the small bowel, protrude through a weak point of the abdominal wall in the groin area, where the blood vessels and ducts from the testicles enter your abdominal cavity. The result is a bulge in your groin area that may extend into the scrotum and be painful or uncomfortable.

Cancer of the testicle. This condition is serious and identified by a lump or swelling within a testicle, sometimes accompanied by a heavy feeling in a testicle. If detected and diagnosed early, this type of cancer often is treatable.

When to seek medical advice

See your doctor if you detect any pain, swelling or lumps in your testicles or groin area, especially if these signs and symptoms linger. Make an appointment with your doctor even if a lump in your testicle isn't painful. Many testicular cancers aren't initially painful.

Screening and diagnosis

Most men discover scrotal masses themselves, either unintentionally or while doing a testicular self-examination to check for lumps.

If you alert your doctor to a scrotal mass, or he or she discovers a lump during a routine office visit, a physical exam and lab tests can confirm an infection or another cause. You may also undergo an ultrasound examination. This painless test passes sound waves through your scrotum to make an image of the contents of your scrotum.

Treatment

Most scrotal masses require minimally invasive treatment or no treatment at all, but some require more serious procedures.

Epididymitis. This usually acute condition can be treated with antibiotics.

Spermatocele. Most spermatoceles are small, cause no symptoms and require no treatment. However, sometimes they can grow large enough to cause signs and symptoms such as pressure, pain or swelling in the scrotum and require surgical removal. Draining the fluid by puncturing the spermatocele through your skin may provide temporary relief. But the fluid may accumulate again soon after.

Hydrocele. Usually, you don't need treatment for a hydrocele unless the scrotum is so swollen that it's uncomfortable.

Hematocele. Surgical drainage is necessary if the hematocele becomes infected, is large or it doesn't seem to be getting better on its own.

Varicocele. If you have a varicocele that's contributing to infertility, surgically tying off the varicocele (ligation) improves your chances of becoming fertile again. Additionally, your doctor may recommend treatment if your symptoms are bothersome.

Orchitis. Doctors use antibiotics to treat orchitis associated with bacterial infections. Treatment for orchitis associated with viral infections, such as mumps, is only by conservative means, such as rest and pain-relieving medications.

Inguinal hernia. Your doctor may recommend surgery if your hernia is painful or bothersome. Hernias can sometimes recur after surgery.

Cancer of the testicle. Stage I testicular cancer, in which cancer is found only in the testicle, and stage II testicular cancer, in which cancer has spread to the lymph nodes in your abdomen, are successfully treated in most cases. Later stage testicular cancers, in which cancer has spread beyond the lymph nodes to other regions of your body, such as your lungs or liver, can be successfully treated in about 70 percent of cases.

Generally, doctors use the following treatments for testicular cancer:

Radical inguinal orchiectomy. This surgical procedure involves removal of one or both testicles through an incision in your groin. Lymph nodes in your abdomen also may be removed (lymph node dissection). If only one testicle is cancerous and removed, it's possible that the other testicle will become cancerous at some time in the future. As a result, your doctor will likely recommend regular follow-up exams with a urologist.

External beam radiation therapy. This treatment uses high-dose X-rays or other high-energy radiation to kill cancer cells.

Chemotherapy. Chemotherapy is used to kill cancer cells outside the testicle. This drug therapy is usually given by intravenous (IV) infusions in four cycles, typically in the hospital. In some cases, chemotherapy may also be given by intramuscular injection or in pill form. Chemotherapy has made the biggest difference in reducing death from testicular cancer.

Stem cell transplant. In this procedure, stem cells are filtered from your blood and frozen. You then undergo chemotherapy, with or without radiation, to destroy the remaining cancer cells in your body. This chemotherapy also destroys your remaining bone marrow. The frozen marrow is then thawed and injected back into you through a needle in a vein.

While this relatively new treatment for testicular cancer has had some promising initial results, it's not routinely recommended by doctors because traditional chemotherapy treatments are typically very successful.

Surgery may be in combination with radiation therapy or chemotherapy or both. Your treatment depends on the type and stage of your cancer. Your age and overall health also are factors in choosing treatment options for testicular cancer.

Prevention

A simple procedure called testicular self-examination can improve your chances of finding a tumor. Beginning at age 15, examine your testicles on a monthly basis.

It's a good idea to examine your testicles once a month, after a warm bath or shower. The heat from the water relaxes your scrotum, making it easier for you to check for anything unusual. Your doctor should also examine your testicles when you have a physical exam.

To do the examination, follow these steps:

Stand in front of a mirror. Look for any swelling on the skin of the scrotum.

Examine each testicle with both hands. Place the index and middle fingers under the testicle while placing your thumbs on the top.

Gently roll the testicle between the thumbs and fingers. Remember that the testicles are usually smooth, oval shaped and somewhat firm. It's normal for one testicle to be slightly larger than the other. Also, the cord leading upward from the top of the testicle (epididymis) is a normal part of the scrotum. By regularly performing this exam, you will become more familiar with your testicles and aware of any changes that might be of concern.

If you find a lump, call your doctor as soon as possible. Testicular cancer is highly treatable, especially when found promptly.

Regular self-examination is an important health habit. But it can't substitute for a doctor's examination. If it's not already part of your exam, ask your doctor to check your testicles whenever you have a physical exam.

If you have an undescended testicle, tell your doctor, who may refer you to a urologist for treatment or a more specialized exam. Having an undescended testicle increases your risk of testicular cancer. Surgical correction of an undescended testicle — moving it from your abdomen down into your scrotum — can reduce your risk.

Adapted from: Mayo Foundation for Medical Education and Research