Testicular cancer is the second most common cancer in Australian men aged 20-39 years1. It accounts for about 20% of cancers in men in this age group and between 1-2% of cancers in men of all ages.
The good news is that testicular tumours are extremely sensitive to chemotherapy and radiotherapy and have a cure rate of more than 95%. This article provides GPs with a clinical overview of testicular cancer — from the initial assessment to long-term follow-up and support.
Should GPs screen for testicular cancer?
There’s little evidence to support routine screening. However, GPs may screen men at higher risk. This includes those with a history of testicular cancer, undescended testes, or infertility, or those with a family history of testicular cancer.
Assessing and diagnosing testicular cancer
More than 70% of testicular cancer patients are diagnosed with stage I disease2. If testicular cancer is suspected, it’s critical that GPs undertake a thorough investigation — as outlined below — and refer the patient to a urologist.
The urologist will form a diagnosis based on inguinal exploration, orchidectomy and en bloc removal of testis, tunica albuginea and spermatic cord. Organ-sparing surgery in specialist referral centres can be attempted in specific cases, for example, if there is a solitary testis or bilateral tumours.
Medical history
Physical examination
To rule out enlarged nodes or abdominal masses, GPs should perform a clinical examination of the testes and a general examination.
In a clinical examination, it can be difficult to distinguish between testicular cysts (which are nearly always cancer) and epididymal cysts (which are rarely cancer). For further guidance on diagnosing epididymal cysts and other non-cancerous lumps, see the section below on benign cysts.
Ultrasound
Within 1-2 days, GPs will need to organise an urgent ultrasound of the scrotum to confirm testicular mass. This should always be performed in young men with retroperitoneal mass.
Investigation and referral
Scrotal biopsy or fine needle aspiration of a testis tumour is not appropriate or advised.
Follow-up
Assessing and diagnosing benign cysts
Lumps, swelling and pain around the testes do not always indicate testicular cancer. Listed below are types of benign cysts that can be found in the scrotum. An ultrasound can confirm the diagnosis.
Epididymal cysts
These are common fluid-filled cysts that feel slightly separate from the testis and are often detected when pea-sized. They should be left alone when small, but can be surgically removed if they become symptomatic.
Spermatocele
Spermatoceles are fluid-filled cysts containing sperm and sperm-like cells. These cysts are similar to epididymal cysts except they are typically connected to the testis.
Hydatid of Morgagni
These are small, common cysts found at the top of the testis. They are moveable and can cause pain if they twist. These cysts should be left alone unless they are causing pain.
Hydrocele
A hydrocele is a swelling in the scrotum caused by a buildup of fluid around the testes. Hydroceles are usually painless but they gradually increase in size and can become very large.
Hydroceles in younger men may indicate an underlying testis cancer, but this is rare. In older men, hydroceles are almost always a benign condition, but a scrotal ultrasound will exclude testicular pathology.
Treating testicular cancer
While a GP may not be directly involved in treating testicular cancer, they may need to convey information about treatment to their patients.
The first stage of treatment is usually an orchidectomy — removal of the diseased testis through an incision in the groin. This is performed under general anaesthetic.
Men can be offered a testicular prosthesis implant during or following orchidectomy. In the rare case a man has a bilateral orchidectomy, he will require ongoing testosterone replacement therapy.
Detailed information on cancer staging, classification and treatment options can be found in our clinical summary guide.
Protecting fertility through semen storage
Men with testicular cancer often have low or even absent sperm production even before treatment begins4,5. Chemotherapy or radiotherapy can, but do not always, lower fertility further1,2. GPs should provide prompt fertility advice to all men considering chemotherapy or radiotherapy, to avoid delaying treatment.
All patients should be offered pre-treatment semen analysis and storage for future use in fertility treatments. Men who have poor sperm counts may need to visit the sperm-banking unit on two or three occasions.
In severe cases, an Andrology referral may be required. Surgically removing one testis does not affect the sperm-producing ability of the remaining testis.
Sperm storage for teenagers can be a difficult issue that requires sensitive handling. Coping with cancer at a young age and the subsequent body image problems following surgery can be extremely difficult. Fatherhood, therefore, is not likely to be a priority concern.
Producing a semen sample by masturbation can also be stressful for young men in these circumstances.
Patient referral
GPs can refer patients seeking long-term semen storage to a fertility specialist or a local infertility clinic.
Free clinical resource
Download the clinical summary guide as a print-ready PDF:
