Cases corner – 28 years old with an enlarged testicle

24th February 2021

Tom, a 28 year old man, presents to you after his partner asked him to come in to be seen. He assures you he personally hasn’t notice anything, but his partner thinks that one testicle may be bigger than the other. He is not sure for how long as they only noticed it last week. He’s not sure but thinks it’s always been like that. You take a detailed history but he has no other symptoms, past medical history or family history of note. On examination, you note that the left testicle is bigger than the right, and the shape is slightly different although still smooth. There is no swelling, tenderness or localised lymphadenopathy.

What do you do next?

  1. Reassure Tom that there are no sinister features on examination, the fact he doesn’t have any symptoms is reassuring and give him safety netting advice
  2. Refer Tom for an ultrasound of the testis
  3. Organise a routine referral to Urology
  4. Organise an urgent 2-week-wait urology referral

This patient is at risk of testicular cancer and would benefit from further investigation. In over 80% of cases of testicular cancer the lump will be painless. Patients reporting a non-painful enlargement, change in shape, or texture of testis should be referred under a 2-week-wait for urgent investigation. Patients who report persistent or unexplained testicular symptoms should be referred for a direct access ultrasound scan.

Almost half of all men diagnosed with testicular cancer will be under the age of 35, affecting men as young as 15. The presentation of testicular cancer may include:

  • Lump or swelling of the testis
  • Dragging sensation/ ache or pain
  • Inguinal lymphadenopathy
  • Back pain
  • Hydrocele (fluid collection in the scrotum)
  • Gynaecomastia

Risk factors for testicular cancer:

  • Patient with cryptorchidism (undescended testicles) are at a higher risk of developing testicular cancer, irrespective of whether they undergo corrective surgery.
  • Family history – brother or father affected by testicular cancer.
  • Patients who have had a testicle biopsy – such as those undergoing infertility investigations may be found to have pre-cancerous cells inside the testicles. This is known as carcinoma in situ or intratubular germ cell neoplasia. Patients have a 50% chance of these cells progressing into in cancerous cells within 5 years.
  • Ethnic group – Caucasian men have a higher risk of testicular cancer