A 42 year old male comes in to the clinic stating that he has noticed a “lump” in one of his testicles. It is
not painful. He says it is behind the right testicle and just slightly above it. His ROS is negative. He has
no history of testicular cancer in the family. He has tried manipulating it to see if anything changes but it
does not help. He tried ice but it did not go away. He says for a couple of days it hurt a little and he
tried elevating the scrotum and that seemed to make the pain go away. He says “it is kind of like I have
a third testicle!”.
Upon examination, his vital signs are stable and his exam is unremarkable. You note a painless mass just
superior and inferior to the right testicle. You are able to move it and it is freely movable.
1. List three differentials for this mass. List your top differential first and give the reason why it is
your top differential.
2. When examining the patient, you examine the scrotum carefully. You note asymmetry with the
left hemiscrotum lower than the right. This is typical.
3. Typically, scrotal pain only affects one side and is not typically bilateral. True or False?
4. When palpating, the normal epididymis is more firm than the testis. True or False?
5. One of the things you can do is transilluminate the testis. For your top dd, will the testis
typically transilluminate? Yes or No?
6. For this patient, it is extremely important to get a semen analysis. TRUE/FALSE
7. Name 10 testicular disorders that are important when evaluating a testicular mass.
8. If the patient is having no pain, what is the desired treatment?
9. If the mass is painful, what is the preferred treatment?
10. If a patient had to have an orchiectomy, why might counseling be an important intervention?
11. How often should testicular self exam be performed?
12. Why is it best to perform the testicular self exam after a warm bath or shower?
13. The differential diagnosis for any testicular disorder should first exclude the possibility of a
________Fill in blank________
14. Explain the difference between a spermatocele and a hydrocele.
15. Testicular malignant neoplasms are very common in the general population. True or False?
16. Testicular cancer is the most common form of cancer in men between the ages of:
a. 15-34 years
b. 35-45 years
c. 46-60 years
d. 61 years and older
17. When documenting the results of the testicular exam, it should include:
a. Any tenderness or pain
b. Discoloration
c. Edema
d. All of the above
18. Which of the following require immediate referral?
a. Torsion of the spermatic cord
b. Hydrocele
c. Incarcerated scrotal hernia
d. A and C
- A, B, and C
19. Why can varicoceles cause infertility?
20. If there is torsion of the spermatic cord, what are two things that can happen if treatment is
delayed?
21. Testicular tumors have been associated with scrotal trauma. True of False?
22. Two things that can result from surgical intervention for testicular tumors are:__1._________
and __2._______________
- Three differentials for the painless mass in the testicle are:
a. Epididymal cyst: An epididymal cyst is a benign fluid-filled sac located in the epididymis, which is a coiled tube behind the testicle. It is the top differential because the mass is painless, freely movable, and located near the epididymis.
b. Spermatocele: A spermatocele is also a benign cyst, but it contains sperm and is connected to the epididymis. It is the second differential because of its similarity to an epididymal cyst.
c. Hydrocele: A hydrocele is a collection of fluid around the testicle, often causing scrotal swelling. While it might be considered as a differential, it is less likely in this case as the patient describes a distinct lump behind the testicle.
- True. The asymmetry with the left hemiscrotum being lower than the right is a typical finding and does not indicate any pathology.
- False. Scrotal pain can affect one or both sides, and it may have various causes, including infections, trauma, or other medical conditions.
- False. The normal epididymis is more distinct and separate from the testis, but it should not be firmer than the testis.
- No. The top differential, an epididymal cyst, will not transilluminate because it is a solid mass filled with fluid.
- False. A semen analysis is not typically indicated for a testicular mass evaluation. It is more relevant for assessing male fertility issues.
- Ten testicular disorders related to a testicular mass include:
- Testicular cancer
- Epididymitis
- Orchitis
- Varicocele
- Testicular torsion
- Epididymal cyst
- Spermatocele
- Hydrocele
- Hematocele
- Inguinal hernia with scrotal extension
- If the patient is having no pain and the mass is confirmed to be a benign and non-threatening condition (e.g., epididymal cyst or spermatocele), no treatment may be required. These conditions often resolve on their own, or observation may be recommended.
- If the mass is painful and related to inflammation or infection (e.g., epididymitis or orchitis), the preferred treatment is typically with antibiotics and anti-inflammatory medications.
- Counseling might be an important intervention if a patient has to undergo an orchiectomy (surgical removal of the testicle). It can help address concerns related to body image, fertility, and emotional well-being after the procedure.
- Testicular self-exam should be performed monthly.
- It is best to perform the testicular self-exam after a warm bath or shower because warm water relaxes the scrotal sac, making it easier to detect any abnormalities or masses.
- The differential diagnosis for any testicular disorder should first exclude the possibility of a testicular tumor or cancer.
- A spermatocele is a benign cyst that contains sperm and is connected to the epididymis. A hydrocele is a collection of fluid around the testicle, typically between the layers of the tunica vaginalis (the membrane covering the testicle). Both are generally benign and non-cancerous.
- False. Testicular malignant neoplasms are relatively rare in the general population but are the most common solid tumor in young adult males.
- a. 15-34 years.
- d. All of the above. When documenting the results of the testicular exam, it should include any tenderness or pain, discoloration, and edema if present.
- e. A, B, and C. Torsion of the spermatic cord, hydrocele, and incarcerated scrotal hernia all require immediate referral for further evaluation and management.
- Varicoceles can cause infertility due to their association with impaired blood flow in the testicular veins, which may raise scrotal temperature and affect sperm production and quality.
- If there is torsion of the spermatic cord and treatment is delayed, two potential complications are testicular ischemia (lack of blood supply) leading to testicular damage or loss, and potential loss of fertility if not treated promptly.
- False. There is no established evidence linking testicular tumors directly to scrotal trauma.
- Two things that can result from surgical intervention for testicular tumors are:
- Removal of the affected testicle (orchiectomy).
- Lymph node dissection in certain cases to determine the extent of cancer spread.