Testicle problems

It is a good idea to examine your testicles regularly, so that you become familiar with your own anatomy. Then you will be able to tell if anything unusual develops.

• The testicles make sperm. They are oval in shape, and are usually about
  4–5 cm long, 3 cm wide and 2 cm thick. One is often slightly larger than the other.
• The epididymis is a sausage-shaped lump stuck onto the back and top of each testicle. It is actually a coil of tiny tubes, which carry and store the sperm. If uncoiled, they would be about 6 metres long.
• The spermatic cords lead upwards from behind the epididymis. They carry the sperm towards the penis, and also contain blood vessels.
• The scrotum is the skin sac that contains the testicles and the epididymis.

How to examine your testicles The best time is after a warm bath or shower, when the skin of the scrotum is relaxed. Support the scrotum and testicles in the palm of your hand, to feel their weight. One testicle may be slightly larger than the other, but they should be about the same weight. Hold a testicle between the thumb and fingers, with your thumb on top and first and second fingers underneath. Roll the testicle gently, feeling for any hard lumps. A normal testicle is oval in shape; it feels firm but not hard and is smooth with no lumps. Feel the epididymis, a sausage-shaped lump at the top and back of each testicle. It will feel soft and perhaps slightly tender. Feel the spermatic cords which lead upwards from the epididymis and behind the testicles. They are firm, smooth tubes. Do the same with the other testicle.

If you are worried about lumpiness of the skin of the scrotum, look at the section on lumps on the scrotum. If you feel a lump within the scrotum, on or alongside your testicle, you must see your doctor straight away. Also see your doctor if one testicle feels enlarged and heavy, or if when you squeeze it gently it feels much firmer than the other side. In all these cases, it could be a cancer of the testicle. This is the most common type of cancer to affect young men in their 20s and 30s (but it can occur at any age). The good news is that cancer of the testicle can be completely cured in 96% of cases. The earlier it is picked up, the better.

In fact, most swellings in the scrotum turn out to be non-cancerous. For example, it is common to have small lumps and cysts in the epididymis and in the spermatic cord. Surgeons do not usually remove these non-cancerous cysts unless they are large and troublesome. It is important that all lumps in the scrotum are examined by a doctor, so even if you think the swelling is non-cancerous have it checked anyway. If your doctor is not sure, he/she will arrange for you to have an ultrasound scan (which is painless).

‘Bag of worms’ or varicocele
If you feel something in your scrotum like a bag of worms (most obvious when you are standing), you probably have a varicocele.

What a varicocele is. The ‘spermatic cord’ that leads upwards from the scrotum carries a tube for sperms to reach the penis, and also veins and arteries. The veins of the spermatic cord can become swollen, elongated and looped, similar to varicose veins in the leg – this is a varicocele. If the veins are only slightly swollen they will be unnoticeable, but moderately swollen veins can often be felt. Varicocele does not usually cause any symptoms, although some men report discomfort or may feel embarrassed if the swollen veins are visible under the skin. About 15% of normal healthy young men have a varicocele, usually on the left side.

Varicocele and fertility. Doctors have been arguing for years about whether a varicocele affects fertility, by damaging the development of sperms in the testicle (British Medical Journal 2004;328:967–8). For example, the blood in the swollen veins could act like a hot water bottle, keeping the testicle too warm. Developing sperms like to be cool, which is why the scrotum hangs outside the body. In fact, varicocele is only slightly more common in men with sperm problems and, if it does affect fertility, it is only a small effect.

Treating a varicocele will probably not improve fertility. In 2001, the Cochrane Collaboration, an international network of experts who look at every scrap of scientific evidence about medical problems, investigated varicocele treatment for fertility. They concluded that routinely treating varicoceles in men who are having fertility problems is ‘ill-advised’, because there is not enough evidence that it does any good. A more recent survey came to the same conclusion (Lancet 2003;361:1849–52).

Missing testicle
Some people have a testicle on only one side. On the other side, the testicle is completely missing or it may be felt as a lump in the groin. In either case, it is called ‘undescended testicle’.

How undescended testicle occurs. Your testicles started to develop when you were a tiny fetus (a few weeks after you were conceived). They began high inside your abdomen, near the kidneys at the back. About 6 months before you were born, they started to journey forwards and downwards towards the groin. Meanwhile, your scrotum was developing ready to receive them. About a month or two before birth, the testicles normally complete the journey by descending into the scrotum.

In about 5% of boys, one testicle doesn’t make the journey from the back of the abdomen to the scrotum before birth. Instead, it becomes stuck inside the abdomen or at the groin. This why it is called ‘undescended testicle’. No one knows why it happens. For unknown reasons, it is commonest in babies born in March/April. It is also common in premature babies (Surgery 2004;22:252 –5).

Most babies with undescended testicle do not need any treatment – in 2 out of 3 cases the testicle will come down naturally before the baby is 3 months old. If not, the baby will usually need an operation to bring the testicle down.

What to do if you have only one testicle. If you are a teenager or an adult with an undescended testicle you should definitely see your doctor. Your doctor should refer you to a hospital specialist (urologist). There is no need to feel at all embarrassed, because all doctors know this is a problem that needs attention. There are at least several issues that you will need to discuss with the urologist.

• Firstly, an undescended testicle is slightly more likely to develop cancer than a normal testicle. The risk is roughly 1 in 2,000. (The risk of testicular cancer in all men is about 1 in 100,000.) In fact, cancer of the testicle is almost always curable, partly because men easily notice a lump on their testicle and therefore it is caught at an early stage. But if the cancer develops in a testicle that is hidden up in the abdomen, it will be difficult to detect. A testicle that has become stuck in the abdomen is unlikely to be producing sperm, so the urologist may suggest that you have an operation to remove it, to prevent it becoming cancerous in the future. This is a complicated decision, which you will have to discuss in detail with the urologist. It may depend partly on your age; cancer of the testicle is most common in young men, so after the age of about 32 years the risk of the operation may outweigh the likelihood of getting cancer and it might be better to do nothing, but your urologist will advise you.
• Secondly, if you have only one testicle you may be worrying about fertility. Although the undescended testicle probably isn’t doing much, you need not be too worried because your other normal testicle is likely to be producing many millions of sperms.
• Thirdly, an undescended testicle is not firmly anchored, and can become twisted on the tissues that surround it. This is called ‘torsion’. Episodes of torsion are very painful. So if you have abdominal pain as well as an undescended testicle stuck in the abdomen, your doctor will need to consider the possibility of torsion.
• Fourthly, if having an empty scrotum on one side bothers you, you can ask the urologist about having an artificial implant to give the appearance and feel of a normal testicle. These are either silicone, or a silicone bag filled with saline (similar to a breast implant).

Useful contacts
Institute of Cancer Research is the research arm of the Royal Marsden Hospital, London, UK. Its website has a page on testicular cancer, which has photographs showing how to examine your testicles. www.icr.ac.uk/everyman/about/testicular.html