A recent survey has found that although 95 per cent of men know how to check themselves for testicular cancer, almost a third have never done so. Victoria Goldman reports... 

 
The study, commissioned by King Edward VII’s Hospital in London, found 23 per cent of men said they would avoid going to the doctor if they found an unusual lump in their body. 
 
The most common causes of scrotal lumps or pain include: 

• torsion, a twisting of the spermatic cord, which leads into each testicle 
• epididymitis or orchiditis, usually caused by an infection 
• hydrocele (a build-up of fluid).1 
• A painless testicular lump may be a sign of testicular cancer.1 

“Testicular pain and swelling can come and go, particularly if caused by a trauma or mild inflammation, but should never be ignored,” says Dr Luke Pratsides, practising London GP and lead GP at Numan, which offers digital healthcare for men. “Men should always see a GP to assess any testicular pain or swelling.” 
 
Testicular/scrotal symptoms 
The scrotum, which holds the two testicles (testes) in place, is normally soft and smooth. It’s normal for one testicle to be larger than the other and for one to hang slightly lower in the scrotum.2 Men should check their testicles regularly and be encouraged to see their GP if they notice:2 

• a lump in their testicles 
• swollen or tender testicles 
• a change in testicular shape or how they feel 
• one testicle getting bigger 
• any skin changes around their testicles
• persistent aching or discomfort in their testicles 

A GP will ask the patient about their symptoms and examine the testicles. The patient may be referred for an ultrasound scan to confirm a diagnosis. 
 
Testicular torsion 
Testicular torsion, when a testicle twists around in the scrotum, can occur in men at any age, but is most common in teenage boys.3 “It usually presents as an acutely painful, swollen testicle, lower abdominal pain and sometimes vomiting,” says Dr Pratsides. “Some patients may have a history of past trauma to the testicle or of milder testicle pain in the recent past caused by partial torsion and then untwisting of the testicle.” 
 
Testicular torsion is an emergency requiring immediate surgery.4 If untreated, it can block the testicular blood vessels, leading to ischaemia and, potentially, the loss of a testicle.5 “The only advice should be to attend A&E immediately,” says Dr Pratsides. “Every minute is crucial and the longer the testicle is torted the less likely the testicle can be saved.” 
 
Epididymitis 
If the epididymis – the tube at the back of the testicles - becomes swollen and painful, this is called epididymitis.3 If the entire testicle is affected, this is called epididymo-orchitis. “The main symptoms are pain and swelling of the testicle or epididymis,” says Dr Pratsides. “In addition, some patients experience fever, pain passing urine or an abnormal discharge from the penis.” 
 
Epididymitis may be caused by a urinary tract infection or sexually transmitted infection (STI) such as chlamydia or gonorrhoea.3 It can also be a side effect of amiodarone treatment. Mumps infection can cause epididymo-orchitis at any age.3  
 
Epididymitis is usually treated with antibiotics. The patient should be advised to rest in bed, elevate their scrotum (eg with supportive underwear), hold a cold pack (or bag of frozen peas wrapped in tea towel) on their groin and take analgesics for any pain, inflammation and fever.6 
 
Hydrocele 
A hydrocele feels like a smooth fluid-filled balloon inside the scrotum.7 There is often no specific cause, but it can be due to minor trauma, an infection, epididymitis, torsion or a tumour. A GP will examine the testicles and shine a light through the scrotum to check for a build-up of fluid. Men aged between 20 and 40 will be referred for an urgent ultrasound, as a hydrocele can be a sign of testicular cancer.8 
 
Hydroceles are often painless and clear up on their own, although any underlying cause needs to be treated. If a hydrocele gets larger over time, this can become uncomfortable and will require surgery to drain it.8  
 
Erectile dysfunction 
Erectile dysfunction (ED) affects around 50 per cent of men aged 50 to 90 at some point, although it can occur at any age.9 It is a symptom, rather than a disease, so it is important that any underlying conditions are properly diagnosed and managed.10 Erectile dysfunction can have a significant emotional impact on sufferers and their partners.12  
 
“Men with ED should see medical advice as it can be the sign of an underlying mental or physical illness,” says Dr Pratsides. “In younger, otherwise healthy, men, ED is usually down to performance anxiety or low mood. In older men, it can be the sign of vascular disease as the result of hypertension, high cholesterol or diabetes. 
 
“It can also be a complication of some urological procedures like prostate operations. In rarer cases, like if the man has never had an erection, then it could be a sign of a hypogonadism and hormone deficiency; this requires a referral to an endocrinologist.” 
 
Erectile dysfunction can often be managed within primary care, with an assessment to check for any associated cardiovascular problems.9,12 It usually responds well to a combination of drug treatment and lifestyle changes.13  
 
Any underlying conditions, such as diabetes and high blood pressure, need to be well-controlled, and treating any depression and anxiety may also help. Lifestyle changes include smoking cessation, losing weight, dietary changes to reduce cholesterol levels, cutting down on alcohol and taking more exercise. 9,13 
 
Cycling can be a risk factor, so men who cycle for more than three hours a week should give up cycling for a while to see if this improves their erectile dysfunction.13  
 
“Losing weight around the belly area is crucial as belly fat produces chemicals that can make male hormones that are important for healthy erections, like testosterone, less effective,” says Dr Pratsides. “Some people find counselling very effective – particularly if the main reason for their ED is performance anxiety.” 
 
Men can try oral phosphodiesterase type-5 inhibitors as a first-line treatment (including sildenafil tablets, which can be bought from a pharmacy without a prescription). Phosphodiesterase type-5 inhibitors increase the blood flow to the penis to cause an erection. 
 
These can usually be prescribed to all men with erectile dysfunction, whatever the cause, as long as there are no contraindications (eg people taking nitrates).9,13 Men can also try vacuum pumps, especially if they want a non-invasive drug-free approach. These devices fit over the penis and then air is pumped out so the penis becomes engorged with blood. 
 
Second-line drug treatments, such as alprostadil, are also available but these are not as convenient and well-tolerated as phosphodiesterase type-5 inhibitors.13 
 
 
References

1. Patient (Professional). Lumps in the groin and scrotum. https://patient.info/doctor/lumps-in-the-groin-and-scrotum (accessed February 2021)

2. Patient. Getting to know your testicles. https://patient.info/news-and-features/getting-to-know-your-testicles (accessed February 2021)

3. NICE Clinical Knowledge Summaries. Scrotal pain and swelling. What are the possible causes of scrotal swelling? https://cks.nice.org.uk/topics/scrotal-pain-swelling/background-information/causes/ (accessed February 2021)

4. NICE Clinical Knowledge Summaries. Scrotal pain and swelling. Scenario: Testicular torsion. https://cks.nice.org.uk/topics/scrotal-pain-swelling/management/testicular-torsion/ (accessed February 2021)

5. Medscape. Testicular torsion – Prognosis https://emedicine.medscape.com/article/2036003-overview#a8 (accessed February 2021)

6. NICE Clinical Knowledge Summaries. Scrotal pain and swelling. Scenario: Epididymo-orchitis. https://cks.nice.org.uk/topics/scrotal-pain-swelling/management/epididymo-orchitis/ (accessed February 2021)

7. Patient (Professional). Hydrocele. https://patient.info/doctor/hydrocele (accessed February 2021)

8. NICE Clinical Knowledge Summaries. Scrotal pain and swelling. Scenario: Hydrocele. https://cks.nice.org.uk/topics/scrotal-pain-swelling/management/hydrocele/ (accessed February 2021)

9. Patient (Professional). Erectile dysfunction. https://patient.info/doctor/erectile-dysfunction (accessed February 2021)

10. NICE Clinical Knowledge Summaries. Erectile dysfunction. What are the causes? https://cks.nice.org.uk/topics/erectile-dysfunction/background-information/causes/ (accessed February 2021)

11. NICE Clinical Knowledge Summaries. Erectile dysfunction. Risk factors. https://cks.nice.org.uk/topics/erectile-dysfunction/background-information/risk-factors/ (accessed February 2021)

12. NICE Clinical Knowledge Summaries. Erectile dysfunction. Complications. https://cks.nice.org.uk/topics/erectile-dysfunction/background-information/complications/ (accessed February 2021)

13. NICE Clinical Knowledge Summaries. Erectile dysfunction. Scenario: Management. https://cks.nice.org.uk/topics/erectile-dysfunction/management/management/ (accessed February 2021)