A Lump or Hardness in the Testicle: Signs of Testicular Cancer and How to Self-Examine

A small hardness noticed in the shower or by chance, a pea-sized bump on the testicle, or an unexplained heaviness in the scrotum... Many men who notice something like this first worry, then tell no one out of embarrassment or in the belief that “it will go away with time”. Yet although most scrotal swellings are harmless, a painless hardness arising from the testicle itself is the commonest sign of testicular cancer in young men and should be assessed without delay.

This article explains who testicular cancer affects, its signs, self-examination, telling normal structures apart from a lump, assessment, treatment and fertility preservation.

Who does testicular cancer affect?

Testicular cancer is rare among cancers overall, yet it is one of the most common cancers in men aged roughly 15 to 40. Because it usually affects men who feel healthy, its signs may be dismissed with the thought “I'm young, nothing will happen to me”. Known risk factors include:

• A history of undescended testicle: The risk persists even after surgery to bring the testicle down; the other testicle also carries a somewhat higher risk.
• Testicular cancer in the family: Particularly in a father or brother.
• A previous tumour in one testicle: A tumour is more likely to develop in the other testicle.
• Certain infertility conditions: Men with markedly abnormal semen parameters have been found to have a slightly higher risk.

Even so, most men diagnosed have no known risk factor.

Which signs should draw attention?

The commonest sign is a painless hardness or lump noticed in the testicle itself. The absence of pain does not make the finding unimportant. Other signs include:

• Enlargement, a change in shape or a firmer consistency in one testicle
• Heaviness in the scrotum, or a dull ache in the groin or lower abdomen
• Fluid collecting in the scrotum over a short period
• Rarely, tenderness or enlargement of the breast tissue

At later stages, symptoms away from the testicle, such as back pain, may appear; however, these have many other causes.

In practice, the commonest problem is not missing the sign, but putting off a visit out of embarrassment or the belief that “it will go away on its own”. Yet this examination is part of everyday urology and is carried out in confidence.

How do you examine your own testicles?

The recommended steps are:

• Timing: Once a month, after a warm shower, while the scrotum is relaxed.
• Rolling: Each testicle is gently rolled in turn, thumb on top, index and middle fingers underneath. The examination should not hurt.
• Surface and consistency: A healthy testicle is smooth and has a similar consistency throughout. A hard spot, a nodule the size of a grain of rice or a pea, or any irregularity should draw attention.
• Comparing: A slight difference in size between the testicles, or one hanging a little lower, is normal.

The aim is not to make a diagnosis but to know what is normal for you and to notice a change early. A new finding should not wait until next month. Anyone unsure of the method can ask their doctor during a visit.

Not mistaking normal anatomy for a lump: the epididymis and other structures

Many men examining themselves for the first time worry that a normal structure is a lump:

• Epididymis: A soft, coiled, comma-shaped structure at the top and back of the testicle; this duct system, where sperm mature, lies against the testicle but feels separate from it.
• Spermatic cord: Running from the testicle to the groin, it contains blood vessels and the sperm duct, which feels like a thin, smooth, firm tube.
• Blood vessels: The veins in the cord may be felt as fine coils; markedly enlarged veins suggest a varicocele.

The key distinction is this: the finding that raises suspicion is a hardness felt within the testicle, as if it were part of it. Structures separable from the testicle mostly have other causes.

Not every swelling is cancer: cysts, hydrocele, varicocele and epididymitis

Most swellings in the scrotum are due to causes other than cancer:

• Epididymal cyst and spermatocele: Soft bumps at the upper back of the testicle, felt separately from it; most are harmless.
• Hydrocele: Fluid collecting between the layers around the testicle. As the fluid can make the testicle harder to examine, a new hydrocele in an adult is checked with ultrasound.
• Varicocele: Enlarged veins that feel like a “bag of worms”; they become more noticeable when standing.
• Epididymitis: An inflammation that usually comes with pain and redness, and sometimes fever. A swelling that has not settled within a few weeks despite treatment should be reassessed; some tumours can at first resemble inflammation.

Telling these apart by touch alone is not always possible; scrotal ultrasound, together with the examination, clarifies the distinction. Rather than waiting in the belief that “it is probably a cyst”, it is wiser to have it assessed.

How is it assessed?

Assessment involves these steps:

• History and physical examination: How long the finding has been present, risk factors and plans for children are discussed; both testicles, the abdomen, lymph nodes and breast tissue are examined.
• Scrotal ultrasound: This is the key step. It shows whether the lump is inside or outside the testicle and whether it is solid or fluid-filled; the other testicle is also examined.
• Tumour markers: Blood levels of AFP, beta-hCG and LDH are measured. Raised levels support the diagnosis, while normal levels do not rule out a tumour; these values are also used in follow-up.
• Staging: Once the diagnosis is clear, imaging such as CT of the abdomen and chest shows whether the disease has spread.

An important detail: no needle sample or biopsy is taken through the scrotum. Procedures through the scrotal skin may allow the disease to spread outside its usual lymphatic pathways; tissue diagnosis is made by removing the testicle through the groin.

Treatment and fertility: what should you know?

When cancer is suspected, the first step of treatment is removal of the testicle together with its cord through an incision in the groin; this operation serves both diagnosis and treatment. For selected small lumps, surgery that preserves testicular tissue may also be considered. Afterwards, depending on the tumour type and stage, regular surveillance may be sufficient, or additional treatments such as chemotherapy or radiotherapy are planned together with oncology. When detected early, testicular cancer is among the highly treatable cancers; however, the course differs from person to person and follow-up continues for years.

• Sperm freezing before treatment: Treatments can affect sperm production, and in some men semen parameters are already low at diagnosis. Sperm freezing should therefore be discussed before surgery wherever possible, without delaying treatment.
• Living with one testicle: The remaining healthy testicle can often maintain hormone production and fertility; as testosterone may fall in some men, hormone levels are also checked during follow-up.
• Testicular prosthesis: For those who wish, a silicone prosthesis can be placed during the same operation or later; it has no function and is entirely optional.

When should you see a doctor?

A urology assessment is advised in these situations:

• A painless hardness, nodule or lump in the testicle: make an appointment rather than waiting for weeks
• Enlargement or a change in the shape or consistency of one testicle
• Heaviness that does not go away, or an ongoing dull ache in the groin
• A swelling that does not shrink despite treatment for inflammation
• A history of undescended testicle, testicular cancer in the family or a previous tumour in one testicle: regular self-examination and check-ups

Sudden, severe testicular pain, however, is a different matter: because testicular torsion is possible, go to an emergency department without waiting for an appointment.

Not every change in the testicle means cancer; the way to find out is not to wait, but to have it assessed with an examination and ultrasound. Monthly self-examination and seeking advice early, without embarrassment, make it more likely that any problem is caught early. Assoc. Prof. Zülfü Sertkaya practises in urology and andrology in Istanbul; assessment and treatment planning for lumps and hardness in the testicle are carried out with individual assessment and confidentiality.

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