A hydrocoele is a collection of clear fluid around the testicle. It usually causes a painless swelling on one side of the scrotum, although both sides can occasionally be affected.

Hydrocoeles are common in babies and older men, but they can also develop during adolescence or young adulthood. In a younger man, the important question is not only “Is this a hydrocoele?” but also “Why has it developed?”

Most hydrocoeles are benign and do not threaten the testicle. Nevertheless, any new scrotal swelling should be examined because conditions such as an inguinal hernia, infection, testicular torsion or testicular tumour can sometimes produce a similar appearance or cause a secondary hydrocoele.

What causes a hydrocoele?

The testicle is partly surrounded by a thin membrane called the tunica vaginalis. This membrane normally produces a small amount of lubricating fluid, which is continually reabsorbed. A hydrocoele develops when fluid production exceeds absorption.

In younger men, possible causes include:

• Idiopathic hydrocoele: No specific cause is identified. This is common.
• Persistent communication with the abdomen: A small channel through which the testicle descended before birth may remain open. This is more typical in children but can occasionally persist into young adulthood and may be associated with an inguinal hernia.
• Inflammation or infection: Epididymitis, orchitis and some sexually transmitted infections may cause fluid to collect around the testicle.
• Trauma: A sporting injury, direct blow or previous scrotal injury can lead to a reactive hydrocoele.
• Previous surgery: Hydrocoeles may occasionally follow groin, hernia, varicocele or testicular surgery.
• Testicular torsion: Twisting of the spermatic cord can produce a reactive hydrocoele, although severe sudden pain is normally the dominant symptom.
• Testicular tumour: A tumour may occasionally be accompanied by a hydrocoele. The hydrocoele itself is not cancer, but the fluid can make examination of the underlying testicle difficult.

What does a hydrocoele feel like?

A typical hydrocoele produces a smooth, soft or tense swelling around the testicle. It may fluctuate in size and often feels heavier as it enlarges.

Symptoms can include:

• painless scrotal enlargement;
• a dragging or heavy sensation;
• discomfort when walking, running or exercising;
• irritation from clothing;
• difficulty examining the testicle;
• embarrassment or concern about appearance; and
• discomfort during sexual activity.

A very large hydrocoele can become inconvenient and may interfere with sport, work or everyday activities.

When is urgent assessment needed?

A hydrocoele usually develops gradually and is not an emergency. Seek urgent medical care, however, if there is:

• sudden or severe testicular pain;
• rapid swelling;
• nausea or vomiting with scrotal pain;
• redness, fever or increasing tenderness;
• a hard lump within the testicle;
• scrotal swelling following a significant injury; or
• a swelling that cannot be pushed back and is associated with groin or abdominal pain.

Sudden testicular pain may represent torsion, in which the blood supply to the testicle becomes twisted. This requires emergency assessment and should never be attributed to “just a hydrocoele.”

How is a hydrocoele diagnosed?

Assessment usually begins with a discussion about how and when the swelling developed, followed by examination of the abdomen, groin and scrotum.

A hydrocoele may transmit light when a torch is placed behind it, a finding called transillumination. This can support the diagnosis, but it does not replace a proper examination.

A scrotal ultrasound is commonly arranged in a younger man, particularly when:

• the hydrocoele is new;
• the testicle cannot be examined clearly;
• there is pain or tenderness;
• the swelling developed after injury;
• the diagnosis is uncertain; or
• an underlying testicular abnormality needs to be excluded.

Ultrasound can confirm that the swelling contains fluid and assess the testicle, epididymis, blood flow and surrounding structures. The European Association of Urology recommends high-frequency ultrasound when investigating a suspected testicular mass because it can determine whether a lesion is inside or outside the testicle and assess the opposite testis. EAU Testicular Cancer Guideline

Urine tests, STI testing or blood tests may also be appropriate when infection or inflammation is suspected.

Can a hydrocoele affect fertility?

For most younger men, a small or moderate uncomplicated hydrocoele does not cause infertility. It does not normally block sperm transport and does not automatically mean that sperm production is abnormal.

There are, however, several important qualifications:

1. The underlying cause may matter more than the fluid.
   Previous torsion, testicular trauma, severe infection, an undescended testicle, testicular cancer or another testicular disorder may affect fertility independently of the hydrocoele.
2. A very large or tense hydrocoele may theoretically affect the testicle.
   Prolonged pressure or increased local temperature has been proposed as a possible mechanism for impaired testicular function. Evidence in adults remains limited, and clinically significant infertility from an isolated hydrocoele appears uncommon.
3. Surgery carries a small fertility-related risk.
   Hydrocoele repair is performed close to the epididymis, vas deferens and testicular blood supply. Injury to one of these structures is uncommon but could affect fertility, particularly when operating on both sides or when the opposite testicle is abnormal. The British Association of Urological Surgeons lists inadvertent injury to these structures as an uncommon recognised complication of surgery. BAUS hydrocoele repair information

A semen analysis is not routinely required for every man with a hydrocoele. It may be appropriate when:

• a couple has been unable to conceive;
• the hydrocoele is very large or present on both sides;
• the opposite testicle is small or abnormal;
• there is a history of undescended testis, torsion, chemotherapy, testicular surgery or significant infection; or
• fertility preservation is an important concern before surgery.

The EAU recommends that the assessment of male infertility include a reproductive and medical history, physical examination, semen analysis and, where indicated, hormonal tests and imaging. It also stresses that semen analysis must be interpreted as part of the couple’s overall reproductive assessment rather than as a simple “fertile or infertile” test. EAU Male Infertility Guideline

Does every hydrocoele need treatment?

No. Treatment depends on the cause, size, symptoms and effect on quality of life.

Observation

A small, painless hydrocoele with a normal underlying testicle can often be monitored. It does not need to be removed merely because it is present.

Observation may include:

• self-awareness of any change in size or consistency;
• periodic clinical review when appropriate; and
• reassessment if pain, rapid enlargement or a new lump develops.

The British Association of Urological Surgeons supports observation when an adult hydrocoele is small or not bothersome. BAUS

Treating an underlying cause

If the fluid is secondary to infection, inflammation or another condition, treatment should address that cause. The hydrocoele may reduce once the underlying problem settles, although established hydrocoeles do not always disappear.

Aspiration

Aspiration involves inserting a needle and draining the fluid. Although this can provide temporary relief, the fluid usually returns because the lining that produces it remains in place.

Aspiration also carries risks of bleeding and infection. BAUS does not regard aspiration alone as curative or standard treatment because recurrence is common. It may occasionally be considered for someone who is unsuitable for surgery. In selected circumstances, a sclerosant may be injected after aspiration, but recurrence and inflammation remain concerns.

Hydrocoelectomy

Hydrocoelectomy is the most reliable definitive treatment for a bothersome adult hydrocoele. Surgery may be considered when the swelling:

• is large or progressively enlarging;
• causes discomfort, heaviness or skin irritation;
• interferes with exercise, work or sexual activity;
• causes significant cosmetic or psychological concern; or
• makes examination of the testicle difficult.

The operation is generally performed through a small scrotal incision under general or spinal anaesthesia. The fluid is drained, and the fluid-producing sac is folded, turned behind the testicle or partly removed to reduce the likelihood of recurrence.

Most procedures are performed as day surgery.

What should you expect after surgery?

Bruising, swelling and discomfort are expected and may initially make the scrotum look larger rather than smaller. Supportive underwear, simple pain relief and protected ice packs can help during the early recovery period.

Strenuous exercise and heavy lifting are generally avoided for several weeks. The testicle may continue to feel somewhat bulkier after repair because of the folded or thickened tissues around it.

Possible complications include:

• bleeding or a scrotal haematoma;
• wound or testicular infection;
• persistent swelling;
• recurrence of the hydrocoele;
• chronic scrotal discomfort;
• anaesthetic complications; and
• uncommon injury to the epididymis, vas deferens or testicular blood supply.

The current BAUS patient information notes that temporary bruising and swelling are very common, while infection, haematoma, recurrence and injury to adjacent reproductive structures occur much less often. Individual risks depend on the size and complexity of the hydrocoele, previous surgery, infection and general health. BAUS hydrocoele repair leaflet

The important message for younger men

A hydrocoele is usually harmless, and many do not require treatment. However, a new scrotal swelling in a younger man should not be self-diagnosed or ignored. Clinical examination and often an ultrasound can confirm the diagnosis and ensure that the testicle underneath is healthy.

Most isolated hydrocoeles do not impair fertility. When fertility is a concern, the entire reproductive history and both testicles should be assessed rather than assuming that the hydrocoele is responsible.

Management should be individualised. For one man, reassurance and observation may be entirely appropriate. For another, surgery may provide worthwhile relief from heaviness, discomfort or embarrassment.

This article provides general patient information and does not replace individual medical assessment. Seek urgent care for sudden testicular pain, rapid swelling, fever or a hard testicular lump.

So, if you have noted a scrotal swelling and this is concerning you and need to have this checked out, see your GP or obtain a referral to see you Brisbane Urologist, Uro-Jo, for peace of mind.

One of the most curable cancers in men

A lump in the testicle can be frightening, particularly because testicular cancer often occurs in younger men. The reassuring news is that testicular cancer is one of the most successfully treated solid cancers.

When detected early, cure rates approach 100%. Even when the cancer has spread to lymph nodes, lungs or other parts of the body, modern chemotherapy and surgery can still cure many men.

The most important message is therefore:

Know what is normal for you, and if something changes, have it checked.

Most testicular lumps are not cancer, but a new lump, enlargement, hardness or persistent change in a testicle deserves medical assessment and usually an ultrasound.

The importance of checking your testicles

There is no population screening program for testicular cancer in Australia.

This makes testicular awareness particularly important.

Cancer Council Australia recommends that men become familiar with the normal shape, size and feel of their testicles and seek medical attention if they notice a lump, swelling, heaviness, aching or another change.

This is slightly different from recommending a rigid population-wide screening program. There is currently insufficient evidence that formal scheduled self-examination reduces mortality from testicular cancer.

Nevertheless, knowing your own anatomy makes sense.

How do I check my testicles?

A convenient time is during or after a warm shower or bath when the scrotal skin is relaxed.

Gently examine one testicle at a time between your fingers and thumb.

Become familiar with:

• The usual size of each testicle
• Its shape
• Its firmness
• The fact that one testicle commonly hangs slightly lower
• The epididymis, which feels like a soft cord-like structure behind the testicle

You are not searching for microscopic abnormalities. You are simply learning what is normal for you.

Seek medical advice if you discover:

• A new hard lump
• Enlargement of one testicle
• A change in shape
• Increasing firmness
• Persistent swelling
• A heavy or dragging sensation
• Persistent testicular discomfort
• An unexplained difference from how the testicle normally feels

How often?

There is some variation between international recommendations.

The NHS in the United Kingdom advises checking the testicles regularly, approximately monthly, whereas Cancer Research UK emphasises awareness of what is normal rather than insisting upon a rigid monthly examination schedule.

In Australia, the practical message is best described as testicular awareness: become familiar with your testicles and investigate a persistent change rather than waiting to see whether it disappears.

Men at increased risk, including those with a previous undescended testicle, previous testicular cancer or significant family history, should discuss their individual surveillance with their doctor.

What is testicular cancer?

Approximately 90–95% of primary testicular cancers are germ-cell tumours.

They are divided into two broad groups:

Seminoma

Seminoma tends to behave in a relatively predictable manner and is extremely sensitive to both chemotherapy and radiotherapy.

Non-seminomatous germ-cell tumour (NSGCT)

This group includes:

• Embryonal carcinoma
• Yolk sac tumour
• Choriocarcinoma
• Teratoma
• Mixed germ-cell tumours

A tumour containing both seminoma and non-seminomatous components is treated as a non-seminomatous germ-cell tumour.

An important clinical rule is:

Pure seminoma should not produce AFP.

If AFP is significantly elevated, the tumour is managed clinically as a non-seminomatous germ-cell cancer even if seminoma is reported in the pathological specimen.

Other testicular tumours

Less common tumours include:

Leydig cell tumours

Most are benign, although malignant variants occur.

Sertoli cell tumours

Again, most are benign but malignant variants are recognised.

Testicular lymphoma

Lymphoma becomes particularly important in older men and is managed quite differently from conventional germ-cell cancer.

Occasionally another cancer can metastasise to the testicle.

How does testicular cancer present?

The classic presentation is a:

Painless testicular lump

A man may notice:

• Enlargement of one testicle
• A hard area
• A new lump
• Alteration in shape
• Increasing firmness
• Scrotal heaviness

Testicular cancer can also cause discomfort or pain.

Therefore:

Pain does not rule cancer in, and absence of pain does not rule cancer out.

Symptoms of more advanced disease

When cancer has spread beyond the testicle, symptoms can include:

• Back pain
• Abdominal discomfort
• Persistent cough
• Shortness of breath
• Chest symptoms
• Enlarged lymph nodes
• Weight loss
• Fatigue
• Breast tenderness or enlargement

Back pain can result from enlarged retroperitoneal lymph nodes behind the abdominal organs.

Diagnosis in Australia

The Australian diagnostic pathway is broadly consistent with European and British practice.

Step 1: Examination

Both testicles should be examined.

The abdomen and lymph-node regions may also be assessed.

Step 2: Testicular ultrasound

A high-resolution scrotal ultrasound with Doppler assessment is usually the first imaging investigation.

It determines whether a lesion is:

• Within the testicle
• Outside the testicle
• Solid
• Cystic
• Vascular
• Potentially malignant

A solid intratesticular mass should generally be considered malignant until proven otherwise.

Step 3: Tumour markers

Blood should ideally be collected before orchidectomy for:

AFP, Alpha-fetoprotein

May be elevated with:

• Yolk sac tumour
• Embryonal carcinoma
• Mixed germ-cell tumours

β-hCG, Beta human chorionic gonadotropin

Can be elevated in:

• Choriocarcinoma
• Embryonal carcinoma
• Mixed germ-cell tumours
• Some seminomas

LDH, Lactate dehydrogenase

LDH is less specific but provides information regarding tumour burden and prognosis.

Importantly:

Normal tumour markers do not exclude testicular cancer.

Markers are repeated after orchidectomy because the rate at which AFP and β-hCG fall provides valuable information regarding whether active cancer remains elsewhere.

Step 4: Staging

Staging commonly involves CT imaging of the:

• Chest
• Abdomen
• Pelvis

The retroperitoneal lymph nodes are particularly important because they represent the characteristic first lymphatic landing zone for many testicular cancers.

MRI can be used in selected circumstances.

PET scanning is not routinely recommended for initial staging.

FDG-PET has a specialised role after chemotherapy in selected patients with seminoma and a persistent residual mass.

Should the testicular lump be biopsied?

Usually no.

A needle biopsy through the scrotum is generally avoided when a germ-cell malignancy is suspected.

The standard procedure is:

Radical inguinal orchidectomy

The testicle and spermatic cord are removed through an incision in the groin.

This provides both treatment of the primary tumour and the tissue required for an accurate pathological diagnosis.

Fertility before treatment

This is particularly important because many patients are diagnosed while young.

The possibility of sperm banking should be discussed before chemotherapy, radiotherapy or other treatments that may impair fertility.

Ideally this conversation begins at diagnosis rather than after treatment has started.

One healthy remaining testicle will usually produce adequate testosterone and sperm, but some men with testicular cancer already have impaired sperm production before treatment.

Management of testicular cancer in Australia

Australian treatment is generally delivered through a multidisciplinary cancer team involving:

• Urologists
• Medical oncologists
• Radiation oncologists
• Radiologists
• Pathologists
• Fertility specialists when required

Complex metastatic, recurrent and post-chemotherapy disease is particularly suited to treatment through centres experienced in germ-cell cancer.

Australian practice broadly follows international evidence-based principles and is closely aligned with European and British practice, while incorporating Australian multidisciplinary cancer-care pathways.

Stage I seminoma

After radical inguinal orchidectomy, approximately 80% of men with unselected Stage I seminoma are cured by surgery alone.

For most reliable patients:

Active surveillance is generally preferred

This avoids exposing the majority of men who have already been cured to unnecessary chemotherapy or radiotherapy.

Surveillance involves scheduled:

• Clinical review
• Imaging
• Tumour markers where appropriate

If recurrence occurs, treatment is usually extremely successful.

Adjuvant carboplatin

A single cycle of carboplatin may be considered for selected patients who prefer adjuvant treatment or for whom surveillance is unsuitable.

Radiotherapy

Radiotherapy is extremely effective against seminoma but is now used much less frequently for Stage I disease because of concern regarding long-term:

• Secondary malignancies
• Cardiovascular effects
• Other radiation-related complications

Thus, in contemporary Australian practice, routine adjuvant radiotherapy for uncomplicated Stage I seminoma has largely moved into the background.

Stage I non-seminomatous germ-cell cancer

Approximately 70% of patients overall are cured by orchidectomy alone.

Management is influenced particularly by the presence or absence of lymphovascular invasion – LVI.

Without lymphovascular invasion

Surveillance is generally preferred for a reliable patient who is able to comply with follow-up.

With lymphovascular invasion

The risk of recurrence is considerably greater.

Options include:

• Surveillance
• One cycle of BEP chemotherapy

BEP consists of:

Bleomycin
Etoposide
Platinum – cisplatin

The advantages of avoiding unnecessary chemotherapy must be balanced against the increased likelihood of requiring several cycles of chemotherapy if metastatic recurrence subsequently occurs.

Retroperitoneal lymph-node dissection, RPLND

RPLND involves removal of lymph nodes from the retroperitoneum at the back of the abdomen.

It has an important but selective role.

In contemporary European and Australian-style practice, RPLND may be considered particularly for:

• Selected marker-negative Stage II NSGCT
• Residual masses after chemotherapy
• Teratoma
• Selected recurrent disease
• Particular patients in whom chemotherapy is undesirable

Modern nerve-sparing RPLND attempts to preserve the sympathetic nerves responsible for normal antegrade ejaculation.

These procedures should ideally be performed in experienced high-volume centres.

Stage II seminoma

For limited Stage IIA or IIB seminoma, treatment options can include:

• Radiotherapy
• Cisplatin-based chemotherapy
• In highly selected cases, specialist nerve-sparing RPLND

The precise choice depends upon lymph-node size, disease distribution, patient factors and the potential long-term consequences of each treatment.

For more extensive Stage IIB and Stage IIC disease, chemotherapy becomes increasingly favoured.

Metastatic seminoma and non-seminoma

Cisplatin-based combination chemotherapy transformed testicular cancer from a frequently fatal metastatic disease into one of the most curable metastatic solid cancers.

Common treatment includes:

BEP

Bleomycin + etoposide + cisplatin.

Depending upon the IGCCCG prognostic classification, treatment commonly consists of three or four cycles.

EP

Etoposide + cisplatin can be used in selected good-prognosis patients when bleomycin is unsuitable.

VIP

Etoposide + ifosfamide + cisplatin has a role in selected circumstances.

Surgery after chemotherapy

Surgery can remain crucial even after successful chemotherapy.

This is particularly important in non-seminomatous germ-cell cancer.

If tumour markers normalise but a residual retroperitoneal mass remains, surgery may reveal:

• Fibrosis or necrosis
• Mature teratoma
• Persistent viable cancer

Teratoma is particularly important because it can be relatively resistant to chemotherapy and radiotherapy.

The EAU recommends surgical resection of visible residual NSGCT masses greater than 1 cm when serum tumour markers are normal or normalising.

What about immunotherapy?

Immunotherapy has revolutionised treatment for several urological cancers.

Unfortunately, germ-cell cancer has not followed the same script.

Checkpoint inhibitors targeting PD-1, PD-L1 and related pathways have been investigated in chemotherapy-resistant germ-cell tumours, but responses have generally been disappointing.

Therefore:

Immunotherapy is not standard first-line treatment for conventional seminoma or NSGCT in Australia, Europe, Britain or the United States.

Its role is currently largely confined to highly selected refractory disease and clinical trials.

European, British, Australian and American guidelines – are they different?

The reassuring answer is:

The major principles are remarkably similar.

All emphasise:

1. Prompt ultrasound of a suspicious testicular mass
2. AFP, β-hCG and LDH assessment
3. Radical inguinal orchidectomy
4. Appropriate CT staging
5. Histological distinction between seminoma and non-seminoma
6. Fertility discussion and sperm banking
7. Surveillance for many Stage I cancers
8. Cisplatin-based chemotherapy for metastatic germ-cell cancer
9. Specialist surgery for appropriate residual or retroperitoneal disease

There are, however, some interesting differences in emphasis.

European approach: EAU

The European Association of Urology guidelines strongly favour avoiding unnecessary treatment.

For Stage I seminoma, surveillance is preferred when the patient can comply with follow-up.

Routine adjuvant radiotherapy is not recommended.

For Stage I NSGCT, the EAU uses lymphovascular invasion prominently for risk-adapted counselling:

• LVI negative → surveillance generally preferred
• LVI positive → surveillance or one cycle of BEP

Primary RPLND has a relatively limited role in Stage I NSGCT.

For marker-negative Stage IIA NSGCT, however, the 2026 EAU guideline supports nerve-sparing RPLND in an experienced specialised centre.

British approach

British practice is broadly similar to European practice.

The NHS pathway centres around:

Ultrasound → tumour markers → inguinal orchidectomy → staging → multidisciplinary oncology review.

Surveillance is commonly used following orchidectomy for appropriate Stage I disease.

Carboplatin remains an option for Stage I seminoma, while BEP chemotherapy is used for appropriate non-seminomatous and metastatic disease.

Radiotherapy retains a role predominantly in selected seminoma rather than non-seminomatous cancer.

British cancer services place considerable emphasis on:

• Specialist germ-cell cancer multidisciplinary teams
• Fertility preservation
• Long-term follow-up
• Minimising unnecessary treatment toxicity

This is very similar to contemporary Australian practice.

How does the American approach differ?

American management follows the same oncological principles, but the American Urological Association – AUA – gives RPLND somewhat greater prominence as an acceptable primary treatment option in selected early-stage disease.

For Stage IA NSGCT, the AUA recommends surveillance but recognises:

• RPLND
• One cycle of BEP

as alternatives for appropriate patients who decline surveillance or may not comply reliably.

For Stage IB NSGCT, American guidance recognises:

• Surveillance
• RPLND
• One or two cycles of BEP

as options following shared decision-making.

This differs subtly from the EAU approach, where primary RPLND in Stage I NSGCT has a considerably narrower role.

Another evolving difference: RPLND for Stage II seminoma

Traditionally seminoma involving retroperitoneal lymph nodes was treated with either:

Radiotherapy or chemotherapy.

American guidelines have increasingly recognised primary RPLND as an option for carefully selected Stage IIA/IIB seminoma with limited retroperitoneal disease, particularly for patients wishing to avoid the potential long-term toxicity of chemotherapy or radiotherapy.

European recommendations are also evolving in this direction.

The 2026 EAU guideline now incorporates nerve-sparing RPLND and newer de-escalation strategies into the management discussion for selected Stage IIA/B seminoma.

This is an excellent example of why testicular cancer management continues to evolve.

Australia: where do we sit?

Australian practice sits comfortably between these international approaches.

For most Australian patients:

Stage I seminoma

Surveillance is generally preferred, with carboplatin available for selected patients.

Stage I NSGCT without LVI

Surveillance is generally preferred.

Stage I NSGCT with LVI

Surveillance or one cycle of BEP following individualised discussion.

Stage II seminoma

Radiotherapy or cisplatin-based chemotherapy depending upon disease volume, with increasingly selective consideration of surgical strategies in specialist centres.

Marker-positive metastatic disease

Cisplatin-based chemotherapy according to IGCCCG prognostic classification.

Residual NSGCT after chemotherapy

Surgical resection when indicated, ideally through an experienced germ-cell cancer service.

Australian cancer care increasingly emphasises multidisciplinary decision-making and treatment that achieves cure while reducing unnecessary long-term toxicity.

Why avoiding unnecessary treatment matters

A 25-year-old cured of testicular cancer may live another 60 years.

That changes the treatment equation.

The question is no longer simply:

“Which treatment will cure the cancer?”

It is also:

“Which treatment will cure this cancer while leaving the smallest possible footprint over the next several decades?”

This is why surveillance has become so important.

Chemotherapy and radiotherapy are extraordinarily effective, but they should be used when their benefit justifies their immediate and long-term risks.

Prognosis

The prognosis for testicular cancer is excellent.

Stage I disease has survival approaching 100%.

Even metastatic disease is frequently curable.

Prognosis depends upon:

• Seminoma versus non-seminoma
• Stage
• Tumour-marker levels
• Sites of metastatic disease
• Response to chemotherapy
• Tumour-marker decline
• Presence of residual disease
• Ability to completely resect appropriate residual masses

Importantly, doctors genuinely use the word cure when discussing metastatic testicular cancer.

After treatment: don’t forget the other testicle

Having had one testicular cancer increases the risk of developing cancer in the remaining testicle.

Men should therefore remain familiar with the remaining testicle and report any new abnormality promptly.

Long-term survivorship care may also address:

• Testosterone levels
• Fertility
• Cardiovascular health
• Kidney function
• Hearing
• Peripheral neuropathy
• Lung health following bleomycin
• Psychological wellbeing
• Sexual health
• Risk of late treatment complications

The take-home message

Testicular cancer tends to arrive at an inconvenient age, when most men are thinking about careers, relationships, families and weekend plans rather than cancer.

Fortunately, it is also one of medicine’s most impressive cancer success stories.

Know your testicles.

Become familiar with what is normal for you.

Don’t ignore a change.

A lump, enlargement, hardness, heaviness or persistent discomfort deserves examination.

Don’t be embarrassed.

Your urologist has quite literally made a career out of discussing these things.

And don’t assume a diagnosis of testicular cancer means the worst.

With modern surveillance, surgery, chemotherapy and selective radiotherapy, the overwhelming majority of men diagnosed with testicular cancer can expect to be cured.

So, if you have felt a testis lump and you are concerned, come see me your local Brisbane Urologist, Dr Jo, to chat to you about treatment. This is URGENT and I will squeeze you in!

Sudden testicular pain is an emergency. This is not a “wait until tomorrow and see how it goes” situation.

There are few occasions in life when being twisted is definitely not a good thing. Testicular torsion is one of them.

Testicular torsion occurs when a testicle rotates around the spermatic cord, twisting the blood vessels that supply it. Think of a garden hose being twisted until the water stops flowing, except this particular hose supplies a rather important piece of anatomy.

The result can be sudden, severe pain and, if the blood supply is not restored quickly enough, permanent damage or loss of the testicle.

The good news is that prompt treatment can often save the testicle. The important word here is prompt.

Sudden severe testicular pain should be treated as testicular torsion until proven otherwise. Go directly to an Emergency Department.

What exactly is testicular torsion?

Normally, each testicle has enough mobility to accommodate everyday movement without being able to rotate freely.

Some boys and men have an anatomical arrangement commonly called a “bell-clapper” deformity, in which the testicle is more mobile within the scrotum than usual. This allows it to rotate around the spermatic cord.

When the cord twists, venous drainage is obstructed first, followed by arterial blood flow. The testicle becomes swollen, increasingly painful and eventually starved of oxygen.

This is why testicular torsion is a time-critical surgical emergency.

Although torsion is particularly common in adolescents, it can occur at almost any age, including infancy and adulthood.

What does testicular torsion feel like?

The classic presentation is difficult to ignore:

• Sudden onset of severe pain in one testicle
• Rapidly increasing scrotal pain or swelling
• A testicle sitting higher than usual or lying at an unusual angle
• Lower abdominal or groin pain
• Nausea and vomiting
• Marked tenderness of the affected testicle
• Occasionally pain that wakes someone from sleep

Some patients experience previous episodes of sudden testicular pain that disappear spontaneously. This may represent intermittent torsion, where the testicle twists and then untwists itself.

A disappearing pain does not necessarily mean that the problem has disappeared.

The clock starts ticking immediately

With torsion, time matters.

The two major factors determining whether a testicle survives are how long it has been twisted and how tightly the spermatic cord has rotated. Current European Association of Urology guidance recommends surgical exploration as soon as possible and notes that the best outcomes occur with very early intervention, ideally within approximately 4–6 hours of symptom onset.

There isn’t a magical cliff at six hours where the testicle suddenly gives up and packs its bags. Salvage may still be possible later, which is precisely why patients should seek emergency treatment regardless of how long the pain has been present.

Don’t wait to see whether it gets better.

And perhaps more importantly:

Don’t be embarrassed.

Emergency doctors and urologists have seen testicles before. Quite a few of them.

How is testicular torsion diagnosed?

The diagnosis begins with the history and examination.

A doctor will examine the abdomen, groin and scrotum and assess the position, swelling and tenderness of the affected testicle.

A Doppler ultrasound can assess blood flow to the testicle and is extremely useful when the diagnosis is uncertain.

However, there is an important catch.

An ultrasound should not delay surgery when torsion is strongly suspected.

The EAU specifically recommends that Doppler ultrasound be used as an adjunct without delaying intervention.

In other words, when the clinical picture is shouting “torsion”, we shouldn’t spend precious time politely asking the ultrasound machine for a second opinion.

Can the testicle simply be untwisted?

Sometimes a doctor can attempt manual detorsion while arrangements for surgery are being made.

This involves carefully rotating the testicle in the direction that releases the twist. Relief of pain may be dramatic when successful.

But this is important:

Successful manual detorsion does not replace surgery.

Residual twisting may remain even when the pain improves, and the testicle can twist again. EAU guidance therefore states that manual detorsion may be attempted while awaiting surgery but must not delay surgical exploration.

Emergency surgery: scrotal exploration

Definitive treatment is an operation called scrotal exploration.

Under anaesthesia, the surgeon makes an incision in the scrotum and examines the affected testicle.

The spermatic cord is untwisted and the testicle is allowed time to recover its blood supply.

Sometimes a rather alarming blue or purple testicle gradually becomes reassuringly pink again. Few colour changes make a urologist happier.

If the testicle appears viable, it is preserved.

Orchiopexy: preventing another twist

If the testicle can be saved, it is secured inside the scrotum using an operation called an orchiopexy or orchidopexy.

The testicle is fixed so that it cannot freely rotate around the spermatic cord again.

But there is another important part of the operation.

We usually fix the other testicle too.

The anatomical predisposition that allowed one testicle to twist may also be present on the opposite side. Therefore, when torsion is confirmed, the unaffected testicle is commonly fixed during the same operation.

Current guidance recommends contralateral orchiopexy at the time of surgery rather than returning later for an elective procedure.

Think of it as discovering that one wheel on the car was loose and sensibly checking the other one while you’re already holding the spanner.

What if the testicle cannot be saved?

Unfortunately, sometimes the blood supply has been absent for too long and the testicular tissue is irreversibly damaged.

If the testicle is clearly non-viable or necrotic, it may need to be removed.

This operation is called an orchidectomy or orchiectomy.

Losing a testicle can understandably be upsetting, particularly for an adolescent or young man. Concerns about appearance, masculinity, testosterone, sexual function and fertility are extremely common.

These concerns deserve a proper conversation rather than a hurried reassurance.

The encouraging news is that one healthy testicle is generally sufficient to maintain normal testosterone production, sexual function and fertility.

What about fertility after testicular torsion?

This subject is more complicated than simply asking whether the testicle survived.

Torsion can damage sperm-producing tissue through the original loss of blood supply and potentially through ischaemia-reperfusion injury when circulation returns.

Long-term studies have therefore reported abnormalities in semen parameters in some men following torsion. The EAU notes reported rates of subfertility of approximately 36–39%, although study results vary considerably and long-term paternity may remain comparable with control populations.

Importantly, having had testicular torsion does not automatically mean that a man will be infertile.

Many men subsequently have normal fertility, particularly when the other testicle is healthy. Studies have also reported normal pregnancy rates following unilateral torsion, whether the affected testicle was preserved or ultimately removed.

For patients concerned about future fertility, particularly after severe torsion, testicular atrophy or problems involving the remaining testicle, subsequent assessment may include:

• Testicular examination and ultrasound
• Measurement of testicular volume
• Semen analysis when appropriate
• Testosterone and reproductive hormone testing
• Fertility counselling where indicated

Can a rescued testicle shrink later?

Unfortunately, yes.

A testicle may look viable during surgery and still subsequently undergo testicular atrophy, becoming smaller over the following months.

Current EAU guidance notes that testicular atrophy can occur even following timely detorsion and fixation, which is why appropriate follow-up is important.

This does not mean the operation failed. The initial period without adequate blood supply may simply have caused microscopic damage that wasn’t visible during surgery.

What about testosterone and sexual function?

For most patients with a normal opposite testicle, testosterone production remains adequate.

Long-term studies suggest that hormonal measurements may differ somewhat following torsion, but overall endocrine testicular function generally remains within the normal range.

Removal of one testicle therefore does not normally cause erectile dysfunction, loss of masculinity or the need for testosterone replacement.

The remaining testicle usually quietly gets on with the job.

Testicular prosthesis: replacing what has been lost

Some patients are bothered by the cosmetic asymmetry following removal of a testicle.

A testicular prosthesis can be placed inside the scrotum to restore a more natural appearance and feel.

The prosthesis does not produce sperm or testosterone. Its purpose is cosmetic and psychological rather than functional.

Depending upon the circumstances, a prosthesis may be inserted during the original operation or at a later date. Prosthesis placement is an established option following orchidectomy, and current EAU guidance recommends that patients undergoing removal of a testicle be offered the opportunity to discuss a testicular prosthesis.

The decision is entirely personal.

Some men want one.

Some don’t.

Both decisions are perfectly reasonable.

Recovery after torsion surgery

Most patients recover relatively quickly following uncomplicated orchiopexy.

There will usually be some swelling, bruising and discomfort for several days. Supportive underwear can be surprisingly valuable during this period. The humble pair of supportive briefs finally gets its moment of glory.

Patients are generally advised to avoid strenuous activity, heavy lifting, cycling and contact sports until healing is satisfactory.

Timing for returning to work, school, sport and sexual activity should be discussed with the treating surgeon because this varies according to the operation and individual recovery.

Could torsion happen again after orchiopexy?

It is unusual, but recurrent torsion after orchiopexy is possible.

The EAU guideline describes recurrence after fixation as rare, but documented.

Therefore, even someone who has previously undergone orchiopexy should seek urgent medical attention if they develop sudden severe testicular pain.

Previous surgery doesn’t grant a testicle diplomatic immunity.

The message worth remembering

Testicular torsion is one of the true emergencies in urology.

If you or your son develops sudden severe pain in one testicle, particularly when associated with swelling, nausea, vomiting or an abnormally positioned testicle:

Don’t wait.

Don’t Google for three hours.

Don’t go to bed hoping it will disappear.

Go to an Emergency Department.

When it comes to testicular torsion, hours matter.

Early surgery may mean the difference between fixing a testicle in place and having to remove it.

And in this particular corner of medicine, keeping both passengers on board is very much the preferred destination.

So, get to your local Emergency Department urgently. I operate out of The Wesley and St Andrews War Memorial hospitals where I am on the on call roster. Ask for your local Brisbane Urologist, Dr Jo Schoeman.

Medical disclaimer

This information is intended for general patient education and does not replace individual medical assessment. Acute or sudden testicular pain requires urgent medical evaluation. If testicular torsion is suspected, attend an Emergency Department immediately. Your local Brisbane Urologist is on an on-call roster at both the Wesley Hospital and St Andrews War Memorial Hospital. Don’t delay!