Page 17 of 17
SU30.1-6 | Penis, Testis and Scrotum — PBL Case
CLINICAL SETTING
Arjun, a 27-year-old amateur footballer, visits his GP because he noticed a painless lump in his right testis while showering about three weeks ago. He had attributed it to a knock during a match, but it has not gone away. He has no urinary symptoms, no fever and feels otherwise well. He is anxious because his partner urged him to get it checked. This case unfolds in stages — discuss each trigger fully before revealing the next.
Trigger 1: The painless lump
On examination the right testis contains a firm, craggy, non-tender mass that is clearly intratesticular — you cannot 'get above' it from the cord, and it does not transilluminate when a torch is shone through it. The left testis and both epididymes feel normal. There is no inguinal lymphadenopathy.
DISCUSSION POINTS
- Why does a painless, firm, intratesticular lump in a man aged 15–35 demand the working diagnosis of germ-cell cancer until proven otherwise?
- How do the clinical signs — 'cannot get above it' and failure to transilluminate — help separate a solid tumour from a hydrocele or epididymal cyst?
- Why is a benign explanation such as 'a knock during football' a dangerous trap here?
- What is the single most useful first imaging investigation of the scrotal contents, and what are you looking for?
Click to reveal Trigger 2: The work-up (discuss previous trigger first!)
Trigger 2: The work-up
Scrotal ultrasound confirms a solid intratesticular mass. Serum tumour markers are sent: AFP is normal, beta-hCG is mildly elevated and LDH is raised. A staging CT of the chest, abdomen and pelvis is arranged to look for nodal and visceral spread.
DISCUSSION POINTS
- How do the markers (AFP, beta-hCG, LDH) help characterise the tumour — and what would a raised AFP have told you about the histological type?
- Why is the diagnosis ultimately made on the orchidectomy specimen rather than on a needle biopsy of the testis?
- Why is the pattern of lymphatic spread of testicular tumours to the para-aortic (retroperitoneal) nodes rather than the inguinal nodes, and how does embryology explain this?
- What is the rationale for offering sperm banking before treatment?
Click to reveal Trigger 3: Definitive management (discuss previous trigger first!)
Trigger 3: Definitive management
Arjun undergoes a radical INGUINAL orchidectomy with high ligation of the spermatic cord. Histology returns as a non-seminomatous germ-cell tumour. The multidisciplinary team plans stage-directed adjuvant treatment and a surveillance schedule using clinical review, markers and imaging.
DISCUSSION POINTS
- Why must the surgical approach be INGUINAL and never trans-scrotal — what is the danger of a trans-scrotal biopsy or approach?
- How does management differ in principle between seminoma and non-seminomatous germ-cell tumours?
- Why are serial tumour markers so valuable in monitoring response and detecting relapse after orchidectomy?
- What counselling about fertility, the contralateral testis and long-term follow-up should Arjun receive?
Group Task Assignments
- Build a comparison chart of the common scrotal swellings (testicular tumour, hydrocele, epididymal cyst, varicocele) by key examination signs (transillumination, ability to get above, consistency) to aid bedside diagnosis.
- Prepare a one-page summary of testicular tumour markers (AFP, beta-hCG, LDH), stating which are raised in seminoma versus non-seminomatous tumours and how they are used in follow-up.
- Draft the key counselling points you would give a young man before radical inguinal orchidectomy, including fertility preservation and the rationale for the inguinal approach.
Learning Issues
Research these questions and bring your findings to the discussion.
- [SU30.6] What is the classification, clinical presentation, investigation (including tumour markers) and principles of management of testicular tumours, and why is radical inguinal orchidectomy the correct approach?
- [SU30.5] How do the clinical signs of transillumination and 'getting above the swelling' distinguish a hydrocele and other scrotal swellings from a solid testicular tumour?
- [SU30.2] How does a history of undescended testis relate to the lifetime risk of testicular malignancy, and what are the implications for counselling and self-examination?