Testicular Cancer vs. Testicle Infection

Testicular cancer occurs when abnormal testicular cells grow unregulated and may spread (metastasize) to other parts of the body. Testicle infection (also termed testicular infection and/or orchitis) generally means infection of the testicles by various bacteria and/or viruses. Although testicle infections do not metastasize, they may spread to structures attached to the testicles such as the epididymis (termed epididymo-orchitis).

• Testicular cancer types vary according to the cell type in which the tumor rises; similarly, testicle infections vary according to the infecting organism (various bacterial and viral species).
• Testicular cancer is one of most curable of all cancers, and most testicular infections are also curable.
• The most common signs/symptoms of testicular cancer are usually noticed by the patient who does a testicular self – exam at home; a painless lump the size of a pea or marble, usually adjacent to a single testicle is found. In contrast, this is not found in testicle infections; they usually present with signs and symptoms of testicular swelling, redness, pain and tenderness of the testicles. Testicular cancer may also have less common symptoms including sensation of heaviness of the testicle, shrinking and/or hardness of testicle, a dull ache in the abdomen pelvis or groin and rarely, breast tenderness. Other symptoms related to testicular infections also include nausea, fever, fatigue, pain with urination, headaches, and body aches.
• It is not known exactly what causes testicular cancers, but certain factors increase the risk of a man developing testicular cancer. A major risk factor is undescended testicles (cryptorchidism). In contrast, there are many known causes of testicle infections; for example, mumps virus, coxsackievirus, sexually transmitted diseases (mainly bacterial like Neisseria and/or Treponema), E. coli, Staphylococcus, Streptococcus and other species of bacteria.
• Testicular cancer treatment is radically different from treatment of testicle infections; for example, the standard treatment is orchiectomy (surgical removal of the testicle containing cancer cells and its attached cord. Other patients may need to undergo radiation and/or chemotherapy. Treatment of testicular infection depends on the underlying cause of the infection (for example, viral infections are usually not treated, but bacterial infections are treated with appropriate antibiotics). However, both testicular cancer and testicular infections need to be followed up by your physician.
• The prognosis for testicular cancer is surprisingly good with cure rates averaging from about 80 to 99%, depending upon the type of cancer cells causing the problem. Like testicular cancer, testicular infections, in general, have a good outcome or cure rate. However, a complication common to both problems is a reduction in fertility, especially in patients that have had testicular cancer (they are about one third less likely to father children).

• The two small testicular glands lie in a pouch of skin beneath and behind the penis called the scrotal sac, or scrotum.
• They are attached to the ejaculatory duct in the lower pelvis by cords called spermatic cords, which contain the vas deferens, the narrow tube through which the sperm moves out of the testis.
• Beside producing and storing sperm, the testicles (or testes) are the main source of male hormones such as testosterone, which are essential for normal sex drive (libido), for erections, ejaculation, and which drive development of male physical traits such as deep voice and body and facial hair.
• Cancer usually occurs in only one testicle. Less than 5% of the time, it occurs in both testicles. (Usually, if a second testicular cancer arises, the two tumors are found at different times, the second perhaps years later.)

Cancer occurs when normal cells transform and begin to grow and multiply without normal controls.

• This uncontrolled growth results in a mass of abnormal cells called a tumor.
• Some tumors grow quickly, others more slowly.
• Tumors are dangerous because they overwhelm surrounding healthy tissue, taking not only its space but also the oxygen and nutrients it needs to carry out its normal functions.

Not all tumors are cancer. A tumor is considered cancer if it is malignant. This means that, if the tumor is not treated and stopped, it will spread to other parts of the body. Other tumors are termed benign because their cells do not spread to other organs. However, almost all tumors start to cause symptoms when they get large enough.

• Malignant tumors can spread to neighboring structures, usually lymph nodes. They invade these healthy tissues, impairing their function and eventually destroy them.
• Tumor cells sometimes enter the bloodstream and spread to distant organs. There, they can grow as similar but separate tumors. This process is called metastasis.
• The most common places for testicular cancer to spread are the lymph nodes in the area near the kidneys (located in the back of the abdominal area and referred to as the retroperitoneum area), and arecalled the retroperitoneal lymph nodes. It also can spread to the lungs, liver, and rarely to the brain.
• Metastatic cancers arising in the testes are more difficult to cure than benign tumors, but still have very high cure rates.
• Testicular cancers can be comprised of one or several different types of tumor cells. The types are based on the cell type from which the tumor arises.
• By far the most common type is germ cell carcinoma. These tumors arise from the sperm forming cells within the testes.
• Other rarer types of testicular tumors include Leydig cell tumors, Sertoli cell tumors, primitive neuroectodermal tumors (PNET), leiomyosarcomas, rhabdomyosarcomas, and mesotheliomas. None of these tumors is very common.
• Most of the information presented here concerns germ cell tumors.
• There are two types of germ cells tumors, seminomas and nonseminomas.
• Seminomas arise from only one type of cell: immature germ cells that have not yet differentiated, or turned into the specific types of tissues they will become in the normal testis. These constitute about 40% of all testicular cancers.
• Nonseminomtous germ cell tumors are composed of mature cells that have already specialized. Thus, these tumors often are "mixed," that is, they are made up of more than one tumor type. Typical components include choriocarcinoma, embryonal carcinoma, immature teratoma, and yolk sac tumors. These tumors tend to be faster growing and to spread more aggressively than seminomas.
• Testicular cancer is the most common type of cancer in young men 15-35 years of age, but it can occur at any age.
• It is not a common cancer, accounting for only 1%-2% of cancers in men.
• The American Cancer Society estimated that about 8,800 new cases of testicular cancer would be diagnosed in the United States and about 380 men will die of the disease in 2016.
• Testicular cancer is most common in whites and least common in blacks and Asians.
• Testicular cancer is one of the most curable of all cancers.
• The cure rate is greater than 90% for most stages. In men whose cancer is diagnosed in an early stage, the cure rate is nearly 100%. Even those with metastatic disease have a cure rate of greater than 80%.
• These figures apply only to men who receive appropriate treatment for their cancer. Prompt diagnosis and treatment are essential.
• Because of its high cure rate, testicular cancer is considered the model of successful treatment for cancer originating in a solid organ. In 1970, 90% of men with metastatic testicular cancer died of the disease. By 1990, that figure had almost reversed - nearly 90% of men with metastatic testicular cancer were cured.

• Most cases of orchitis in children are caused by infection with the mumps virus.
• Orchitis caused by a bacterial infection most commonly develops from the progression of epididymitis, an infection of the tube that carries semen out of the testicles. This is called epididymo-orchitis.
• The majority of cases of mumps orchitis occur in prepubertal (less than 10 years old) males, while most cases of bacterial orchitis occur in sexually active men, or in men older than 50 years of age with benign prostatic hypertrophy.

Testicular Cancer Symptoms

Most testicular cancers are discovered by the man himself when he notices a painless swelling, lump, or pain in a testicle.

• The lump may be small (the size of a pea) or large (the size of marble or even larger).
• Less common symptoms include a lasting ache or sensation of heaviness in the testicle.
• Significant shrinking of a testicle or a hardness of the testicle are other less common symptoms.
• Occasionally, a dull ache or fullness in the abdomen, pelvis, or groin is the only symptom.
• Rarely, the first symptom may be breast tenderness (3%), a result of hormonal changes brought on by the cancer.

Changes in the testicle can be detected early by practicing monthly testicular self-examination. Self-exam is easy to do. Testicular self-examination is key to recognizing testicular cancer early. Males older than 18 years of age should be encouraged to perform monthly inspections of each testicle. Notify your health-care provider about any suspicious finding or concern.

Testicle Infection Symptoms

The symptoms associated with orchitis may range from mild to severe, and the inflammation may involve one or both testicles. Patients may experience the rapid onset of pain and swelling, or the symptoms may appear more gradually. Symptoms of orchitis may include the following:

• Testicular swelling
• Testicular redness
• Testicular pain and tenderness
• Fever and chills
• Nausea
• Malaise and fatigue
• Headache
• Body aches
• Pain with urination

In epididymo-orchitis, the symptoms may come on and progress more gradually.

• Epididymitis initially causes a localized area of pain and swelling on the back of the testicle for several days.
• Later, the infection increases and spreads to involve the whole testicle.
• Possible pain or burning before or after urination and penile discharge may also be seen.

Testcular Cancer Causes

It is not known exactly what causes testicular cancers. Certain factors, listed here, appear to increase a man's risk of developing a testicular cancer. Many others have been proposed, but are either unproven or discredited.

Cryptorchidism: The testicles form in the abdomen of the developing fetus. While the fetus is still in the womb, the testicles begin their gradual descent to the scrotum. Oftentimes, this descent is not complete at birth but occurs during the first year of life. Failure of the testicle to appropriately descend into the scrotum is called undescended testicle, or cryptorchidism.

• It can occur on one or both sides.
• If the testicles do not fully descend, the infant usually undergoes surgery to bring the testicle(s) into the scrotum.
• The risk for testicular cancer is three to five times higher in males born with cryptorchidism, even after surgery to bring the testicle(s) into the scrotum.
• Because of this increased risk, men with this type of condition should be even more rigorous about performing regular testicular self-exams.

Testicle Infection Causes

Orchitis in children most commonly occurs as a result of a viral infection.

• The virus that causes mumps is most commonly implicated as the cause of orchitis.
• Approximately one third of boys will develop orchitis from mumps infection.
• It is most common in young boys, and testicular inflammation typically develops 4-6 days after the onset of mumps.
• There are case reports of mumps orchitis occurring after immunization with the mumps, measles, and rubella (MMR) vaccine, but this is rare.
• Other less common viral organisms which can cause orchitis include varicella, coxsackievirus, echovirus, and cytomegalovirus (associated with infectious mononucleosis).

Less commonly, orchitis can be caused by a bacterial infection. Generally speaking, most cases of bacterial orchitis occur from the progression and spread of epididymitis (inflammation of the coiled tube on the back of the testicle), either from a sexually transmitted disease (STD) or from a prostate gland/urinary tract infection. This condition is termed epididymo-orchitis.

• Bacteria that can cause orchitis from prostate gland/urinary tract infections include Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus and Streptococcus species.
• Bacteria that cause sexually transmitted diseases, such as gonorrhea, chlamydia, and syphilis, can cause orchitis in sexually active men, typically between the ages of 19-35 years. People may be at risk if they have many sexual partners, are involved in high-risk sexual behaviors, if their sexual partner has had an STD, or if the person has a history of STDs.

Individuals may be at risk for non-sexually transmitted orchitis if they have not been immunized against mumps, if they get frequent urinary tract infections, if older than 45 years of age, or if they frequently have a catheter placed into their bladder.

Testicular Cancer Treatment

The initial treatment for testicular cancer is orchiectomy (surgical removal of the testicle and the attached cord). This is the standard therapy and is recommended for all men with testicular cancer.

Whether a patient has additional therapy following surgery depends on a number of factors: the tumor type, the location and extent of the cancer (whether it is limited to the scrotum or has spread to the abdominal cavity or other sites), and the serum tumor marker levels (AFP and beta-HCG). Men should discuss their urologist's recommendations and the risks and benefits of each therapy before making a decision. Some individuals may want to consider getting a second opinion before beginning treatment.

For germ cell tumors, the following options are available for treatment after orchiectomy.

Surveillance: This is sometimes called "watchful waiting" or "observation." What it means is that the patient receives no further treatment after orchiectomy but must adhere to a very strict schedule of follow-up visits with a urologist. The idea is to detect any potential residual or recurrent cancer and then proceed with treatment at that point.

• Surveillance protocols may vary by physician, but a typical protocol would require visits every two months for the first year, with tumor markers, chest X-ray, and CT scan of the abdomen done at every visit or every other visit.
• Follow-up is lifelong, gradually (over five or more years) tapering the frequency of the visits and tests to once per year (as long as no cancer is detected).
• Surveillance is a calculated gamble. The patient is betting that they have no residual disease but that, if they do, it will be found early while still highly curable. The advantage to this choice is that patients are avoiding the potential side effects of and lengthy recovery from chemotherapy or radiation therapy.
• If a patient is concerned about being able to stick with the rigorous surveillance schedule, immediate surgery, radiation, or chemotherapy may be the best choice.
• Surveillance is not recommended for all men with testicular cancer. Generally, it is reserved for men with stage I disease at low-risk of recurrence.
• Statistically, men who choose surveillance for select stage I cancer have just as good a chance of ultimate cure as men who proceed with immediate treatment.
• The risks and benefits are complex. These should be discussed in great detail with the physician before making a decision.

Chemotherapy: Combinations of chemotherapy drugs are the standard, whether a cancer is good risk or poor risk. The revolution in treatment of testicular cancer is attributed to the use of these drug regimens. The drugs are given in cycles consisting of about five days of intense treatment followed by a recovery period of approximately three weeks.

• Chemotherapy is the standard treatment for stage III disease.
• Patients will be referred to a cancer specialist (oncologist) for chemotherapy.
• Good-risk tumors (as determined by blood tumor marker levels and the radiographic extent of disease) are treated with a combination called BEP (bleomycin [Blenoxane], etoposide [VePesid], and cisplatin [Platinol]) for three cycles or a combination of etoposide and cisplatin for four cycles.
• Poor-risk tumors are also treated with BEP but for four cycles. Another option is VIP (etoposide [VP-16], ifosfamide [Ifex], and cisplatin).
• Each cycle lasts three to four weeks, although the next cycle may be postponed if the person has severe side effects.
• In cases of testicular cancer when the initial chemotherapy either fails to get rid of all evidence of the cancer recurs after the first line of chemotherapy, high-dose chemotherapy with stem cell transplant is used.
• Side effects of the standard chemotherapy regimens may include reduction in kidney function, alterations in skin sensation (17%-45% of men), hearing changes (30%-40%), decreased blood circulation to extremities (25%-50%), cardiovascular disease (18%), testosterone deficiency (15%), lung damage, infertility (30%), and a slight increase in the incidence of secondary solid tumors.

Radiation therapy: Radiation is the targeting of high-energy radiation beams directly at the tumor. In testicular cancer, the beam is targeted mainly at the lower abdomen to destroy any residual disease in lymph nodes.

• Radiation is usually offered for stage I or low-volume stage II seminoma. It is not recommended for nonseminomatous germ cell tumors.
• Patients will be referred to a specialist in radiation therapy (radiation oncologist) for this treatment.
• The radiation is given in a series of brief treatments five days a week, usually for three to four weeks. The repeated treatments help destroy the tumor.
• The remaining testicle is shielded to prevent damage to healthy tissue.
• Side effects include nausea, vomiting, diarrhea, loss of energy, irritation or mild burning of the skin exposed to the radiation beam, impaired fertility, and slightly increased risk of other cancers.

Surgery for Testicular Cancer

Surgery: A second more complex surgery is offered to some men. This surgery is designed to remove any residual cancer in the retroperitoneal lymph nodes and is called a retroperitoneal lymph node dissection, or RPLND.

• This surgery is not offered to all men with testicular cancer. It is usually offered to men with stage I or II nonseminomatous germ cell tumors who are thought to have a high risk of cancer in the retroperitoneum. It is also commonly recommended following chemotherapy if abnormally enlarged lymph nodes are present in the retroperitoneum. It is almost never offered to men with seminoma.
• The decision to go ahead with RPLND is based on tumor marker levels and findings of CT scan of the abdomen after orchiectomy. Rising or persistently high tumor marker levels or enlarged lymph nodes on the CT scan after orchiectomy strongly suggest residual cancer. Most experts recommend chemotherapy in these cases, not RPLND.
• In some cases, both RPLND and chemotherapy are recommended.

Summary of treatment by stage

• Stage I
  • Seminoma: Orchiectomy with or without radiation to the retroperitoneum
    • There is a 15% chance that tumor will spread to the retroperitoneum.
    • Because radiation can eliminate this cancer 99% of the time and is generally very well tolerated, radiation therapy is typically recommended.
    • Single dosage of chemotherapy (carboplatin [Paraplatin]) may be an effective alternative treatment but is not commonly recommended in the United States.
    • For those who choose surveillance, frequent visits (every one to two months) and tests are essential.
  • Nonseminomatous germ cell tumors: Orchiectomy followed by RPLND or chemotherapy
    • Of men who have no evidence of cancer spread on CT scan, 30%-50% do have microscopic spread. This risk can be predicted by a pathologic evaluation of the testicular tumor and depends on the presence of embryonal carcinoma or invasion of the cancer into the lymphatic/blood vessels. Elevated tumor markers which do not return to normal after the orchiectomy indicate this as well.
    • Treatment options include surgery to remove the lymph nodes in the retroperitoneum (RPLND), chemotherapy, or surveillance.
• Stage IIA
  • Seminoma: Orchiectomy followed by radiation therapy, although chemotherapy is also effective
  • Nonseminomatous germ cell tumor: Chemotherapy or RPLND
• Stage IIB
  • Seminoma: Either radiation or chemotherapy
  • Nonseminoma: Either chemotherapy or RPLND
• Stage IIC, III
  • Seminoma: Chemotherapy followed by post-chemotherapy RPLND, if needed
  • Nonseminoma: Chemotherapy followed by post-chemotherapy RPLND, if needed

Most non-germ cell testicular tumors usually require no further treatment after orchiectomy. If there is a high-risk of metastases or if metastases are present, further surgery is often recommended.

Testicle Infection Treatment

The medical treatment of orchitis depends on the underlying cause of infection, specifically whether it is caused by a bacterial or viral organism.

People with bacterial orchitis or bacterial epididymo-orchitis require antibiotic treatment. Antibiotic therapy is necessary to cure the infection.

• Most men can be treated with antibiotics at home for 10-14 days. Longer courses may be required if the prostate gland is also involved.
• If a patient has high fever, is vomiting, if he is very ill, or if he develops serious complications, the patient may require admission to a hospital for IV antibiotics.
• Young, sexually active men need to make sure that all of their sexual partners are treated if the cause is determined to be a STD. They should either use condoms or abstain from sexual relations until all partners have completed their full course of antibiotics and are symptom-free.
• Antibiotics prescribed will depend on the patient age and underlying cause of the bacterial infection. Antibiotics commonly used may include ceftriaxone (Rocephin), doxycycline (Vibramycin, Doryx), azithromycin (Zithromax) or ciprofloxacin (Cipro).

If the cause of orchitis is determined to be viral in origin, antibiotics will not be prescribed. Mumps orchitis will generally improve over a 1-2 week period. Patients should treat symptoms with the home care treatments outlined above.

Individuals diagnosed with orchitis should follow-up with their health care practitioner to ensure improvement, and to monitor for the development of any potential complications. Certain patients may require referral to a urologist. Call a health care practitioner or go to the emergency department if a person's symptoms worsen at any time during treatment.

Testcular Cancer Prognosis

After treatment for testicular cancer, most men enjoy a full, cancer-free life. The patient's ability to have an erection and orgasm will likely not change after testicular cancer treatment. However, men who wish to father children in the future are strongly urged to take advantage of sperm banking in case their fertility is impaired by the cancer or treatment.

Orchiectomy alone does not affect fertility, but chemotherapy, radiation therapy, and RPLND all may affect fertility in different ways. At 10 years, testicular cancer survivors are one-third less likely to father children as their peers.

Survival rates depend on the stage and type of testicular cancer.

• Stage I seminoma has a 99% cure rate.
• Stage I nonseminoma has about a 97%-99% cure rate.
• Stage IIA seminoma has a 95% cure rate.
• Stage IIB seminoma has an 80% cure rate.
• Stage IIA nonseminoma has a 98% cure rate.
• Stage IIB nonseminoma has a 95% cure rate.
• Stage III seminoma has about an 80% cure rate.
• Stage III nonseminoma has about an 80% cure rate.

Testicle Infection Prognosis

Generally speaking, most cases of viral orchitis and antibiotic treated bacterial orchitis will improve without complications. However, certain potential complications that can be encountered include:

• Some individuals with orchitis may experience shrinkage (atrophy) of the affected testicle
• Impaired fertility, or rarely sterility
• Repeated episodes of epididymitis
• Scrotal abscess
• If left untreated, rarely loss of testicle or death.