174: The Lowdown on Testicular Lumps - When to Worry and What to Do

Scot: So you're doing the self-exam, or maybe your doctor found it. We're talking about a lump that is around your testicles. Any lump should be checked, but just because you find a lump isn't a reason to necessarily panic. There are a lot of reasons that lumps could be there. And then the question is, "What do you do about them?"

Mitch: Can I panic a little bit?

Scot: Yes.

Mitch: Just a little if there's . . . Okay. Just making sure.

Scot: Yes. This is "Who Cares About Men's Health," with information, inspiration, and a different interpretation of men's health. This is a Men's Health Essentials episode. We're going to talk about different types of lumps you might be able to find around the testicles that aren't something to worry about, but you might want to do something about. If you've been diagnosed with one of these, this episode could be useful for you.

My name is Scot. I bring the BS. The MD to my BS is urologist Dr. John Smith.

Dr. Smith: Howdy.

Scot: And he's a "Who Cares About Men's Health" convert, just a little panicked, but that's okay.

Mitch: It's not a Mitch episode today, though. So who has the lumpy testicles?

Scot: I mean, we do reveal a lot on the show. I don't like that you keep calling them lumpy.

I would say about 10 years ago, I noticed a lump during a self-exam. So I went into the doctor and I found out that I had a spermatic cord cyst on my left testicle. I was told it was completely benign. It's not cancerous or anything like that. I said, "Well, what are we going to do about it?" And they're just like, "Well, just don't worry about it." Okay, fine.

And then just recently, now I found another one on the other side. Now, I haven't had that one ultrasounded, so I'm hoping it's something similar. But in this whole process, the one on the left, I've noticed, is starting to bother me a little bit. It's starting to hurt. Not all the time, but sometimes just kind of a numb pain. Sometimes I just notice it. Depending on how I'm sitting or standing, I can tell it's there. And I'm wondering what I should do about that.

So, Dr. Smith, if you have a lump that you have checked out by your doctor . . . Now, first of all, if it's hard testicles, that's something to really worry about, because that could be potentially cancer, right?

Dr. Smith: Right.

Scot: Yeah. What we're talking about is an additional lump. It's almost like you've got a third testicle in there, a second testicle, right? So what are some possible reasons you might have a lump that's not cancerous kind of like I did? Like I said, you've got the epididymal cysts. You've got the spermatic cord cysts. Are there other things that are kind of like that that somebody may have been diagnosed with?

Dr. Smith: Yeah, so a lot of people come in and they think there's something wrong. There are a handful of things that are there. One is a hydrocele, or just a benign fluid collection around the testicle, that causes swelling. You can have it on one side or both sides.

An epididymal cyst happens in the epidermis, which is the organ on top of the testicle. It kind of looks like a mullet if you look at the anatomy of it on top of the testicles.

Scot: That's so fitting that a testicle would have a mullet.

Dr. Smith: It is, really. I mean, it'd be better if it had a mustache, but yeah, mullets are good enough. And so there's that, and then you've got varicose veins, which we call a varicocele, where you have enlarged blood vessels that can sometimes feel like a bag of worms if they're severe. But sometimes it just feels like a fullness in the scrotum if they're not quite as severe as you would feel when they get to feel like a bag of worms.

And then you've got your spermatic cord cysts. Those are the main things that you'll see. And then there's also something called a tunica albuginea cyst, which feels like a little BB on the testicle. Those are the most common ones that I see in my practice where people come in and they are panicking a little bit, Mitch.

Scot: So like I said earlier, when I went in with my spermatic cord cyst and they did the ultrasound, they said everything is fine, it's not cancerous. And then I just said, "What do I need to do about it?" Nothing. A few years later, I had another conversation with a urologist because it was getting bigger, and I'm like, "Well, now do I do something?"

So that's the question that I have, is for somebody that's been diagnosed with one of these things that we've talked about, at what point does somebody want to do something about them? I mean, I guess it wasn't impacting anything else in my life, like my fertility or anything like that. Is that the case with all of these?

Dr. Smith: Well, the varicocele or the enlarged blood vessels are the one that we worry most about if we're looking into fertility. It's the most likely to cause fertility issues, and those are treated oftentimes to help if there is a fertility problem.

Not everybody that has a varicocele would have a fertility problem. Some people have them and they have children, and it's not a problem.

If it's something where you're trying to have children and you're unable to and then you have an examination and they say, "Hey, you have a varicocele," they'll usually treat that varicocele to help improve sperm parameters.

So that's the one that you would look into that would affect fertility. The others are not going to affect fertility for the most part.

Scot: All right. And how big should I let this thing get? To the point where I can go to work and start charging admission to see it or what?

Dr. Smith: I mean, if your modeling career is over, then I guess you can do something about it. If not, you just let it go. But no, a lot of times we leave them alone until they become symptomatic, meaning they start to interfere with your ability to do your daily activities.

Say you're a cyclist or you do certain things and you're like, "It's really getting in the way size-wise," as far as the things you do, or if you like to wear more form-fitting clothing and you're like, "This is kind of starting to really be uncomfortable," would be a reason to do it. Or if it became painful. Like you mentioned, yours is starting to become a little bit painful. That would be one of the reasons that you would look into having something done.

Scot: What kind of pain are we talking? It's something I can stand, but I'm just aware it's there at times.

Dr. Smith: And that becomes the big thing of when do you do it? How much pain do you have to live through before you can get this thing removed? I think it's any time you make the decision that it bothers you enough that you would undergo surgery to remove it.

Understand the only way to get rid of it would be to undergo a surgical procedure to get rid of it. So if you're like, "It doesn't bother me enough I would have surgery for it," then you're probably not there.

Scot: Okay. I am curious, though, Dr. Smith. Let's just say that I can kind of deal with it right now. I have a feeling that the conversation really is about the trade-off. Is surgery worth it? Are the potential downsides that could happen with surgery worth the potential upside of getting rid of whatever pain level you might be at? And I do want to talk about the downsides, because I am seriously considering having a conversation about this with my own urologist, which everybody should do. But I'd like to go in having a little bit of knowledge.

Is there something I'm doing that's making it grow? Or is there something I can do that would slow the growth? If it hung out at this size, it would be fine, but it seems like they're getting bigger and bigger by the year.

Dr. Smith: There's nothing that you can really do. There's no literature out there that says, "If you do this or that, or you wear tighter-fitting undergarments, or whatever that it's going to make it happen."

The biggest thing that you want to have that conversation with the urologist is "What else can be done?" so I usually walk people through the algorithm of treating these things, and there is a less invasive way of doing it. We usually start with trying some non-steroidal anti-inflammatories. You take some ibuprofen over the counter for a little while to see if the pain goes away.

The other thing about this is when you do surgery, there's no guarantee you're going to get rid of the pain. And so they'll usually go through that and say, "Often we get rid of the pain once we take these out, but there's no guarantee." So you may undergo surgery and still have pain, but it would get rid of that lump that's there.

And so that becomes the discussion, because obviously, there is always a risk of bleeding, infection, damaged internal structures. Any time you have surgery, those are risks. Granted, a majority of the time, they're not high risks in the scrotum, because the scrotum, you can get in there and do what you need to do without a lot of problems.

But that being said, there's always that, and then if you're not going to get rid of the pain, and there's that chance, then it really is, "How much are you willing to undergo? If you knew it wasn't going to get rid of the pain, would you still do it?"

Scot: So the non-invasive thing, taking some anti-inflammatories, is that something I'll be doing for the rest of my life? Or what's the purpose of that?

Dr. Smith: So normally, we have you do it for two or three weeks to see if you can reset things and get the pain kind of under control and decrease the inflammation. It's not a forever thing. But I have had patients that will do that now and again every few years if it flares up. That's how they've been able to deal with it, and they don't have surgery for it.

Mitch: Now, when it comes to these particular types of lumps and bumps, how quick should they be growing? I mean, I hear about the moles that you're supposed to keep an eye on, or the lumps that you feel other places in your body, and if it goes particularly fast, that's also concerning.

Dr. Smith: Yeah, a lot of times it's variable. You'll have some people come in and they're like, "Yeah, this thing was half the size six months ago," or, "This thing has been here for 15 years, and it hasn't gotten any bigger."

And so really, a lot of it just comes down to each individual person and how the growth just transpires and goes through. Some are going to grow faster than others, and then other people are going to have them they're just going to be the size of a small marble for 15 to 20 years. And so really, those are the conversations you have.

Usually the people come in that are a little bit more panicked than less panicked are the ones who've had considerable growth or size change over the short-term.

Scot: So in the case of if you decide to do surgery, there are the standard surgical issues that could happen that you've already discussed, generally small chance that those types of things are going to happen. Is there a chance when you're in there removing one of these that you could damage something so I'm not producing testosterone anymore, or the amount that I need to produce?

Dr. Smith: Yeah, there are things that could affect your testosterone when you mention that. The main thing that you're looking for would be a testicular artery injury. A majority of surgeons, any of them that are going to do this surgery are going to bring a Doppler ultrasound in. And what that is, is it's an ultrasound that checks the artery to make sure that you're protecting that.

You'll usually move that out of the way while you're doing surgery to make sure you don't damage the testicular artery. If that is damaged, you'd lose blood supply to the testicle and that could affect testosterone and sperm production. And that's the main thing that would be a big no-no, if you had surgery and that got injured.

Scot: What does the actual surgery look like? Is this "I go into the hospital for a few days" sort of thing, or "I'm not moving for a few weeks"? Or is it outpatient? What would happen if I decided to get surgery? What would that look like?

Dr. Smith: Yeah, you'd be home the same day. You'd go in, you'd have surgery. Outpatient surgery is one of those things where they say, "Oh, the surgery takes about 30 to 40 minutes." Well, the surgery does, but you've got to show up early, and then they have to check your blood pressure and do all that jazz.

And then the anesthesia folks have to come and talk to you to make sure you understand all the risks associated. Then you go back and get put to sleep. Then you have the procedure that takes between 30 and 60 minutes. And then after that, you come out, you have to wake up, and they have to make sure that you can eat, drink, and pee before you leave.

So you're there four, six, eight hours. But really, the surgeon's time when the surgeon is in there doing your operation is 30 to 60 minutes.

Mitch: So this isn't like, say, a vasectomy or something where it's all endoscopy, local anesthesia, in and out.

Dr. Smith: So you would have some anesthesia. Generally, they'll do what's called monitored anesthesia care where they just take you back and you kind of go into twilight and they do it while you're sleeping.

You could feasibly do a lot of these while people are awake, but in the United States, it's just easier to put people to sleep, and we often do that. But there are places where some surgeons will do some of these while people are awake if, let's say, the person has compromised lungs or something like that. But that's something that you don't see super often.

Scot: And is this laparoscopic? How big of an incision are we talking?

Dr. Smith: Usually the incision is in the scrotum. So for the hydrocele surgery, the epididymal cyst, and the spermatic cord cyst, generally, the incision is in the scrotum about four centimeters, so one to two inches. And then you get in there, you deliver the testicle out of that, and then you're able to do the surgery, put everything back in, and then sew up that incision.

For the varicoceles, we generally ligate those vessels up higher and near the spermatic cord, in a similar region where you would have an incision done for hernia repair, like an inguinal hernia repair, just lateral to the base of the penis. That's generally where they would go into that.

Scot: About an inch and a half? I mean, what if you had a bigger lump than that?

Dr. Smith: Sometimes the incisions are larger, but in general, your incisions are large enough to open up and deliver the testicle and get what you need done.

Scot: So you're not deflating those cysts. You're not draining them first and then pulling them out?

Dr. Smith: No. Sometimes you will do that depending on the size. Normal or moderate sized ones you don't usually do that. But the hydroceles sometimes you'll end up doing that because they're large enough where you've got one the size of a grapefruit that's siting on . . .

Scot: What?

Dr. Smith: Oh, yeah. I mean, I would say Google it, but don't Google it.

Mitch: I'm Googling it.

Scot: I guess I'm being a big baby. I thought mine was large, but it's no grapefruit size. If somebody has something that large, though, are you stretching out the skin of the scrotum? Will it not ever go back? In that case, would you want to maybe get it out before it got that big?

Dr. Smith: Well, yes and no. I mean, some of them grow quickly where they're like, "This happened over the last six months." And it's one of those things where you come in and it got big really, really quick. It's not like they were necessarily sandbagging and not trying to come in.

Now, there are people who've had them that way for 10 years where they're like, "Yeah, it just didn't bother me that much." And then other people come in and they're like, "Yeah, man, this wasn't here yesterday," kind of thing.

Scot: Man.

Mitch: Geez. Don't Google it, by the way, listeners. I just would have assumed I would have gone and got this looked at earlier, but you're saying they can grow pretty fast.

Dr. Smith: You can have them grow pretty fast. But the larger ones, sometimes they will have to do a scrotoplasty where they'll take some of the excess skin and then do a little bit of a tidy-up procedure. They'll do that when they take it out if there is excess skin, but that's a case-by-case basis.

Scot: And then what does recovery look like after I've had the surgery done? How long am I out of action, can't do stuff?

Dr. Smith: I mean, you can get up and start walking around, not doing anything super strenuous for a couple weeks. Generally, you're not violating any big structures where . . . Like a hernia, you've got to be careful for four to six weeks before you start lifting things. With this, you don't have that. You just need the skin to heal.

So generally, for a couple of weeks, we ask you not to do anything super strenuous, and then ease back into things. And then hold off from intercourse, things like that for a week or two while the skin heals up as well, just to allow things to get healed up.

A majority of surgeons will use suture that absorbs on its own so that you don't even really need to go back to have any stitches removed or anything like that. And then you're kind of on your way.

Scot: So would you say the recovery is comparable to a vasectomy? Or do you have to be more careful after a vasectomy than you would after this surgery?

Dr. Smith: I think you could say they're comparable. I mean, if you had a big hydrocele where they did a little bit more as far as possibly removing some excess skin or things like that, it's probably a little bit more than a vasectomy just because they're delivering the testicle and doing that. But overall, the same kind of aches and pains that you'd have after a vasectomy would be very similar.

Scot: And then if I wanted to go back to exercising, strength training, that sort of thing, how long?

Dr. Smith: Usually a week or two. I would obviously talk to your surgeon, I mean, some people are a little bit more . . . you've met people who are a little bit more conservative than others as far as when they're ready to jump back in and do things. Some surgeons will say, "Hey, get back at it as soon as you feel ready." And some of them will say, "Hey, take two or three weeks off and make sure you let everything heal."

And so whatever your surgeon recommends is what I would recommend for you, to follow their guidance because they were the ones who were there doing the surgery.

Scot: Right. And if you have to do physical labor, that would be a good conversation to have with your surgeon as well.

Dr. Smith: Absolutely.

Scot: Yeah. And then the big question is . . . So we've already talked about if I get them removed, the pain might not go away. Is there anything in the literature that talks about percentages of that, by the way? Are there any stats on the pain thing?

Dr. Smith: So it's big ranges. I mean, 20% to 70%. But that being said, I will say this. There are other procedures that are done to mitigate pain in the scrotum and testicles that could be done if your pain didn't go away, but again, you'd be looking at another procedure. And so that would be something to think about.

But it's not like there's nothing that can be done. It's just that it might require another procedure, but you wouldn't want to just go gangbusters and do it all at the same time. If the one procedure works well, you should take that one first and see if it takes care of what you need.

Scot: And then will these conditions come back? Will these cysts come back after they've been removed?

Dr. Smith: So there is a possibility of return. Generally, after surgery, it's low, like single-digit return rate for them. I mean, there always is that risk, but in general, most of the time you're pretty safe.

Scot: Okay. So no returns. What about new ones?

Dr. Smith: So that's the other part too with some of the epididymal cysts, things like that. They generally occur because there's a blocked tube. The epididymis is literally just a series of tubes, and so at any point, another one of those tubes could become blocked and create an epidermal cyst.

The hydroceles generally have a lower chance of coming back because you've removed the sack surrounding the testicle, whereas the epididymal cyst, if any of the tubes within the epididymis become blocked, you can create a new epididymal cyst.

Scot: What about the spermatic cord cyst?

Dr. Smith: Similar too. If there's another area where you have a blockage there, you could have those.

Scot: So it's the tube thing again.

Dr. Smith: Yeah.

Scot: Okay, got you.

Dr. Smith: But again, depending on where this spermatic cord cyst originates depends on the likelihood it would come back.

Scot: Oh, really? Would a surgeon be able to give you some sort of an estimate after they got in and removed it?

Dr. Smith: Yeah, and usually, when you're working these things up, you'll get an ultrasound to get a good idea of actually what you're dealing with, and sometimes they can tell from that.

Scot: Oh, that's cool. Is there anything that we didn't cover?

Dr. Smith: No, I think we covered most of it. I think if you are concerned, go see somebody. At the very least, get an ultrasound. It'll give you a good idea, "Is this something to truly be worried about, or is it something that you can just watch?" I think we covered the majority of it.

Scot: Okay. Mitch, do you have any questions?

Mitch: No, I'm good.

Scot:What was that?

Mitch:I don't know. This show sometimes leads me to see things that I will never unsee. And I just would hope that men that are out there listening, if your lump is getting big, you should probably go talk to a doctor.

Scot: I mean, I did, and it's continuing to get big. It's not grapefruit big. Fools rush in. You were warned. Don't go to YouTube.

Mitch: Oh, yeah. No, totally.

Scot:You did.

Mitch:I'm a rush-in fool. I'm here.

Scot: All right. Well, I have an appointment with my urologist in the next day or two, so I feel well armed in this conversation now. I do appreciate that, Dr. Smith.

My last thing I wonder about and worry about is I'm 53 years old, right? So I'm thinking, "Well, maybe I should just get it done now while I'm younger and healthier versus maybe another 15 years from now, that's when it really starts bothering me. Then I'm not as healthy and I'm concerned of possibly more side effects from a surgery." Is that silly, or no? What do you think?

Dr. Smith: I always tell people we've made things so safe surgically these days. I mean, people go in and they're like, "Yeah, I'm going to have my hips replaced and my knees done," and we act like it's no big deal. "Yeah, Bob just had both of his knees done last week." And in reality, there are real risks to that.

Age, there is a risk for anesthesia with age. And so I think a lot of those things, you do think about some of them, and you should. Surgery is never a big deal until it's on you. And then in urology, it's never a big deal until it's on your genitals, right? So in that regard, you're two strikes in. You might as well have that conversation and really think about it.

But if it's not bothering you that bad, you can watch it. But again, I think you're thinking along the right lines.

Scot: Okay. I mean, based on growth, they keep getting bigger. So I don't know. Do they just ever just stop?

Dr. Smith: Yeah, you could have them get big to a point and then stop. But I mean, if they are continuing to get bigger, and you're noticing it month over month, year over year, it may be something to say, "Hey, I'm not interested in this thing just continuing to get larger." At some point, the Magic 8 Ball doesn't tell you when they're going to stop.

Scot: Any takeaways, Mitch, other than when a doctor tells you don't look it up on Google?

Mitch: That's what I have learned today. I mean, it's the same stuff as always, where it's just like, "Hey, if something is bothering you or something is concerning you, it might be worth going in and talked about."

Scot: My takeaway is you should have any lump checked. I made a terrible assumption on my deal. So I had the one on the right side that I knew about when I found the one on left side. I'm like, "Oh, that's just the same thing." Well, I don't know that. It probably is because it's not on the testicle, but I was a little mad at myself for not going in and just making sure earlier on that one.

And then when this other one started hurting again, that's when I thought, "Well, maybe I should go in and have them looked at, have a conversation."

So I just think that if you find any lump, you should just go in, just have that peace of mind before it turns into something that you don't want it to turn into.

Dr. Smith, anything you'd like to finish this off with?

Dr. Smith: No. I think you guys covered it. If you have concerns, it's worth it to go get it checked out. A simple ultrasound will give you all the ammunition you need to know how worried you should be. And then you have that conversation of where to go.

Scot: If you have any questions, comments, thoughts on today's episode, we'd love to hear from you. You can email us at hello@thescoperadio.com.

Thanks for listening. Thanks for caring about men's health.