Testicular cancer is the most common cancer in males aged 15 to 49 and is one of the most curable cancers, even when it has spread. This makes early diagnosis critically important. The GP's role is rapid referral rather than watchful waiting. NICE NG12 recommends considering a suspected cancer pathway referral for non-painful enlargement or change in shape or texture of the testis, and considering a direct-access ultrasound (arranged urgently per the local pathway) for unexplained or persistent testicular symptoms. The practical rule: if the lump is not clearly separate from the testicle, arrange urgent ultrasound and referral to exclude malignancy. Epididymal lumps that are clearly posterior and separate from the testicle are usually benign (epididymal cyst, spermatocele), but examination is not always reliable — ultrasound confirms an uncertain diagnosis.

Cryptorchidism (undescended testis) is the most important risk factor for testicular cancer — it increases the risk, and importantly, the risk persists even after orchidopexy (surgical correction). Explain the increased risk and encourage testicular awareness and prompt reporting of any change. Gynaecomastia as a presenting feature of testicular cancer occurs in beta-hCG secreting non-seminomatous germ cell tumours (NSGCT) — beta-hCG stimulates oestrogen production in peripheral tissues, causing breast development. A young man with new gynaecomastia + any scrotal abnormality must have urgent testicular USS.

Secondary varicocele is an important diagnostic trap — a new left-sided varicocele that does not empty on lying down (non-draining varicocele) should raise suspicion for a left renal cell carcinoma compressing the left renal vein and preventing drainage of the left gonadal vein. Renal USS is indicated. A right-sided varicocele (less common anatomically) should also prompt investigation as it may indicate inferior vena cava obstruction from a tumour. New adult hydroceles — particularly where the testis cannot be felt — should be investigated with scrotal USS to exclude an underlying testicular tumour — a secondary hydrocele forms when a tumour irritates the tunica vaginalis and increases fluid production.

Tumour markers (AFP, beta-hCG, LDH) are usually taken before orchidectomy within the specialist pathway — they serve as baseline values against which response to treatment and recurrence are monitored. If orchidectomy is performed without pre-operative markers, subsequent tumour marker trends cannot be interpreted. AFP is produced by yolk sac tumour elements — it is often elevated in NSGCT but not in pure seminoma. An elevated AFP in a man with apparent seminoma on biopsy means the tumour contains NSGCT elements (mixed germ cell tumour) and changes the treatment approach.

Testicular salvage falls with time from onset, but surgery should not be withheld after 6 hours — salvage may still be possible. Any clinician who suspects torsion must arrange immediate transfer to the emergency department/urology (999 if unstable or no safe transport) — there is no role for "watchful waiting" or "return if worse." The clinical rule is: if in doubt, explore. Epididymo-orchitis and torsion can be clinically indistinguishable — Doppler USS can help but should not delay surgical exploration when torsion is clinically likely. A urologist would rather perform an exploration showing epididymo-orchitis than miss a torsion.

The antibiotic choice for epididymo-orchitis depends on the likely cause, judged from sexual risk, urethral discharge, insertive anal intercourse, recent instrumentation, urinary tract abnormality, urinary findings, previous microbiology and local resistance — age is only a rough surrogate. Sexually acquired: ceftriaxone 1 g IM single dose plus doxycycline 100 mg BD for 10–14 days (BASHH). Enteric: per local guidance; fluoroquinolones only when other commonly recommended antibiotics are inappropriate. Completing the full course is important as shorter courses risk inadequate treatment leading to chronic epididymitis and subfertility from epididymal scarring.

The inguinal approach for orchidectomy (rather than trans-scrotal) is critically important for staging — the scrotum has different lymphatic drainage (inguinal lymph nodes) compared to the testicle (retroperitoneal paraaortic nodes). A trans-scrotal biopsy or orchidectomy redirects tumour cells into scrotal and inguinal lymphatics, changing staging and potentially requiring inguinal radiotherapy or lymphadenectomy. This is why GPs should never attempt to biopsy or aspirate a scrotal mass. Sperm banking is a fertility preservation service available on the NHS before gonadotoxic treatment — it is often not discussed adequately in the rushed perioperative setting. GPs are well-placed to proactively ask young patients with testicular cancer whether sperm banking has been discussed.

Testicular awareness — knowing what is normal and reporting changes promptly — is reasonable advice, especially for higher-risk men, though monthly self-examination is not a proven screening intervention. The Orchid Cancer charity (orchid-cancer.org.uk) provides excellent patient leaflets that can be handed out in clinic. Proactively asking about body image concerns after orchidectomy is important — many men experience significant distress about testicular loss, affecting relationships and self-esteem, but rarely raise it without direct enquiry.

Surveillance-based management for Stage I testicular cancer (no metastases) avoids the toxicity of adjuvant chemotherapy in the many patients who would never relapse — it is the preferred approach in most UK centres for low-risk Stage I disease. The GP's role during surveillance is to ensure the patient attends all appointments (non-attendance rates are significant in this young demographic) and to recognise symptoms of relapse (back pain, dyspnoea, abdominal lump) promptly. The risk of contralateral testicular cancer is higher than the general population risk — all testicular cancer survivors should be encouraged to stay aware of changes in the remaining testis and report them promptly.