In busy day-to-day practice, we are often faced with puzzling situations. A useful mnemonic is 4-T: torsion, trauma, tumour and tuberculosis (infections). This case review in the BMJ is about a 34-year-old man presenting to A&E with left testicular pain and a lump. He was pyrexial with raised white blood count (WBC) and C-reactive protein (CRP). Mid-stream urine (MSU) results were not included. On first impression, it appeared to be a case of epididymo-orchitis. However, scrotal ultrasound with Doppler study revealed a mixed echogenic lesion with a cystic component. There was marked hyperaemia of the left testicle. On blood tests, all tumour markers were raised (red-flags!). The patient underwent radical orchidectomy. The histology report was mixed-germ cell tumour. The learning points and my comments are: 1) A high degree of suspicion is necessary and ask for a second / senior opinion; 2) Scrotal Doppler ultrasound is ‘Gold Standard’ and should be arranged as soon as possible if any case of epididymo-orchitis is not settling; 3) There should be early discussion with the patient / relatives about differential diagnosis of tumour; 4) Reassure the patient that, even if it turns out to be a tumour, overall survival from testicular cancer is excellent – nearly 90% five-year survival; 5) Discuss with the patient about sperm cryo-preservation and fertility issues; 6) Discuss testicular prosthesis; 7) Such cases can have medico-legal repercussions so seek advice from Medical Defence Union / Medical Protection Society (MDU / MPS) as necessary.
