12. Know Your Balls

As men we normally have two balls, or testes, which are located in a pouch or sac of skin, called the scrotum, underneath our penis. They are easy to feel and check, yet many men never do so. This is a pity because testicular cancer is common in young men and is also easily curable if caught early. So, for the sake of your health, you should know your balls. Of course, many simple testicular problems have nothing to do with cancer at all and some of the more important and common conditions are described in this chapter.

The testicles are the male sex glands and are part of the male reproductive system. In adult men, each one is normally somewhat smaller than a golf ball. The spermatic cord is like a flexible tube that goes from each testis to the lower abdomen. The spermatic cord contains the blood vessels that take blood to and from the testis, and the vas deferens which take sperm from the testis to the penis.

Firstly, they make the male hormone testosterone. This hormone is responsible for the development of the reproductive organs and other male characteristics, such as body and facial hair, deep voice and broad shoulders. Secondly, they produce and store sperm, which carry the genetic code to create a baby. Sperm cells are carried from the testicles through small tubes called the vas deferens to the seminal vesicles. Fluid from the vesicles and from the prostate gland is added. During ejaculation (orgasm), this fluid, now called semen, travels through a tube (the urethra) in the centre of the penis and out of the body.

By examining yourself regularly, you will be more confident about your own body and in a better position to notice any changes in a previously normal testicle. If you notice any change in the size of a testis, or any abnormal lumps, swellings or tender spots, then you should see your doctor. Doctors are used to examining testes and will be able to advise if the abnormality is serious or not.

It is important to remember that most abnormalities are not cancer. However, cancer of the testes is the most common cancer in young men in Ireland and affects about one in every 500 men between the ages of 15 and 50. If it is caught early, it can almost always be easily treated and cured. Therefore, it is important to practise regular testicular self-examination so that you get to know how your testes normally feel. This allows any changes to be more easily detected.

Testicular Self-Examination (TSE) Procedure

Practise this regularly, at least once a month. The best time for testicular self-examination is just after a warm bath or shower, when the scrotal tissue is more relaxed.
While standing in front of a mirror, place the thumbs on the front side of the testicle and support it with the index and middle fingers of both hands.
Gently roll the testicle between the fingers and thumbs. The testes can move around a little in the scrotum, but cannot usually move enough to twist round fully.
Feel for lumps, hardness or thickness. Compare the feelings in each testicle. Normal testes feel like smooth and slightly spongy balls inside the baggy scrotum. It is normal for one testis to be slightly bigger than the other, and for one to hang slightly lower than the other.
You can normally feel the spermatic cord through the skin of the scrotum just above the testis. It feels like a thick piece of string.
If you find any swelling, lump, unusual tenderness or other abnormality, see your doctor as soon as possible.

Orchitis means inflammation of a testis (testicle). Epididymitis means inflammation of the epididymis (the structure next to the testis that is involved in making sperm). Because the testes and epididymis lie so close together in the scrotum, it is often difficult to know whether either or both are inflamed.

Symptoms come on over a day or so and include a swollen, tender and red scrotum. It may feel warm to touch as well as sore. You may have a temperature and generally feel unwell. There may be other symptoms, such as burning when passing urine, depending on the underlying cause. If a urinary tract or sexually transmitted infection appears to be the cause then a urine test or penile swabs will be done.

Treatment usually involves a course of antibiotics and symptoms normally resolve over a week or so. Supporting underwear sometimes helps to ease the pain. Complications are uncommon and a full recovery is the norm. However possible complications include:

A hydrocele is a collection of fluid in the scrotum next to a testis. A hydrocele feels smooth, like a small fluid-filled balloon inside the scrotum. It usually occurs on one side, but sometimes a hydrocele forms over both testes. They vary greatly in size. Hydroceles usually have no symptoms unless they get large, in which case they may cause some discomfort.

Most hydroceles occur in older men and usually there is no underlying cause. Sometimes it may occur as a result of an infection, injury or tumour of a testis. Your doctor can diagnose a hydrocele by shining a light against the scrotal skin: a hydrocele will cause the scrotum to light up like a lantern. Sometimes an ultrasound scan of the testes is done to check the testes to make sure there is no underlying cause of the hydrocele.

Treatment options for a hydrocele include draining the fluid and repairing the hydrocele with a surgical procedure. Watchful waiting (no active treatment) can be a very reasonable option too, especially in older men. If there is an underlying problem with the testis this will need to be treated as well.

A varicocele (pronounced var-ih-ko-seal) is like a swollen or varicose vein in your scrotal sac. It has been described medically as like feeling a mass of quivering worms. The majority of varicoceles are found on the left side of the scrotum. Varicoceles are common and can affect about one in every seven young men. Most of the time a varicocele does not mean any underlying serious condition, but occasionally it can be due to other problems in the abdomen, such as a kidney tumour.

Varicoceles are usually painless and have no symptoms. Some men may notice a ‘dragging’ feeling or slight discomfort from their varicocele. This may only occur at the end of the day, especially if you were on your feet all day.

They are usually harmless. There is a higher rate of infertility in men with a varicocele compared to those who do not have one. This may be due to the increased temperature in the testes caused by the swollen veins. The testis on the side of the varicocele can become smaller, or not develop as much as the other side. This may contribute to infertility too. If you are infertile and you have a varicocele, your specialist will be able to advise on current research related to this issue. Sometimes, if they are large, they can be treated surgically.

Torsion of the testis is a condition that requires an emergency operation. It occurs when a testis twists around in the scrotum. In some people the testes can move around in the scrotum more than usual. If a testis twists round, the blood supply to the testis is blocked in the twisted spermatic cord. The effect of this is that the testis, with its blood supply cut off, becomes damaged and will ‘die’ unless the blood flow is quickly restored.

Torsion is most common in teenage boys, shortly after puberty, and it is uncommon in men over the age of 25.

The main symptom of torsion is severe pain in the testicle. Sometimes pain is also felt in the belly area due to the nerve supply to the testes. The pain tends to come on quite quickly and becomes severe over a few hours. The affected testis soon becomes swollen, red and very sore to touch.

Torsion of the testis is an emergency because if the blood supply to the testis is cut off for more than about 6 hours, permanent damage to the testis is likely to result. An emergency operation is usually done to untwist the testis and spermatic cord and ‘fix’ the testis in position so that torsion can’t happen again. There is an increased chance of torsion occurring in the other testis at a later date so that testis is also fixed at the same time to prevent this from happening. The operation ideally should be within a few hours of the symptoms starting in order to maximize the chance of saving the testis. Otherwise, the testis may have to be removed.

Sometimes sharp pains, which last a few minutes and go just as quickly, can occur in the testes of boys and young men. This can be due to partial twisting of the testis, which then untwists again with relief of symptoms. This can be an early warning sign of a possible torsion later on. It is important to get prompt medical advice if these symptoms occur. Sometimes if these warning pains occur, an operation is recommended to fix the affected testis so as to prevent full-blown torsion later on.

The presence of blood in the ejaculate is called haematospermia (pronounced hem-at-o-sperm-e-a). This is usually a harmless symptom; however, it can cause major worry and anxiety for an affected man. Usually there is no underlying medical cause and detailed investigations are not needed. Less commonly, it may be associated with abnormalities of the urinary tract, including kidney and prostate problems, and occasionally is associated with other more generalised illnesses, such as cirrhosis of the liver or parasitic infections. Men aged over 40 with persistent haematospermia may need to be referred to a urologist, especially if they have other symptoms or abnormal findings on examination.

The muscle wall of the stomach area normally forms a good protective barrier to the intestines that lie underneath it. If this muscle wall weakens in an area then the intestines can bulge through. This is called a hernia. Hernias occur most commonly in the groin area as this is usually the weakest point of the abdominal muscle wall. Sometimes hernias can be seen elsewhere, such as at the site of an old operation scar or near the belly button. Occasionally, particularly in obese individuals, a hernia occurs in the centre of the abdominal wall where the muscle layers join together. Over time hernias can increase in size and sometimes hernias in the groin area can track all the way down into the scrotum.

The main symptom is a bulge or lump felt under the skin. A hernia may be first noticed after a strain, for example, lifting a heavy object or coughing. This lump can usually be pushed back at first. Hernias may cause a sense of discomfort but they are not usually painful.

Hernias can be successfully treated by a small operation, which can normally be done as a day case procedure. A stitch or mesh is put into the weakened muscle area to strengthen it. It is important not to do any heavy lifting for several weeks after this procedure to minimise the chance of recurrence.

Treatment to fix a hernia is normally advised because, if untreated, it may become bigger with time. There is also a small chance that a hernia might strangulate. This is where the bowel bulging through the gap in the muscle twists, cutting off its blood supply. This can cause severe pain and requires an emergency operation to fix it. It is not unlike torsion of the testis. Fortunately, strangulation of a hernia is uncommon but it is a good reason to have your hernia fixed routinely.

Peyronie’s disease is a condition of the penis where firm rope-like or fibrous plaques form in the soft spongy tissue of the penis. These plaques don’t stretch so that, when the man develops an erection, the penis tends to bend. Sometimes this bend can become so severe that sexual intercourse becomes impossible. Peyronie’s disease is not linked to either infection or cancer of the penis.

Any man can develop Peyronie’s disease. It usually occurs in men aged over 40, but can be seen in younger men.

The exact cause is not yet fully understood. In some men there may be a family history of this condition. Many men who get Peyronie’s disease also have diabetes or heart disease. Some men who get Peyronie’s disease also have Dupuytren’s contracture, which is a similar fibrotic condition found in the tendons in the palm of the hand that causes a progressive bending, usually of the fourth finger.

The first symptom tends to be penile pain and discomfort, which occurs with an erection as the plaque is stretched. This pain with an erection usually goes within a few months. The next thing the affected man notices is a thickened feeling or lump (plaque) in the shaft of his penis. After this he may notice that the penis tends to become more curved when erect. This can make sexual intercourse more difficult and uncomfortable and it may eventually become impossible. Erectile dysfunction is commonly seen in men with Peyronie’s disease.

Fortunately, many men with Peyronie’s disease have a mild form of the condition, which doesn’t interfere with sexual intercourse. These men need no treatment. For men with more severe forms of the condition, several treatment options can be tried, including injections into the penile plaques or surgery to try to straighten the penis. Unfortunately there is no guarantee of success, as the underlying cause of Peyronie’s disease remains unknown.

A vasectomy is a simple and highly effective method of contraception. It is sometimes known as male sterilisation. A vasectomy is a procedure that involves cutting the two tubes leading away from the testes, called the vas deferens, so that sperm can no longer get into the semen. A vasectomy is usually considered to be a permanent form of contraception, although in some cases the procedure can be reversed, if necessary (but with difficulty).

A vasectomy works by preventing sperm from reaching the semen that is ejaculated from the man’s penis during sex. It is a quick and usually painless surgical procedure, which is carried out under local anaesthetic. This means that, in most cases, you will be able to return home within an hour or so of your procedure.

The risk of side effects or complications after a vasectomy is low and these are usually minor; they may include some bleeding or bruising at the scrotum. Mild infection is uncommon. Less commonly, a swelling called a sperm granuloma may occur due to an inflammatory reaction to sperm released into the bloodstream or tissue during the procedure. Much rarer is when the ends of the vas deferens may reconnect with one another, which could result in your partner getting pregnant.

There is currently no evidence of any increased risks of prostate cancer or other long-term health complications. However, these matters are the subject of ongoing research.

A vasectomy shouldn’t affect your sex drive or ability to have erections or orgasm. The only difference is that the semen you ejaculate will not contain sperm. The body continues to produce sperm after the procedure, but the testicles naturally reabsorb the unneeded sperm.

After the procedure it is generally recommended to use additional precautions until a sperm test is done after four months or so. If this is clear then sex can take place without additional precautions.

Vasectomy is a very effective method of permanent birth control. The figures say only about 15 out of 10,000 couples get pregnant the first year after a vasectomy. It is a permanent procedure, so, as a couple, you need to be sure that your family is complete. Remember, a vasectomy does not give any protection against sexually transmitted infections (STIs). Condoms are the most effective method of preventing STIs. To protect yourself and your partner from STIs, use a condom every time you have sex.

The menopause is the name given to the change that occurs in women when their ovaries (the parts of the female body that make eggs) start to shut down, causing a rapid drop in female hormone levels. The effects of this in women include symptoms like hot flushes, sweats and mood swings, as well as loss of fertility. Age-related hormone changes are very different in men than in women. Levels of the male hormone (testosterone) do start to gradually decline in men from the age of 40 onwards, but there is no rapid drop in hormone levels. So the term ‘male menopause’ is not an accurate description.

For the majority of ageing men, testosterone levels, while reducing, still remain in the normal range. About 20 per cent of men may experience symptoms of testosterone deficiency, which are uncommon in men under the age of 60. In recent years, testosterone replacement therapy has become available. It has received a lot of media attention as an agent to promote male strength and virility: an ‘anti-ageing pill’. While there is no doubt it can be helpful for men with proven testosterone deficiency, it can have potentially serious side effects.

It also affects male behaviour and aggressiveness and is essential for the libido or sex drive, as well as for normal erection and sexual performance.

The changes that occur around puberty, when a boy becomes a man, are related to the effects of testosterone. These include the growth spurt of the body, deepening of the voice, development of facial hair, development of the male shape and development of the penis and testicles. If you are unfortunate enough to lose your testicles before puberty your voice will not deepen and you will always have a full head of hair.

Testosterone is made in the testicles and this is under the control of the pituitary gland, a small pea-sized gland in the brain.

There is huge variation here. Many men with declining testosterone levels remain symptom-free, as their testosterone levels remain in the normal range. Some men with low testosterone levels have no symptoms. The only way to diagnose testosterone deficiency with certainty is by a blood test. Symptoms vary from person to person and may overlap with symptoms of normal ageing. Testosterone deficiency, however, may be associated with the following symptoms and signs:

Many of the symptoms of testosterone deficiency can overlap with many other medical conditions. Therefore, if you feel you may be suffering from some of these symptoms, it is important to have a good chat with your family doctor, who will be able to help you decide on their likely significance.

It all depends. This is a decision that should be taken in close consultation with your doctor, having regard to all the potential pluses and minuses (see table below). Certainly, if you have proven testosterone deficiency, there may be some benefits in terms of helping with some of the symptoms described above. Testosterone can increase muscle mass and strength, improve bone density, and boost red blood cell count. Whether it can improve libido, erectile function or sexual performance in older men remains unclear.

There are several types of TRT available. The most common types are a patch that is stuck onto the skin, an injection or a gel. If you are using a testosterone gel it is important to let the gel dry fully before you have contact with your partner. Otherwise she may become more muscular as well!

There is no doubt TRT can cause many potentially serious side effects. The oral tablet form of testosterone is not used as it can have serious effects both on the liver and the heart.

Testosterone can cause the prostate gland to enlarge and this enlargement of the prostate gland can put pressure on the urethra, causing prostate symptoms, such as urinating more often, difficulties with starting or stopping the stream, terminal dribbling and having to pass urine at night. Potentially much more serious is the fact that TRT can promote the growth of prostate cancer, which may already be lying dormant in the prostate gland. Therefore it is most important that you get your prostate checked out before considering going down the road of TRT. Talking to your doctor about your prostate health, combined with blood tests (PSA) and a rectal examination of the prostate, can give you a good idea of your prostate health (see Chapter 8).

Using TRT to treat low testosterone due to ageing is controversial. Despite the obvious appeal of testosterone replacement for older men, most doctors advise against it; on balance, the risks seem to outweigh the benefits. TRT has definite risks, especially in terms of prostate cancer and heart disease, and it may not improve your symptoms. TRT may also have possible long-term health risks that are not yet known.

There is no doubt that many men experience a bit of a midlife crisis, typically between the ages of 45 and 65. There may be many reasons for this. Mostly the physical changes that can occur in middle age, such as middle-age spread, baldness, sagging muscles and expanding waist line, are in direct conflict with media and societal images of the all-powerful male: young, athletic, muscular and sexually omnipotent. This time is often one of uncertainty for men in terms of work and career. There can be a certain loss of energy and loss of confidence, some erectile dysfunction issues and a fear of ageing. However, many of the issues and challenges at this stage of life can be successfully addressed:

Make time for the ‘non-urgent’; prioritise important areas of your life that can often be overlooked when you are too busy. This includes friendships, family and hobbies.

Know your own body and what is normal for you.
Practise testicular self-examination regularly (see page 216).
Be confident enough to seek help if you have any worries or concerns in this area.
Remember your doctor is there to help you.
Testosterone levels start to drop in many men from the age of 40.
However, testosterone levels often stay in the normal range.
There are many symptoms of testosterone deficiency.
Testosterone replacement therapy has potential risks and benefits.
A healthy lifestyle can actively combat the effects of ageing.