Prevention and treatment of testicular tumors and cryptorchidism: A guide to men's health.

Testicular Tumors

This disease can occur in men of any age, but it is most common in men around their thirties and forties. The incidence of testicular cancer is much higher in men with cryptorchidism than in those with complete testicular descent, which also illustrates that prolonged exposure to higher body temperatures is harmful to the testes. Seminomas are the most common testicular tumors (accounting for 40%–50% of all testicular tumors), followed by teratomas (20%–50%), embryonal carcinomas (16%–20%), teratomas (1%–5%), and interstitial cell tumors (1%–5%). Although malignant testicular tumors are relatively rare, accounting for only 1.5% of male malignant tumors, the high mortality rate and severe impact on fertility and sexual function make this disease highly valued.

The clinical presentation of testicular cancer is diverse. Most patients present with a testicular mass, while some are diagnosed during routine checkups due to symptoms of metastatic lesions, infertility, or during physical examinations. Approximately half of the patients experience testicular pain. If testicular enlargement and a mass are found, testicular cancer should be highly suspected.

【Treatment Methods】 All patients with testicular cancer should undergo surgery. For seminoma patients, the 10-year survival rate after orchiectomy and radiotherapy in the lymphatic drainage area is 90%, while the survival rate for other types of testicular tumors is very low. Patients with non-seminomatous testicular cancer often require simultaneous retroperitoneal lymph node dissection, but the incidence of infertility after retroperitoneal lymph node dissection is very high. If the patient wishes to continue conceiving after surgery, semen should be collected and cryopreserved before surgery for postoperative artificial insemination.

Although the incidence of erectile dysfunction in post-operative testicular cancer patients is very low, it can still be encountered clinically. The cause of this type of erectile dysfunction is unknown, but it may reflect hypogonadism resulting from various factors such as orchiectomy, radiotherapy, and repeated chemotherapy. When patients complain of decreased libido and erectile dysfunction after treatment, their blood testosterone levels may have significantly decreased. There is no evidence that testosterone replacement therapy promotes testicular tumor recurrence or accelerates tumor growth. Therefore, these patients usually regain libido and sexual intercourse ability after hormone therapy.

Attention should be paid to the emotional impact of testicular cancer and surgery on patients. Many patients feel intense remorse for their past sexual behavior, believing that the occurrence of testicular tumor is a malignant result of past masturbation, sexually transmitted diseases, or excessive sexual activity, a punishment for themselves, thus significantly altering their subsequent sexual behavior. Other patients may feel inferior because of the loss of a testicle. These patients are likely to experience significant anxiety about their sexual ability. During intercourse, patients often focus on whether their sexual function is normal, which distracts them and inappropriately places them in a detached, observer position, affecting the natural progression of sexual response. Similarly, some patients who equate male sexual function with fertility may feel discouraged and frustrated due to loss of ejaculation ability or infertility caused by medication and chemotherapy, and may develop erectile dysfunction due to excessive anxiety about fertility.

Providing sexual counseling guidance to patients with testicular tumors before and after surgery is crucial. The type and cause of anxiety experienced by the patient (and their partner) should be identified, and the couple should be guided on effective and appropriate methods to reduce sexual problems. For unmarried men concerned about their physique in future sexual relationships, implantation of a biologically non-reactive artificial testis may be considered to improve scrotal appearance. Finally, patients should be taught how to examine their testicles themselves to detect testicular masses or other lesions early.

Cryptorchidism

Cryptorchidism is defined as the failure of one or both testes to descend into the scrotum, remaining at any point along their descent path. During fetal development, if the descent of the testes is obstructed, the testes may become "anchored" and unable to be found in the scrotum, resulting in cryptorchidism. There are three main factors contributing to this condition:

Firstly, anatomical factors. These include: a short or absent frenulum of the testes during embryonic development, preventing full descent; adhesions between the mesentery and peritoneum, hindering descent; abnormal development of testicular blood vessels, such as curvature or folds, which pull on the testes from above and restrict descent; excessively short spermatic cord vessels or vas deferens; excessively large testes; a tight inguinal canal; or a lack of an opening at the distal end of the external inguinal ring into the scrotum, preventing the testes from entering the scrotum; and abnormal scrotal development, such as a scrotum that is too small to accommodate the testes.

Secondly, endocrine factors. Testicular descent requires sufficient impetus, namely, the stimulation of fetal testicular interstitial cells by maternal gonadotropins to produce androgens. When the testes themselves are defective, they do not respond to gonadotropins, resulting in cryptorchidism. Because testicular descent occurs when the concentration of gonadotropins in the blood is high, a deficiency in maternal gonadotropins can also lead to incomplete testicular descent.

Thirdly, there are genetic factors. Some patients with cryptorchidism have a significant family history, so genetic factors may be one of the causes.

There may be other reasons for cryptorchidism. It is expected that with the continuous advancement of medical technology, these causes will be clarified, leading to the discovery of effective prevention and treatment methods to stop the occurrence of this disease.

Common complications of cryptorchidism include:

① Infertility. As we know, under normal circumstances, the scrotum temperature is 2-3°C lower than body temperature; this temperature difference is one of the important conditions for ensuring spermatogenesis. In bilateral cryptorchidism, because the testicles are not within the scrotum, the temperature difference between the testicles and body temperature is eliminated. Increased temperature can cause testicular epithelial atrophy, thus hindering spermatogenesis and leading to infertility. Unilateral cryptorchidism, starting from the second year after birth, can also damage the normally positioned testicle on the opposite side; if left untreated, it can also affect fertility.

② Hernia. This is often due to incomplete testicular descent, preventing the processus vaginalis from closing and allowing abdominal contents to descend. Hernias are a complication of cryptorchidism, with domestic reports indicating around 50% and international reports indicating 66%–97%.

③ Spermatic cord torsion. This may be caused by excessive contraction of the cremaster muscle, underdeveloped gubernaculum testis, or excessive testicular movement. Statistics show that approximately 50% of patients with spermatic cord torsion have cryptorchidism. ④ Testicular trauma. The testicle located in the groin is easily injured due to its superficial location and the fact that the posterior wall of the groin is harder and less elastic than the scrotum, lacking cushioning.

⑤ Malignant transformation. The chance of malignant transformation in undescended testicles is 30 to 50 times higher than in normally positioned testicles. In addition, the incidence of tumors in the contralateral testicle is also higher in patients with unilateral undescended testicles than in normal individuals. ⑥ Psychological trauma. The absence of a testicle in the scrotum can cause psychological trauma and feelings of inferiority in patients.

Undescended testicles may lead to several adverse complications, so timely treatment is advisable. Currently, the main methods are as follows:

【Waiting therapy】 Normally, the testicles descend into the scrotum at birth. However, in some infants, due to delayed embryonic development, the descent of the testicles may be delayed until 3 months to 1 year after birth. Therefore, if an infant has cryptorchidism at birth, there is no need to rush to use medication or surgery to try to reposition the undescended testicle. Patience is key; the undescended testicle can descend spontaneously. A study of 3612 male infants found that true cryptorchidism rarely descends after one year of age. This phenomenon reminds us that simply waiting without taking active measures is only suitable for children under two years old.

[Hormonal Therapy] Some cases of cryptorchidism are caused by endocrine reasons. As mentioned earlier, the descent of the testicles in the womb is closely related to maternal gonadotropins. Based on this, in recent years, many scholars have achieved relatively good therapeutic results by first using LH-RH (gonadotropin-releasing hormone) followed by HCG (human chorionic gonadotropin). The total HCG treatment dose should be 10,000 to 20,000 units, specifically 1500 units every other day. Another option is a short-term high-dose pulse therapy, with 4000-6000 units injected intramuscularly daily for three days. If the treatment is effective, the testicle may descend into the scrotum 2-3 weeks after medication. The appropriate age for treatment is 2-9 years old; treatment is ineffective before and after this age. Synthetic LH-RH nasal spray method: LH-RH (1 mg/mL) 1.2 mg, sprayed 6 times daily via the nose, for a course of 4 weeks. This method is more suitable for young children. If this method is ineffective, HCG therapy can still be effective; therefore, the above two methods can be used in combination.

[Surgical Treatment]

(1) Testicular fixation: Forcibly fixing the testicle into the scrotum via surgery is the most important and effective method for treating cryptorchidism. Most patients achieve successful treatment with this method. The timing of surgery is very important; too early may lose the opportunity for spontaneous descent, while too late will affect testicular function. Previously, it was recommended that the age be 2-5 years old, and no later than 6 years old. In recent years, some scholars have proposed that surgical treatment should be performed before the age of 2, arguing that pathological changes have occurred in the testicular tissue of children after the age of 2.

(2) Testicular transplantation: With the widespread use of microsurgery, autologous testicular transplantation has achieved good results in treating high-lying cryptorchidism. Doctors ingeniously remove the entire undescended testis along with its blood vessels, "relocating" it to the scrotum, and then, under a microscope, carefully anastomosing the testicular blood vessels to the inferior abdominal artery and vein to ensure testicular blood circulation.

(3) Orchiectomy: Once significant testicular hypoplasia, atrophy, or softening and loss of function is found, the undescended testis should be removed without hesitation to prevent future malignant transformation.