HISTORY. Obtain a thorough health history, particularly about the occurrence of risk factors. Any male born between 1940 and 1971 should be asked if his mother took any drugs to maintain her pregnancy. The earliest sign of testicular cancer is a small, hard, painless lump that cannot be separated from the testicle; it is occasionally accompanied by low back pain. Men often describe a feeling of "heaviness" or "dragging" in the testicles. These symptoms are often mistaken for epididymitis or muscle strain. Tenderness in the breast may also be present. Inquire about back pain, vague abdominal pain, nausea and vomiting, anorexia, and weight loss, all findings that suggest metastasis. Only 25% of men experience symptoms related to metastasis prior to diagnosis.

PHYSICAL EXAMINATION. The testes may be enlarged and swollen. A hydrocele or hema-tocele may be present. A testicular tumor can be distinguished from a hydrocele by transillumination (inspection of the testes by passing a light through its walls): a tumor does not transillu-minate, whereas a hydrocele appears red and a normal testicle illuminates clearly. Because the tumor produces estrogen, inspect the patient for gynecomastia.

A testicular examination is accomplished by placing the index and middle finger on one side of the testicle with the thumb on the other side. Digital separation of the anterior testes from the posterior elements, including the epididymis and cord, is performed with care so that the intrascrotal contents can be palpated. A gentle rolling motion enables the examiner to palpate each testicle completely. A normal testicle is egg-shaped and feels smooth and firm but not hard. One testicle may naturally be larger than the other. A change in size or the presence of a lump is considered to be an abnormal finding. With testicular cancer, the lump is generally painless. Also, palpate the surrounding area for the presence of enlarged lymph nodes. Lymphadenopathy, especially in the abdominal and supraclavicular regions, is also found in more advanced disease.

PSYCHOSOCIAL. The diagnosis of cancer at any time is a lifestyle-altering event, but it is particularly disrupting to this young population. Interruption of schooling or work schedules, financial coverage for medical expenses, transportation to and from scheduled therapies, and child-care issues are a few of the concerns expressed by patients.

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