Hypospadias is the condition where the urethra opens along the underside or ventral aspect of penile shaft. First-degree hypospadias is seen in 50-75% cases, where the urethra open on the glans penis. Second-degree hypospadias is seen in 20% cases where the urethra opens on the shaft, and third-degree in 30% cases with the urethra opening on the perineum. The severe cases are usually associated with undescended testis (cryptorchidism) or chordee, where the penis is tethered downwards and not completely separated from the perineum.

It is a common male genital birth defect but varying incidences are noted in different countries. There is no obvious inheritance pattern noted. No exact cause has been determined, however several hypotheses include poor response to androgen, or interference by environmental factors.

According to the American Joint Committee on Cancer (AJCC) 2002 guidelines, the nodal staging of testicular seminoma is the following:

N0: no regional lymph node metastases

N1: metastasis with lymph nodes 2 cm or less in their greatest dimension or multiple lymph nodes, none more than 2 cm

N2: metastasis with lymph nodes greater than 2 cm but not greater than 5 cm in their greatest dimension, or multiple lymph nodes, any one mass greater than 2 cm, but not more than 5 cm

N3: metastasis with lymph nodes greater than 5 cm in their greatest dimension.

The patient in this case has N2 testicular seminoma. This TNM staging is extremely important because treatment options are decided depending on this classification.

Germ cell tumours represent 90% of primary tumours arising in the testis. They are broadly divided into seminomas and non-seminomas. Seminomas are the most common testicular germ cell tumour seen in 40% cases. The other non-seminomatous histological subtypes include embryonal (25%), teratocarcinoma (25%), teratoma (5%) and pure choriocarcinoma (1%).

According to AJCC guidelines, the serum tumour marker staging is the following:

S0: marker studies within normal limits

S1: lactate dehydrogenase (LDH) less than 1.5 times the reference range, beta-human chorionic gonadotrophin (β-hCG) <5000 mIU/ml, and alpha-fetoprotein (AFP) <1000 ng/ml S2: LDH 1.5–10 times the reference range, β-hCG 5000–50,000 mIU/ml or AFP 1000–10,000 ng/ml S3: LDH greater than 10 times the reference range, β-hCG >50,000 mIU/ml or AFP >10,000 ng/ml.

According to this, the patient’s tumour belongs to the S1 stage.

The AJCC uses the TNM, Gleason score and PSA levels to determine the overall stage of prostatic cancer. This staging is as follows:

Stage I: T1, N0, M0, Gleason score 6 or less, PSA less than 10; or T2a, N0, M0, Gleason score 6 or less, PSA less than 10

Stage IIa: T1, N0, M0, Gleason score of 7, PSA less than 20; or T1, N0, M0, Gleason score of 6 or less, PSA at least 10 but less than 20; or T2a or T2b, N0, M0, Gleason score of 7 or less, PSA less than 20

Stage IIb: T2c, N0, M0, any Gleason score, any PSA; or T1 or T2, N0, M0, any Gleason score PSA of 20 or more; or T1 or T2, N0, M0, Gleason score of 8 or higher, any PSA

Stage III: T3, N0, M0, any Gleason score, any PSA Stage IV: T4, N0, M0,any Gleason score, any PSA; or any T, N1, M0,any Gleason score, any PSA; or Any T, any N, M1, any Gleason score, any PSA.

The patient in this case has a T2 N0 M0 G2 tumour, meaning it belongs in stage II

The AJCC uses a TNM system to stage prostatic cancer, with categories for the primary tumour, regional lymph nodes and distant metastases:

TX: cannot evaluate the primary tumour T0: no evidence of tumour

T1: tumour present, but not detectable clinically or with imaging T1a: tumour was incidentally found in less than 5% of prostate tissue resected (for other reasons)

T1b: tumour was incidentally found in more than 5% of prostate tissue resected

T1c: tumour was found in a needle biopsy performed due to an elevated serum prostate-specific antigen

T2: the tumour can be felt (palpated) on examination, but has not spread outside the prostate

T2a: the tumour is in half or less than half of one of the prostate gland’s two lobes

T2b: the tumour is in more than half of one lobe, but not both

T2c: the tumour is in both lobes

T3: the tumour has spread through the prostatic capsule (if it is only part-way through, it is still T2)

T3a: the tumour has spread through the capsule on one or both sides

T3b: the tumour has invaded one or both seminal vesicles

T4: the tumour has invaded other nearby structures.

In this case, the tumour has a T1c stage.

Varicocele refers to dilatation and increased tortuosity of the pampiniform plexus – which is a network of veins found in spermatic cord that drain the testicle. Defective valves or extrinsic compression can result in outflow obstruction and cause dilatation near the testis. Normal diameter of the small vessels ranges from 0.5 – 1.5mm. A varicocele is a dilatation more than 2mm.

The plexus travels from the posterior aspect of testis into the inguinal canal with other structures forming the spermatic cord. They then form the testicular veins out of which the right testicular vein drains into the inferior vena cava and the left into the left renal vein.

It affects 15-20% men, and 40% of infertile males. Usually diagnosed in 15-25 years of age, they are rarely seen after 40 years of age. Because of the vertical path taken by the left testicular vein to drain into left renal vein, 98% idiopathic varicoceles occur on the left side. It is bilateral in 70% cases. Right-sided varicoceles are rare.

Symptoms include pain or heaviness in the testis, infertility, testicular atrophy, a palpable mass, which is non-tender and along the spermatic cord (resembling a ‘bag of worms’). The testis on the affected side might be smaller.

Diagnosis can be made by ultrasound. Provocative measures such as Valsalva manoeuvre or making the patient stand up to increase the dilatation by increasing the intra-abdominal venous pressure.

The primary tumour staging for testicular seminoma is as follows, according to AJCC guidelines:

Tis: intratubular germ cell neoplasia (carcinoma in situ)

T1: tumour limited to testis/epididymis without vascular or lymphatic invasion; the tumour can invade into the tunica albuginea but not the tunica vaginalis

T2: tumour limited to testis/epididymis with vascular or lymphatic invasion or tumour extending through the tunica albuginea with involvement of the tunica vaginalis

T3: tumour invading the spermatic cord, with or without vascular/lymphatic invasion

T4: tumour invading the scrotum, with or without vascular/lymphatic invasion.

According to these guidelines, the tumour in this case has a T2 stage.

Peyronie’s disease leads to development of fibrous plaques in the penile soft tissue and occurs in 1% of men, most commonly affecting white males above 40 years age. It is a connective tissue disorder named after a French surgeon, François de la Peyronie who first described it. Symptoms include pain, hard lesions on the penis, abnormal curvature of erect penis, narrowing/shortening, painful sexual intercourse and in later stages, erectile dysfunction. 30% cases report fibrosis in other elastic tissues such as Dupuytren’s contractures of the hand. There is likely a genetic predisposition as increased incidence is noted among the male relatives of an affected individual.

Embryonal carcinoma is a non-seminomatous germ cell tumour of the testis, accounting for 25% testicular tumours. Other germ cell tumours include seminoma, teratoma and choriocarcinoma. Embryonal carcinomas are known to occur in men aged 25-35 years, and occasionally in teens. They are rarely seen in ovaries of females. It can spread to the vas deferens and also to the aortic lymph nodes. Embryonal carcinomas are known to have elements of fetal origin such as cartilage. Usually, the main tumour is about 2.5cm long, with an extension of 8-9cm along the testicular cord. Contiguous spread to the testicle is seen in less than 1% cases.