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.

Primary syphilis is transmitted via sexual contact. Lesions on genitalia, called a chancre occur after an asymptomatic incubation period of 10-90 days (average 21 days) after exposure. This chancre is a typically solitary (can be multiple), firm, painless, ulceration over the skin at the point of exposure to spirochete, seen on penis, vagina or rectum. It heals spontaneously after 4-6 weeks. Local lymphadenopathy can be seen.

Diagnosis is made by microscopy of fluid from lesion using dark-field illumination, taking care to not confuse with other treponemal disease. Screening tests include rapid plasma regain (RPR) and Venereal Diseases Research Laboratory (VDRL) tests. False positives are known to occur with these tests and can be seen in viral infections like hepatitis, varicella, Epstein-Barr virus, tuberculosis, lymphoma, pregnancy and IV drug use. More specific tests should therefore be carried out in case these screening tests are positive.

The Treponema pallidum hemagglutination assay (TPHA) and the fluorescent treponemal antibody absorption (FTAABS) test are based on monoclonal antibodies and immunofluorescence and are more specific. However, they can too show false positives with other treponemal diseases like yaws or pinta. Other confirmatory tests include those based on enzyme-linked immunoassays.

Inflammation of the glans penis is known as balanitis. Associated involvement of the foreskin is then known as balanoposthitis. More likely to occur in men who have a tight foreskin that is difficult to pull back, or poor hygiene.

Prostatic adenocarcinoma is the commonest solid malignancy and non-dermatological cancer in men above 50 years age. Increasing in incidence with age and the highest risk seen in the black population. About 75% of cases are seen in men over 65 years. Other tumours affecting the prostate include undifferentiated prostate cancer, squamous cell carcinoma, and ductal transitional carcinoma, but these occur less commonly. Sarcomas usually affect children. Hormones play a role in the aetiology of prostate adenocarcinoma unlike the other types. Intraepithelial neoplasia is considered a precursor of invasive malignancy.

Phimosis is the inability to fully retract the foreskin of the penis in an uncircumcised male. It can be physiological in infancy, in which it could be referred to as ‘developmental non-retractility of the foreskin. However, it is almost always pathological in older children and men. Causes include chronic inflammation (e.g. balanoposthitis), multiple catheterisations, or forceful foreskin retraction. One of the causes is chronic balanitis xerotica obliterans. It leads to development of a ring of indurated tissue near the tip of the prepuce, which prevents retraction. Contributory factors include infections, hormonal and inflammatory factors. The recommended treatment includes circumcision.

The TNM staging used for penile cancer is as follows:

TX: primary tumour cannot be assessed

T0: primary tumour is not evident

Tis: carcinoma in situ is present

Ta: non-invasive verrucous carcinoma is present

T1: tumour is invading subepithelial connective tissue

T2: tumour is invading the corpora spongiosum or cavernosum

T3: tumour invading the urethra or prostate

T4: tumour invading other adjacent structures.

In this case, the patient has a T1 tumour.

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.

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.

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 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.