Sunday, January 16, 2011

A College Student's Reticence

I was working in a student health center of an urban university campus when I walked into a exam room and was greeted by a 25 year old male patient and his girlfriend. 
Directing my attention towards the young man, I asked, “So what brings you in?”
The patient, whom I’ll call Rick, stammered and finally spoke, “my girlfriend says that she feels something ‘down there’ and she insisted on my coming in.”
“I see.” 
I turned towards his girlfriend and asked her, “what exactly are you feeling?”
She said, “Rick has something in his testicle on his right side, it’s rather large and round.”
“Okay.  Are you having any symptoms whatsoever, Rick?  In other words, any change in your urination, any pain, any blood in your urine?”
“No, I don’t have any of those symptoms, in fact I wouldn’t  be here if it wasn’t on the account of my girlfriend here.  I’m not having any problems at all.”
‘Alright.  Do you take any medications or have any allergies to medications?”
“Anything in your past medical history, such as allergies, asthma or anything else?”
“No, I’m perfectly fine.”
“What’s in your family history, any diabetes, high blood pressure, cancer, heart disease?”
“Yeah, my Dad has high blood pressure and my grandfather died of a heart attack.”
“Okay, well then why don’t you sit up on the exam table and let me listen to your lungs, heart and do an abdominal exam on you first.  Then you’ll have to drop your drawers so that I can do a thorough exam of your testicles.”
With a grumble under his breath, he moved over to the exam table and sat down.
I listened to his lungs, heart and then did a thorough abdominal exam on him.  Everything was normal so far.  I then turned around to the girlfriend and asked her to leave the room while I did Rick’s testicular exam. 
“Okay, now that she’s out of the room, Rick I need you to drop your drawers so that I can feel this mass she says you have.”  While he was complying with my request, I reached for a pair of exam gloves to put on.
I turned back around and with the patient in a standing position I felt both testicles.  The patient definitely had some sort of a mass in his R testicle that didn’t belong there.  It was above his testes below the spermatic cord.  It was round and non-tender. 
“I’m going to switch the exam room light off and then use my penlight to see whether I can make the penlight transilluminate it, in other words, will the light go through it?”
I switched off the overhead exam room light and turned on my penlight.  Putting it next to his testicles I tried to illuminate the mass, but it wouldn’t allow the light to go through it.  That told me that the mass was solid, not cystic.  I also knew that because the mass was round and not marbled feeling that it wasn’t a conglomeration of blood vessels. 
My next move was to try to reduce it.  So I asked Rick to lie down on the exam table.  I tried to push the mass back up towards the spermatic chord and out of his testicle.  It wasn’t moving, so it was not reducible so that meant most likely that it wasn’t a hernia with incarcerated bowel involved.

Medical providers have been relatively good at teaching their female patients to do breast self-examinations, but were we’ve fallen down in doing appropriate patient education and instruction is with our young male patients.  Very few of them know and understand the importance of inspecting and feeling their own testes, making sure that they don’t have any new masses which have shown up.  Young male patients particularly don’t know they are at risk for testicular cancer as early as 15 years of age. 

It’s taken many, many years to bring breast cancer out of the closet and allow it to be spoken about.  We have Betty Ford and Happy Rockefeller to thank for that.  They brought it out in the open in about 1975.  But who can bring testicular cancer out of the closet?  Currently there is only one, Lance Armstrong.  We need more than just him to move awareness of this disease forward.  For it is a very treatable and curable disease. 
“You can get dressed now.  Do you want me to invite your girlfriend back in while I go through the next steps or leave her in the hallway?”
“I guess you can let her back in.”
I opened the exam room door and called for his girlfriend to come back in.  Once she was seated, I turned to Rick and said, ‘your girlfriend has done you a favor.  The round mass in your right testicle could not be illuminated, hence it is not a simple cyst.  I also could not reduce it, so it’s most likely not a hernia.  Additionally, because it lacks a marbling effect to it, it’s not a group of blood vessels.  So the one thing we are left with is that it could be testicular cancer.  You’re of the age range that testicular cancer attacks, between the ages of 15-25 and then again between the ages of 55-65.”
I went on “so with that said I need to refer you over to the University Medical Center and have the urology service see you. They will repeat the physical exam I just did on you as well as do an ultrasound.  After that they will schedule you for surgery. Based on your pathology report, urology will then schedule any necessary follow-ups.”
“Do you have any questions for me before I go out to the scheduling desk and call over to the urology service for your appointment?”
“So I did a good thing by making him come in here like I did?” asked Rick’s girlfriend.
“Yes, you did,”: I replied.
Rick’s face was pale, without words as he looked from his girlfriend and then back at me.  He was trying to digest the fact that he could have cancer which was probably unthinkable to him at the moment. 

Wives/girlfriends are so important to the health of their mates.  Men tend to shy away from seeing physicians for a myriad of reasons.  One of these is denial, another one is pride, and a third one is fear of revealing self to an unknown provider.  And this is where wives come into the picture.  They are the impetus for getting their male partners into be seen by a physician or medical provider.  I’ve seen many a wife drag, push or cajole her spouse into the exam rooms.  Many times it is the wife who tells me what is going on with her spouse, it’s not the husband. 

I left the exam room to schedule his appointment with the urology service over at University Medical Center.  I came back into the room to find Rick with a stoic facial appearance and his girlfriend quietly sitting in the chair.  I advised Rick of his upcoming appointment with the urology service and stressed to him that he couldn’t miss the appointment no matter what his school schedule was. 
I didn’t expect to hear anything further about Rick.  We typically didn’t receive any follow-up information on the patients we referred, but a week later I received a call from the urology resident who was seeing Rick in the clinic.  He wanted to tell me that I had done a bang-up job in working Rick up, sending over all of the clinic information on him and now he was being scheduled for his ultrasound and surgery.  Based on his exam it did indeed look like testicular cancer. 
“Can I ask a favor?”
“Okay, what is it?”
“When the surgical pathology report comes back can you please call me and tell me what it showed?”
“Sure, seeing that you are the referring service and did such a bang-up job, that’s the least I can do.  I’ll keep your phone number with me and when Rick’s pathology comes back I’ll give you a holler.”
Ten days later I received a return phone call from the urology resident regarding Rick’s pathology report. 
“You were right on the money, he’s got germ cell cancer, stage 1b, it was fully contained in the testes which we removed, all his nodes were negative.  So he is now cancer free.”
“Oh, that’s great news.  Thanks for calling.”

Cancer, that dreaded word.  But for a man having testicular cancer is unthinkable.  Their manhood is tied up in with their sexual function and size of their given male anatomy.  Yet, testicular cancer has one of the highest cure rates there is.  As with all cancers it is split into 4 stages according to how far it has spread. 

Stage one is where it is contained within the organ of origin.
Stage two is where it has spread to the local surrounding lymph nodes.
Stage three is where the cancer has spread to regional lymph nodes
Stage four is where the cancer has spread to other surrounding structures and generally has invaded major organs.

We as medical providers need to do better in regards to educating our patients about what to look for and when to seek medical care.  Preventive care needs to be at the forefront of our medical care. 

1 comment:

  1. So, I've been slowly going through all your posts and have understood just about everything medical. Then I come across "bang up job" and had to look that up to see if it was good or bad haha!

    Glad I found your blog! Lot of interesting information on here!