TC Twice: Second or Bilateral Testicular Cancer

Who this page is for

This page is for men who have cancer in both testicles at the same time, men who previously lost one testicle and have now developed a new cancer in the remaining testicle, and men who are already living without functioning testicular tissue. Some of the same planning also applies when surgery will leave behind only a small, damaged or poorly functioning testicle.

This page is not intended for men whose testicles are being removed to treat prostate cancer. Bilateral orchiectomy is still used as androgen-deprivation treatment for prostate cancer in some settings. In that situation, lowering testosterone is the purpose of the operation, so testosterone replacement is a different and usually inappropriate issue.

Finding out that you may lose both testicles, or the only one you have left, can hit much harder than the medical words suggest. On top of worrying about the cancer, many men immediately wonder what this means for sex, fertility, masculinity, appearance, energy, relationships and whether they will still feel like themselves.

Those are reasonable concerns. Life will not be exactly the same, but it is usually far more normal than people fear when they first hear the news. If the cancer is treated successfully and testosterone is replaced appropriately, most aspects of everyday life and sexual life can continue much as they did before. You can still have sexual desire, erections and orgasms. You can still exercise, work, build muscle, maintain strong bones and feel like yourself. The two changes that require deliberate planning are fertility and testosterone replacement.

If Surgery Has Not Happened Yet

Before the last adequately functioning testicle is removed, make sure three things have been addressed:

  1. Fertility: bank sperm before surgery if future biological children are even a possibility. Once the last functioning testicle is removed, no new sperm can be produced.
  2. Your hormone baseline: obtain serial morning testosterone measurements, plus LH, FSH and usually SHBG, while the testicular tissue is still present.
  3. Your replacement plan: know who will prescribe testosterone, what you will start with, and when it will begin. Do not wait until you are miserable from low testosterone before anyone thinks about replacement.
On this page:

First, Deal With the Cancer Correctly

Having testicular cancer a second time, or having tumors in both testicles, is uncommon. It does not automatically mean that the cancer is more advanced or less curable. Each tumor still has to be evaluated according to its pathology, tumor markers and stage.

If this is a second testicular cancer, your old treatment records matter

A cancer that develops later in the remaining testicle is a metachronous second primary testicular cancer. That is different from the first cancer recurring in lymph nodes, lungs or another metastatic site.

If you previously received chemotherapy, radiation, RPLND or other major treatment, make sure the new team knows exactly what you received and what long-term problems you developed. Prior cisplatin exposure, bleomycin-related lung problems, kidney or hearing problems, neuropathy, previous radiation fields and prior surgery can all matter when a new treatment plan is chosen. This does not mean that a particular treatment can never be used again. It means that a rare second-cancer situation deserves individualized review, preferably with germ-cell-tumor expertise when the choices are complicated.

Could part of the testicle be saved?

Radical inguinal orchiectomy remains the standard operation for a testicular germ-cell cancer. But a tumor in a solitary testicle, or tumors in both testicles, is one of the uncommon situations in which testis-sparing surgery (partial orchiectomy) deserves serious consideration.

The question is not simply whether you would like to keep the testicle. Almost everyone would. The question is whether the tumor and the remaining normal tissue make preservation medically worthwhile. This is most plausible when the tumor is small and localized, enough normal testicular tissue can remain, preoperative hormone function is reasonably good, and an experienced surgeon and pathologist can perform the operation with frozen-section examination. Current guidance generally expects more than half of the testicular tissue to remain; many published series have concentrated on tumors smaller than about 2 cm or occupying less than half of the testicle.

If you have a tumor in your only testicle or cancer in both testicles and the tumor appears small enough that meaningful normal tissue might remain, it is reasonable to ask for review at a center experienced with testis-sparing surgery before accepting removal of all remaining testicular tissue.

The tradeoffs need to be understood:

Chronic testicular pain is not a prominent recurring complication in the published testis-sparing series. The better-documented downsides are local recurrence, possible need for another operation, loss of fertility, testicular atrophy in a small minority, and eventual testosterone deficiency. In other words, saving the testicle can be worthwhile, but it does not guarantee that the saved testicle will remain fertile or hormonally normal forever.

See the TCRC's Testicular Cancer Experts List and the main Orchiectomy page for more about cancer treatment.

What Is Life Without Testicles Actually Like?

The emotional reaction can be bigger than the physical reality. Testicles are tied up with ideas about masculinity, fertility, sexuality and appearance, and some men do feel shocked, embarrassed, less attractive or simply different after losing them. Those feelings deserve to be taken seriously.

Physically, however, the situation is much more manageable than many men expect. Testosterone can be replaced. With adequate replacement, losing both testicles does not by itself take away your sex drive, erections, orgasm, male appearance, strength or ability to live a normal life.

Sex drive and erections

Low testosterone can reduce sexual desire and can contribute to erection problems. With appropriate testosterone replacement, libido and erectile function can remain normal. Erections also depend on blood vessels, nerves, medications, general health and psychological factors, so testosterone is not the answer to every erection problem.

Orgasm and ejaculation

Removing the testicles does not remove the nerves responsible for orgasm. A man can still have an orgasm. If the prostate, seminal vesicles and ejaculatory nerves are intact, he can also still ejaculate fluid. Other testicular-cancer treatment, particularly some forms of retroperitoneal lymph-node surgery, can separately affect ejaculation.

Fertility

After both testicles are removed, a man is sterile: he can no longer produce sperm. He may still ejaculate fluid, but it will contain no sperm. Testosterone replacement cannot change that. Sperm that was banked before surgery can still be used later with assisted reproduction, which is why fertility preservation has to be addressed before the last functioning testicle is removed.

Dating, relationships and body image

Some men worry that losing both testicles will make them less desirable to a future partner. In real life, people react in all sorts of ways. Some survivors are private about it, some joke about it, and TCRC has heard from men who have even turned the story into a successful icebreaker. You do not have to do that. The larger point is that having had cancer and losing your testicles does not make you less capable of being a sexual or romantic partner. If someone cannot get past that history, finding that out early may be more useful than harmful.

Appearance and prostheses

Some men strongly prefer the appearance and feel of a testicular prosthesis. Others do not care about having one, and some decide against it after discussing the possible feel, position and complications. It is a personal choice, not a medical requirement. A prosthesis may be placed at the time of orchiectomy or later in selected cases. See the TCRC Testicular Implants page for more detail.

Before Surgery: Fertility, Hormone Testing and the Replacement Plan

Bank sperm before the last functioning testicle is removed

If future biological children are even a remote possibility, tell the treatment team immediately. Sperm cryopreservation should be arranged before removal of the last functioning testicle. More samples provide more options later, but even one usable sample can matter. Modern fertility treatment can sometimes work with very limited stored sperm.

If an ejaculated sample cannot be produced, or contains no usable sperm, ask promptly about surgical sperm retrieval. In selected patients, sperm retrieval can be coordinated with the cancer operation. Fertility preservation should be organized quickly so that it does not create an unsafe delay in cancer treatment.

Get a real preoperative hormone baseline

Once the last functioning testicular tissue is gone, you cannot go back later and discover what your untreated hormone levels used to be. When the clinical schedule allows it, obtain at least two morning total-testosterone measurements on separate days. If the results are very different and there is enough time, a third measurement can make the baseline more useful.

The useful preoperative hormone tests are:

For suspected testicular cancer, these hormone measurements are separate from the usual pre-orchiectomy tumor markers, AFP, beta-hCG and LDH. Those tumor markers remain essential for diagnosis, staging and follow-up.

If beta-hCG is elevated: hCG is not just a tumor marker. It can act like LH and stimulate Leydig cells in the testicle to make testosterone. An hCG-producing tumor can therefore raise testosterone and suppress the patient's own LH and FSH. The effect can occur with hCG values in the tens or low hundreds of IU/L, not just with extremely high levels. There is no single proven cutoff at which the effect begins, so testosterone, LH, FSH and hCG need to be interpreted together. Hormone results obtained before the new cancer can be especially valuable.

Have the testosterone prescription plan settled before surgery

Do not leave this for somebody to remember after the operation. Before surgery, know who is going to manage testosterone replacement, which preparation will be used first, when it will start, and when the first properly timed follow-up blood test will be done. Ideally, the prescription should already be written and, when practical, filled and waiting at home so treatment is not delayed by calls, insurance approvals or pharmacy problems after the orchiectomy.

When the last functioning testicle is removed, testosterone production falls very quickly. Replacement should normally begin immediately after surgery or very soon afterward unless there is a specific medical reason not to do so. There is no benefit in waiting for hot flashes, loss of libido, fatigue or other symptoms to prove what is already known.

If no functioning testicular tissue remains, testosterone replacement is a lifelong requirement. The specific method may change over time. See Testosterone: Replacement Therapy for the practical choices, dose adjustment and monitoring.