Promoting men’s awareness, self-examination, and help-seeking for testicular disorders: a systematic review of interventions

Objectives

The aim of this updated systematic review is to evaluate the effectiveness of experimental studies promoting men’s knowledge and awareness of testicular disorders and/or self-examination, behaviours and/or intentions to examine their testes, and help-seeking behaviours and/or intentions for testicular symptoms. The outcomes of this review are presented below using the PICOS (participants, interventions, comparisons, outcomes, and study design) framework:

Outcomes:

1. The effect of intervention on men’s knowledge and awareness of testicular disorders and/or self-examination, compared to baseline and/or control conditions (i.e., alternative intervention or no intervention).

2. The effect of intervention on men’s behaviours and/or intentions to examine their testes, compared to baseline and/or control conditions (i.e., alternative intervention or no intervention).

3. The effect of intervention on men’s help-seeking behaviours and/or intentions for testicular disorder symptoms.

Protocol and registration

This updated systematic review is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist²². The review questions and methods were predetermined and were not amended during the review process. The protocol of the original review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018093671.

Eligibility criteria

Studies were eligible for inclusion if they used any experimental design and were conducted among men who did not have a diagnosis of a testicular disorder. Studies addressing the review outcomes and studies evaluating the effect of intervention(s) compared to baseline and/or control conditions were included. The full inclusion criteria are reported in Table 1 using the PICOS framework.

Men with a diagnosis of a testicular disorder, studies with women only, studies with a paediatric population, and studies where findings from men, women, and/or paediatric populations are indistinguishable were excluded. Additionally, quantitative descriptive studies, qualitative studies, opinion papers, reviews of the literature, and conference abstracts were not eligible for inclusion. Theses and dissertations were also excluded because the merit of their use in systematic reviews is questionable²³.

Information sources and search strategy

The following electronic databases were searched in August 2023: Academic Search Complete, Medline, CINAHL, PsycINFO, ERIC, and The Cochrane Library. In addition, eligible studies were sought from trial registries including the World Health Organisation International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov. Reference lists of eligible papers were also reviewed. As this is an updated version of a previous review, the search was limited to records published between April 2018 and August 2023.

The following keywords were searched based on title and abstract using Boolean operators “OR” and “AND”: “testicular disease*” OR “testicular disorder*” OR “testicular cancer” OR “testicular neoplas*” OR “testicular tumor*” OR “testicular tumour*” OR “testicular malignan*” OR “benign testicular disorder*” OR “benign testicular disease*” OR “testicular torsion” OR epididymitis OR orchitis OR epididymo-orchitis OR hydrocele OR varicocele OR spermatocele OR “testicular symptom*” OR “testicular pain” OR “testicular lump*” OR “testicular swelling” OR “scrot* symptom*” OR “scrot* pain” OR “scrot* lump*” OR “scrot* swelling” AND knowledge OR awareness OR practice* OR self-exam* OR “self exam*” OR feel* OR screen* OR “early detect*” OR help-seeking OR “help seeking” OR “help-seeking intention*” OR “help seeking intention*” OR “help-seeking behavior*” OR “help-seeking behaviour*” OR “help seeking behavior” OR “help seeking behaviour” AND intervention* OR inform* OR educat* OR “health education” OR “health promotion” OR trial* OR experiment* OR stud* OR program*.

Study selection and data extraction

Records identified from electronic databases and trial registries were exported to Covidence, an online software used to facilitate screening and data extraction. Duplicates were deleted automatically in Covidence.

All records were screened based on title and abstract. Following the exclusion of irrelevant records, the full text of potentially eligible studies was obtained for further screening. Title, abstract, and full-text screenings were conducted by two independent reviewers. Screening conflicts were resolved by consensus.

A standardised extraction table was used to extract data from experimental studies^19,20. Data were extracted by one reviewer and cross-checked for accuracy by a second reviewer. The following data were extracted: author(s) and year; aim(s); country, setting and funding; participants; design and theoretical underpinning; intervention(s); outcome(s) and data collection; and findings presented according to the review questions.

Quality assessment

The methodological quality of the included studies was appraised using the Mixed Method Appraisal Tool (MMAT) which allows the appraisal of various study designs²⁴. In the context of the present review, the quality of randomised controlled trials (RCT) and non-RCTs was appraised. Voting on each quality item was conducted on a “yes”, “no”, and “cannot tell” basis. Quality appraisal was conducted by one author and verified by a second author.

Data synthesis

A meta-analysis with summary measures of treatment effect using weighted/standard mean difference, risk/odds ratios, and 95% confidence was planned using RevMan 5, if the included studies were sufficiently homogenous. However, the included studies were heterogeneous in terms of intervention format, data collection, study design, and participant allocation; therefore, findings from the reviewed studies were synthesised meta-narratively.

Study selection

A total of 623 records were identified from electronic databases and clinical trial registries. No additional records were identified from reference list checks. Following the exclusion of duplicates, 608 records were screened based on title and abstract. Of those, 17 full-text articles were assessed for eligibility and 12 were excluded. Five studies were included in the present review. The full study selection process and reasons for exclusion are presented in Figure 1.

Figure 1. Flow diagram detailing study identification, screening, and selection process.

Study characteristics

Two studies were conducted in Turkey^25,26. The remaining studies were conducted in Ireland²⁷, India²⁸, and Pakistan²⁹. Three of the studies had a theoretical underpinning including the Health Belief Model^25,26 and the Pre-Conscious Awareness to Action Framework²⁷. Two studies explored awareness of TC and TSE and TSE behaviours^25,29. Sagir and Alitnel²⁶ addressed TSE behaviours only, Shenbagagap et al.²⁸ explored TSE awareness only, while Saab et al.²⁷ explored TC and TSE awareness, TSE intentions and help-seeking behaviours for testicular symptoms. Sample sizes ranged from 49²⁷ to 124²⁹ participants. Two studies used a quasi-experimental design^26,28, two were pre-post pilot studies^27,29, and the remaining study was an RCT²⁵.

Quality assessment

All five studies had clear research questions and used appropriate data collection methods. The RCT met all the MMAT criteria²⁵. As for non-RCTs (n=4), only two studies accounted for confounders and reported that participants were representative of the target population^26,27. It was unclear in two studies if measurements were appropriate regarding both, outcome and intervention^28,29. While it was only unclear in one study if the intervention was administered as intended²⁸. The four non-RCTs met the remaining MMAT criteria (Table 2).

Synthesis of results

The full data extraction table and findings from individual studies are presented in Table 3.

Awareness of testicular disorders and self-examination

Four of the reviewed studies addressed men’s awareness of TC and TSE^25,27–29. Akcali and Tastan²⁵ conducted an RCT comparing the effect of two interventions (PowerPoint presentation and video using the Health Belief Model [Group 1] and traditional PowerPoint presentation [Group 2]) on men’s awareness of TC and TSE. The study also assessed men’s health beliefs in relation to TC and TSE²⁵. At pre-test, 70.6% (n=24) in the intervention group and 56.3% (n=18) in the control group had no previous knowledge of TC. Knowledge increased significantly at post-test for both groups but was significantly higher in Group 1 (p<0.05). Saab et al. conducted a pre-post study to enhance men’s (n=49) awareness of testicular diseases using a brief virtual reality game²⁷. Testicular knowledge and testicular awareness increased significantly immediately post-test (p<0.05)²⁷. This increase was maintained one month post-test (p=0.033). Waheed et al. also conducted a pre-post pilot study to assess men’s (n=124) knowledge regarding TC and TSE²⁹. At pre-test, most participants had never heard of TC (82%, n=102) and TSE (92%, n=94). While almost all participants (93%, n=95) did not know if TC was most commonly seen in 15–35 ages male groups. Likewise, 92% (n=94) did not know that having undescended testes increase the risk of TC. All participants reported that their knowledge of TC improved at post-test and 97% (n=99) agreed to share their knowledge with members of their family and friends²⁹. Shenbagapraba et al. used a quasi-experimental design to assess the effect of video assisted teaching on men’s (n=50) knowledge of TSE²⁸. At pre-test, only 4% (n=2) had adequate knowledge regarding TSE. However, 74% (n=37) had adequate knowledge about TSE at post-test²⁸.

Behaviours and intentions to perform testicular self-examination

TSE behaviours and/or intentions were explored in four of the reviewed papers^25–27,29. In the study by Akcali and Tastan, only one participant in the intervention group and three in the control group reported practicing TSE²⁵. This increased significantly to 82.4% (n=28) among the intervention group and 59.4% (n=19) among the control group at post-test (p<0.05)²⁵. Over three quarters of participants (77.6%, n=38) in the study by Saab et al. reported that they intend to feel their testes at pre-test²⁷. Of the 22.4% (n=11) participants who did not intent to feel their testes, 54.5% (n=6) reported feeling their testes at post-test²⁷. TSE rate in the Sagir and Altinel’s study was 4.2% in the intervention group and 2.3% in the control group at pre-test²⁶. At post-test, this increased significantly to 83.3% in the intervention group and 4.5% in the control group performing a TSE (p<0.001)²⁶. In the study by Waheed et al., 92% of participants had never performed TSE at pre-test with more than half of participants (58.3%) mentioning lack of education as a reason for not doing²⁹. In addition, 97% never requested to get information about TSE, while 96% never asked for information about TC at pre-test. At post-test, 76% agreed to do a TSE as soon as possible, and 20% within that month, while 4% patients denied doing a TSE²⁹.

Help-seeking behaviours and intentions for testicular symptoms

Only one study addressed men’s help-seeking for testicular symptoms²⁷. Help-seeking intention scores for testicular swelling and testicular lumps were 3.5/7 at pre-test which significantly increased to 3.8/7 immediately post-test for both symptoms (p<0.001 and p=0.003 respectively). Similarly, help-seeking intention scores for testicular pain were 3.2/7 at pre-test which increased significantly to 3.8/7 immediately post-test (p<0.001)²⁷.

Summary of evidence

Five studies were included in this updated systematic review. Overall, the reviewed literature showed that there was an increase in men’s awareness of TC and TSE and behaviours and intentions to perform TSE in response to various interventions, at least in the short-term. The included studies seldom addressed help-seeking behaviours and intentions for testicular symptoms. Indeed, only one study addressed this outcome and found a significant increase in intentions to seek help for symptoms of concern following a virtual reality game²⁷.

Examples of interventions that successfully increased men’s awareness of TC and TSE included: PowerPoint presentation underpinned by the Health Belief Model²⁵, an online educational brochure also underpinned by the Health Belief Model²⁶, video-assisted teaching²⁸, a motivational video²⁹, and a virtual reality game²⁷. Of note, only Saab et al.’s study aimed to promote men’s awareness of BTDs as opposed to only TC²⁷. BTDs are more common than TC and a delay in help-seeking for benign testicular symptoms is also linked to negative health outcomes. For instance, a delay of more than 6 hours for pain caused by testicular torsion significantly reduces the chances of salvaging an ischemic testis⁷. Likewise, untreated epididymitis can lead to severe orchitis, sepsis, and in some cases irreversible infertility^5,6.

As for TSE, a Cochrane review conducted by Ilic and Misso¹⁴ found no definitive evidence regarding the risks and benefits of regular TSE; therefore it was recommended that at-risk groups, such as men with a family history of TC, undescended testis, or testicular atrophy, ought to be advised by their physician regarding the risks (e.g. false positives and concomitant anxiety) and benefits (e.g. early detection) of TSE. As a result, whether to conduct monthly TSE has been polarised into two competing positions. Since 2011, the U.S. Preventive Services Task Force “recommends against screening for testicular cancer in adolescent or adult men”¹⁵ (p. 483). Proponents of monthly TSE, however, argue that such recommendations are not based on definitive evidence¹⁶. Saab et al. called for a middle ground, using the concept “testicular awareness” whereby men are taught how to feel their testes and establish a baseline of what is normal for them without necessarily promoting “scheduled” TSE^8,30.

As stated, help-seeking was only addressed in one study²⁷. A number of quantitative and qualitative descriptive studies found that men’s intentions to seek help for testicular symptoms (e.g., lumpiness, swelling, and pain) are low^31–33. Saab et al. conducted a qualitative descriptive study to explore men’s (n=29) awareness of testicular disorders and intentions to seek help for testicular symptoms³³. It was found that men lacked awareness of testicular disorders in general and BTDs in particular, as a result many reported that they would most likely delay help-seeking. In addition to lack of awareness, the following were identified as barriers to help-seeking: lack of familiarity with own testes, symptom misappraisal, low perceived risk of TC, embarrassment, fear, denial, false optimism, fatalism, machoism, stoicism, false reassurance by others, and healthcare system barriers such as access, cost and waiting time³³. By contrast, the following were identified as facilitators to help-seeking: personal or family history of a testicular disease, inherent health-seeking drive, and access to support³³.

Only Saab et al. considered men’s preferred learning strategies during intervention design and delivery²⁷. Previously, Saab et al. interviewed 29 men about their preferred strategies for learning about testicular disorders³⁴. Overall, participants were open to learning about testicular disorders and recommended interventions that are brief, interactive, simple, and light-hearted rather than funny/cheeky³⁴. Thornton warned against the use of “cheeky” humour and puns as these can be potentially offensive and ineffective³⁵. Another factor worth considering in health promotion intervention design and delivery is men’s literacy and health literacy levels. A meta-narrative systematic review of 31 studies exploring men’s information-seeking behaviours in relation to cancer prevention found that younger men and those with high literacy and health literacy levels were more likely to engage with information delivered using technological means³⁶. By contrast, men who were older, belonged to ethnic minorities, and had low literacy and health literacy levels were more likely to engage with health information delivered by peers, physicians, and churches³⁶.

Strengths and limitations

Rigour was ensured by systematically reporting this review using the PRISMA checklist. Moreover, a thorough search of electronic databases, trial registries, and reference lists was conducted, and records were independently screened by more than one reviewer to avoid omitting important records. However, the search was limited to records published between 2018 and 2023, which increases the risk of study selection bias, and only findings that were relevant to the review outcomes were discussed, which increases the risk of reporting bias. Due to heterogeneity, a meta-analysis was not plausible. Therefore, while promising interventions were identified and included in this updated review, definitive evidence regarding effectiveness cannot be determined.