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Experiences in implementation of a programme to reduce doses to patients from radiographic examinations are described. A preliminary survey of entrance doses for selected examinations, calculated from mean exposure factors, identified equipment and examinations requiring attention. Subsequently more detailed studies were carried out with thermoluminescent dosimeters (TLDs). Results were coordinated with the aid of a database, which was used to monitor the agreement between dose calculations and TLD measurements. Surveys highlighted that doses from lumbar and thoracic spine examinations were high throughout the region. Reductions of 26-36% in entrance dose and 20-25% in effective dose were achieved by raising tube potentials for these examinations. This gave a reduction in annual collective dose of 4 man-Sv with no cost implication. In some departments dose charts were used to support the purchase of new screens. Surveys revealed a wide range in other factors such as transmission of X-ray table tops and results are being used in planning replacement of equipment.

The association of gynaecomastia and testicular tumours is well described in the literature. A testicular examination should be routine as part of the assessment of young males presenting with breast enlargement. We describe two cases where gynaecomastia preceded the appearance of testicular swelling by several months. Case reports Case 1 A 27 year old man was routinely referred to a general surgery department and assessed by a breast surgeon (RB) for bilateral gynaecomastia. On examination, the testes were normal. Six months later he was referred to the urology department with a history of persistent terminal haematuria. The patient mentioned during the examination that he had discovered a lump in a testicle since his attendance at the breast clinic. He had paid no attention to it and had not complained about it to his general practitioner. An abdominal examination showed an epigastric mass. An urgent ultrasound scan confirmed a testicular tumour measuring 2.4×2.0×1.6 cm and a retroperito-neal mass measuring 6.9×7.3 cm resulting from meta-static deposits in para-aortic lymph nodes. His fetoprotein was raised (639 700 IU/l (normal < 7000 IU/l)), as was his total human chorionic gonado-trophin (64.0 IU/l (reference range 0.1-3 IU/l)). The patient was admitted urgently for radical orchidectomy and endoscopic assessment. The cystos-copy showed venous congestion of the bladder neck as the likely source of haematuria. Histology testing of the orchidectomy specimen showed 80% classic seminoma and 20% mature teratoma. The staging computed tomogram confirmed the enlargement of para-aortic and inguinal lymph nodes consistent with metastatic disease. The patient was referred to the regional oncology service for further treatment in the form of chemoradiation. Case 2 A 20 year old man with unilateral breast enlargement was routinely referred to a general surgery department by his general practitioner. He was seen in a breast clinic six weeks later (by RB), where a testicular swelling was discovered on physical examination. An urgent ultrasound scan confirmed a testicular tumour. His testicular tumour markers were substantially raised (fetoprotein 3 290 000 IU/l and total human chorionic gonadotrophin 87.0 IU/l). The patient was admitted for urgent radical orchid-ectomy. The staging computed tomogram showed no evidence of metastatic disease. Histology testing of the orchidectomy specimen showed features of mixed germ cell tumour, with 50% of differentiated teratoma, 25% of embryonal carci-noma, and 25% of yolk sac tumour. The patient was referred to the regional oncology service for further management. Discussion The incidence of gynaecomastia in adult men is reported as being 35-65%, depending on the criteria for diagnosing gynaecomastia and the age group. 1 However, only 2% of men presenting with gynaeco-mastia are found to have testicular tumours. 2 Gynaeco-mastia is usually attributed to an imbalance of oestrogen and androgen but may be due, in part, to a more direct action of luteinising hormone or human chorionic gona...

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Scrotal ultrasound scans carried out on 156 patients were reviewed in a retrospective study and the sonographic findings and indications evaluated. Ultrasound was able accurately to distinguish the normal from the pathological scrotum. Extratesticular lesions were readily differentiated from testicular lesions. Abnormal testicular echo patterns were usually associated with tumours, but orchitis, granulomas and haematomas were found to have a similar appearance. Occult testicular tumours could readily be identified. Ultrasound was also useful in excluding underlying pathology in hydroceles, in the diagnosis and follow-up of epididymitis and other epididymal lesions and in the assessment of underlying testicular damage in traumatic haematoceles. Ultrasound may also be useful in post-orchiectomy follow-up examinations to exclude tumour in the contralateral testis.