TESTIS AND SCROTUM

UNDESCENDED TESTIS

CRYPTORCHIDISM

 Refers to testes located somewhere along the normal path of descent (prepubic, external inguinal ring, inguinal canal, abdominal)

Testes absent from the scrotum after 3 months of age are unlikely to descend fully.

 An incompletely descended testis tends to atrophy as puberty approaches.

Early repositioning of an incompletely descended testis can preserve function.

Clinical features:

-more common in Rt. Side

-bilateral in 20%

-secondary sexual characteristics are normal

-the site of testes could be

                                                Intra-abdominal (retro-peritoneally)

                                                Inguinal

                                                In the superficial inguinal pouch

Retractile testis:

During childhood the testes are mobile and the cremasteric reflex is very active. In some boys, the least stimulation of the skin of the scrotum or thigh will result in the testis disappearing to the superficial ring or into the inguinal canal.

Retractile testes are more common than incompletely descended testis.

Need no treatment.

HAZZARDS OF incompletely descended testis:

-sterility in bilateral cases

-pain

-an associated indirect inguinal hernia is often present and may cause symptoms

-torsion

-epididymoorchitis

-testicular atrophy

-Increase liability of malignant disease.

Ectopic testis

Testis found outside its normal path of descent

Usually it fully developed but the main hazard is liability to injury.

Sites of ectopic testis:

-superficial inguinal ring

-perineum

-root of the penis

-femoral triangle

Treatment

• Undescended testes must be brought down before age 1-2 years as irreversible changes occur; after age 2 they should be brought down to monitor for malignancy

• Hormonal therapy (hCG or LH may facilitate their descent)

• Surgical descent (orchiopexy)

ABSENT TESTIS

Vanishing testis describes a condition in which a testis develops but disappears before birth.

Epididymo-orchitis

Inflammation confined to the epididymis is epididymitis; when infection spreads to the body of the testis, the condition is known as epididymo-orchitis.

EPIDIDYMITIS

Etiology;

• Infection

• < 35 years - gonorrhea or Chlamydia (STDs)

• > 35 years - from GI tract

• Instrumentation

• Reflux;

Increased pressure in prostatic urethra (straining, voiding, heavy lifting) causes reflux of urine along vas deferens ––> sterile epididymitis

Signs and symptoms

• Sudden onset scrotal pain and swelling +/– radiation along spermatic cord to flank

• Scrotal erythema and tenderness

• Fever

• irritative voiding symptoms

• Reactive hydrocele, epididymo-orchitis

Diagnosis

O/E;

 Pain may be relieved with elevation of testicles (Prehn’s sign); which is absent in testicular torsion

• Urinalysis (pyuria), urine C&S

• Urethral discharge: Gram stain for gram-negative cocci or rods

• If diagnosis clinically uncertain, must do

• Colour-flow Doppler ultrasound

• Nuclear medicine scan

• Examination under anesthesia (EUA)

Treatment

• Antibiotics

• GC or Chlamydia - ceftriaxone 250 mg IM once followed by doxycycline 100 mg BID x 21 days

• Or in other type (non-STD) ?   broad spectrum antibiotics for 2 weeks

• Scrotal support, ice, analgesia

ORCHITIS

Etiology

• Usually a result of bacterial infection (epididymo-orchitis)

• 30% of post-pubertal males with mumps get orchitis

• Mumps orchitis usually follows parotitis by 3-4 days

• Other rare causes

• Tuberculosis (TB)

• Syphilis

• granulomatous (autoimmune) in elderly men

Signs and symptoms

• Fever and prostration

• With or without hydrocele

Diagnosis

• Red, swollen scrotum

• Blue testis

• No urinary symptoms

Treatment

• Mumps hyperimmune globulin

• Analgesics, antipyretics

• Steroids

• Ice, bed rest, scrotal elevation

_ Complications

• If severe, testicular atrophy

• 30% have persistent infertility problems

TORSION

Torsion of the testis of two types: torsion of testicular appendix or testicles itself.

Testicular Torsion (also called spermatic cord torsion); Testis rotate medially causing strangulation of the blood supply ––> ultimately leads to necrosis of entire gonad if not treated within 5-6 hours

It possible occurring at any age, but most common in adolescence (12-18 years) due to pubertal increase in testicular volume

Incidence

• ~1/4000, males < 25 years

Predisposing factors

• Cryptorchid testis

• Trauma (although 50% occur during sleep)

• Bell clapper congenital deformity of the testis.

 Narrow mesenteric attachment from cord on to testis/epididymis ––> testis falls forward and is free to rotate within tunica vaginalis

• Anomalous development of tunica vaginalis or spermatic cord

Signs and symptoms

• Acute onset of severe scrotal pain, swelling +/- nausea/vomiting

• Retracted and transverse testicle (horizontal lie)

• No pain relief with testicle elevation (negative Prehn’s sign)

• Epididymis may be palpated anteriorly in the early stages

 Diagnosis

• Ultrasound with colour-flow Doppler probe over testicular artery (if torsion, no blood flow)

• decrease uptake on 99M Tc-pertechnetate scintillation scan

• Examination under anesthesia and surgical exploration

Treatment

• Emergency manual detorsion ––> THEN elective bilateral orchiopexy

• Failure of manual detorsion requires surgical detorsion and bilateral orchiopexy (fixation)

Prognosis

• < 12 hours - good prognosis

• 12-24 hours - uncertain prognosis ––> testicular atrophy.

• > 24 hours - poor prognosis ––> orchiectomy is advised.

HYDROCELE

Definition; A hydrocele is an abnormal collection of serous fluid in some part of the processus vaginalis, usually the tunica, but may occurs within the spermatic cord.

Etiology

• Usually idiopathic

• found in 5-10% of testicular tumours

• associated with trauma, orchitis, epididymitis

Types

• communicating hydrocele: patent processus vaginalis (a form of indirect inguinal hernia) ––> usually seen in children.

• Non-communicating hydrocele: processus vaginalis is not patent

Diagnosis

• Usually a non-tender cystic intrascrotal mass which transilluminates

• Ultrasound (definitive), especially if < 40 years of age (rule out tumour)

Treatment

• Nothing if small, well tolerated and no complications

• Surgical

Complications

• Hemorrhage into hydrocele sac following trauma

• Compression of testicular blood supply

VARICOCELE

A varicocele is a varicose dilatation of the veins draining the testis.

 Etiology

• Dilated veins in the pampiniform plexus (90% on left side); incompetent valves in testicular veins

• Left internal spermatic vein is longer and joins the left renal vein (On the right it empties into the vena cava)

• 30% of men with infertility have varicocele (associated with testicular atrophy)

Diagnosis

• Usually asymptomatic, but may be painful

• Mass of dilated, tortuous veins, “bag of worms”

• Heavy sensation after walking or standing

Infertility

Treatment

• Surgical ligation of testicular vein above inguinal ligament

• Percutaneous vein occlusion (balloon catheter, sclerosing agents)

• In the presence of oligospermia, surgically correcting the varicocele may improve sperm count and motility in 50-75% of patients