Undescended testis, torsion, scrotal swellings, testicular tumours and infections

Overview

Scrotal problems are common, and several are urgent. Torsion must be operated on within hours. A testicular tumour is the commonest cancer of young men and is highly curable. Undescended testes need surgery in infancy.

The key bedside questions for any scrotal swelling are: Can I get above it? Is it part of the testis or separate? Does it transilluminate?

Applied anatomy

• The left testicular vein drains into the left renal vein; the right into the IVC.
• Testicular lymph goes to the para-aortic nodes; scrotal skin drains to the inguinal nodes.
• The epididymis lies behind the testis and is felt separately. The cremasteric reflex tests L1–L2.

Undescended (incompletely descended) testis

Definitions

Incidence

• About 4% of term boys at birth; higher in preterm babies.
• About two-thirds descend in the first 3 months; after that, descent is unlikely. Incidence at 1 year is about 1%.
• More often on the right; bilateral in about 20%.

Positions

Intra-abdominal (just inside the deep ring), intracanalicular (the commonest), extracanalicular (at the neck of the scrotum), or ectopic.

Consequences

• Infertility: heat damages spermatogenesis; histological changes from 1–2 years; worst when bilateral.
• Malignancy: risk about 5–10 times normal, mostly seminoma.
• Hernia: about 90% have a patent processus vaginalis.
• Torsion and trauma are more likely.

Assessment

• Examine in a warm room with the child relaxed; milk the groin towards the scrotum.
• Retractile testis: scrotum well developed; the testis can be brought down and stays; no treatment (follow up, since some ascend).
• True undescended testis: hemiscrotum often underdeveloped; the testis cannot be brought to the scrotum base.
• Impalpable testis: diagnostic laparoscopy (imaging adds little); with hypospadias, consider a disorder of sex development.

Treatment: orchidopexy

• Timing: 6–12 months of age (before 1 year), to protect fertility and allow cancer detection.
• Palpable testis: inguinal approach; mobilise the cord; ligate the patent processus vaginalis; divide cremaster fibres and lateral bands; place the testis in a subdartos pouch.
• High or intra-abdominal testis: staged (Fowler–Stephens) procedure, often laparoscopic.
• Orchidectomy for an atrophic post-pubertal testis when the other is normal.

Torsion of the testis

Pathophysiology

• Twisting blocks venous outflow first (haemorrhagic infarction), then arterial inflow.
• Bell-clapper deformity (high investment of the tunica vaginalis, testis swings loosely) is the commonest cause and is usually bilateral.
• Triggers: cremaster contraction with sport, straining or sex. Neonates get extravaginal torsion of the whole cord.

Clinical features

• Peak 10–25 years.
• Sudden severe pain in the testis, groin or lower abdomen, with vomiting.
• Swollen, very tender testis lying high and horizontal; cremasteric reflex absent; lifting the testis does not ease the pain.
• Usually no fever or urinary symptoms; earlier brief attacks suggest intermittent torsion.

Outcome depends on time

• Untwisted within 6 hours: almost 100% salvage.
• At 24 hours: about 20%.
• 720° twists kill the testis faster than 360°.

Management

1. Urgent scrotal exploration whenever torsion is possible; do not delay for Doppler. Consent for orchidectomy too.
2. Untwist and assess viability.
3. Viable: fix with three non-absorbable sutures. Dead: orchidectomy.
4. Always fix the opposite testis (the anomaly is usually bilateral).

Differential diagnosis of the acute scrotum

Common scrotal swellings

Approach

Hydrocele

Fluid in the tunica vaginalis (part of the processus vaginalis).

• Ultrasound is essential if the testis cannot be felt, especially in a young man (exclude tumour). Never aspirate a hydrocele that might hide a tumour.
• Treatment: small ones need nothing; surgery for large ones: Lord's plication (thin sac) or Jaboulay eversion (thick sac). Aspiration soon refills.

Varicocele

• Dilated, tortuous veins of the pampiniform plexus.
• About 15–20% of adult men; about 90% left-sided.
• Why left? The left testicular vein is longer and enters the left renal vein at a right angle; valves are often absent or incompetent; the vein can be compressed by a loaded sigmoid colon.
• Dragging ache, worse at the end of the day; scrotum hangs low; "bag of worms" on standing, empties on lying down; cough impulse; the testis may be smaller.
• May warm the testis and impair sperm production; the link with infertility is debated.
• Sinister sign: a new left varicocele in an older man that does not empty when lying down suggests a left renal tumour blocking the left renal vein. Image the kidney.
• Treatment: none if asymptomatic; for pain, embolisation first, or surgical ligation; recurrence is common (about 20% after embolisation).

Epididymal cyst and spermatocele

Both lie separate from the testis. Leave small ones alone; excise large or painful ones (aspiration is useless for multilocular cysts). Warn young men that surgery may block sperm transport on that side.

Testicular tumours

Epidemiology and risk factors

• About 1–1.5% of male cancers, but the commonest solid cancer in young men; incidence is rising.
• Seminoma peaks in the fourth decade; non-seminomatous germ cell tumours (NSGCT) in the third decade. Lymphoma is the commonest testicular tumour in older men (often bilateral).
• Risk factors: undescended testis, previous tumour in the other testis, Klinefelter syndrome, family history.

Classification

Clinical features

• Painless, hard lump or enlargement of the testis (commonest); heaviness.
• Occasional pain from bleeding into the tumour (mimics torsion).
• Lax secondary hydrocele.
• Gynaecomastia in about 5% (mainly NSGCT, hCG).
• Metastases: back or abdominal pain (para-aortic nodes), epigastric mass, cough and haemoptysis ("cannonball" lung metastases), supraclavicular nodes.

Investigations

1. Scrotal ultrasound: mandatory; hypoechoic intratesticular mass; also checks the other testis.
2. Tumour markers before orchidectomy: AFP, β-hCG, LDH. Raised in about half of cases; used for diagnosis, prognosis and follow-up.
3. CT chest, abdomen and pelvis for staging (usually after orchidectomy).
4. Repeat markers after orchidectomy; they should fall according to their half-lives (AFP 5–7 days, hCG 2–3 days). A slower fall or a rise means residual disease.

Staging (simplified)

Treatment

• Radical inguinal orchidectomy: through a groin incision, the cord is clamped early and divided at the deep ring.
• Never use a scrotal incision or scrotal biopsy, which would open new lymph drainage to the inguinal nodes and risk scrotal recurrence.
• Offer sperm banking and a prosthesis.

Prognosis is excellent: about 90–95% 5-year survival for seminoma without metastases, and over 90% for good-prognosis NSGCT.

Testicular and scrotal infections

Epididymo-orchitis

• Infection usually reaches the epididymis along the vas from the urethra, prostate or bladder. It starts in the tail of the epididymis.
• Young, sexually active men: Chlamydia trachomatis (commonest), gonorrhoea.
• Older men: E. coli and other urinary organisms, from outflow obstruction, UTI or catheters and instrumentation.
• Gradual pain and swelling, fever, dysuria, urethral discharge; tender swollen epididymis; elevating the testis eases the pain; cremasteric reflex preserved.
• Investigations: urine dipstick and culture, NAAT for chlamydia and gonorrhoea, urethral swab, ultrasound (abscess, and to exclude tumour).
• Treatment: doxycycline (± ceftriaxone for gonorrhoea) in young men, with partner tracing; a quinolone in older men; at least 2 weeks; scrotal support, analgesia, fluids. Drain an abscess.
• Complications: abscess, atrophy, chronic pain, infertility.

Tuberculous epididymo-orchitis

• Spreads (usually retrograde) from the seminal vesicles or prostate; starts at the lower pole (tail) of the epididymis.
• Craggy, painless epididymis; beaded vas; lax hydrocele (about 30%); discharging sinus on the back of the scrotum.
• About two-thirds have renal TB: check three early-morning urines, chest X-ray, CT urography.
• Anti-TB drugs; epididymectomy if no response after about 2 months.

Mumps orchitis

• The commonest orchitis; in about 20–30% of post-pubertal males with mumps, as the parotid swelling settles.
• Painful swollen testis; may be bilateral; IgM serology.
• Complications: testicular atrophy, infertility if bilateral. Treatment is supportive.

Other causes: syphilitic gumma (painless) and filariasis (hydrocele, chylocele, scrotal elephantiasis).

Fournier gangrene

• Necrotising fasciitis of the scrotum, penis and perineum; polymicrobial (aerobes and anaerobes) with obliterative endarteritis of skin vessels.
• Risk factors: diabetes, alcoholism; minor perineal trauma or instrumentation; no cause in over half.
• Sudden pain, toxaemia, crepitus, black necrotic skin; testes usually spared.
• Treatment: resuscitation, IV broad-spectrum antibiotics and urgent radical debridement; skin grafting later.

Quick revision

• UDT: 4% at birth, 1% at 1 year; canal commonest; orchidopexy 6–12 months.
• Retractile testis: can be brought down, scrotum normal; no surgery.
• Torsion: 10–25 years; bell-clapper; absent cremasteric reflex; explore now; fix both.
• Appendix torsion: blue dot, pre-pubertal boys.
• Hydrocele: surrounds testis, transilluminates; ultrasound if testis impalpable.
• Epididymal cyst: separate, behind testis, transilluminates; spermatocele has sperm.
• Varicocele: 90% left; bag of worms; new non-emptying left varicocele → renal tumour.
• Tumours: ultrasound + AFP/hCG/LDH → inguinal orchidectomy; para-aortic nodes.
• Seminoma: AFP normal, radiosensitive; NSGCT: BEP.
• Epididymo-orchitis: chlamydia in young, E. coli in old; Prehn relief; doxycycline or quinolone.

Written by The House Job from standard references (Bailey & Love; Kumar and Clark's Clinical Medicine).

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