Evaluation of Testicular

Disorders

Richard E. Freeman MD MPH

2013
Lock Haven University
Section 1

TESTICULAR EVALUATION
Testicular Anatomy
History
 Age of Patient helpful in limiting differential and determining responsible
organisms :
 Nature of Pain:
 Severity
 Quality
 Radiation
 Alleviating/Aggravating factors
 Sexual History
 Associated constitutional symptoms
 Associated urinary symptoms
 Dysuria, frequency, hesitancy
 Discharge- etc
 Other
 Activities involved with:
 Sports-lifting, trauma
Physical Exam
 Always complete GU: - be systematic
 Inspection- entire perineum- over, under, and beside
 Skin- cysts, ulcers, erythema/rash, parasites
 Masses-
 Palpation
 Inguinal- hernias, masses, nodes
 Scrotum- Cord, Epididymis, Testes
 Penile shaft – palpate from bulbous to tip- masses tenderness ulcers
 Milk the shaft – discharge- Examine urethral meatus
 Rectal
 Hemorrhoids
 Prostate
 Masses
 Occult blood

Abdominal Exam - Complete

 ?? Parotids
Diagnostic Studies
 Urinalysis
 Urethral Discharge
 Gram Stain
 Culture
 PCR (Chlamydia/GC)
 Ultrasound
 Doppler Ultrasound
 Testicular Scan
 Doppler Ultrasound

Diagnosis Appearance on U/S

Normal testis Normal blood flow
Testicular Torsion Absent or decreased blood flow
Epididymitis/Orchitis Increased blood flow
Appendiceal Torsion Normal blood flow
Section 2

THE PAINFUL TESTICAL

Case 1
 A ten year old male presents to your clinic
complaining of acute testicular pain while
playing outside this afternoon. There is no
history of trauma. He is afebrile and denies
any recent symptoms of viral illness. On
physical exam you note a tender right testicle
that has a transverse lie in the scrotal sac.
Elevating the testicle exacerbates symptoms.
TESTICULAR PAIN:
Differential Diagnosis
 Epididymitis/Epididymo-Orchitis
 Orchitis
 Testicular Torsion
 Torsion
 Torsion of Testicular appendix
Torsion Testicle
 Severe pain - abrupt onset
 Possibly previous history of
similar episode that resolved
 Absence of cremasteric
reflex on affected side
suggestive of torsion
 High riding testicle with
transverse lie of testicle-
suggests torsion
 Prehn’s sign- lack of pain
relief with testicle
elevation
Torsion Testicle
 Occurs due to anatomic defect in scrotal
development- Tunica Vaginalis compltely
surrounds the testes and possibly the cord.
 No attachment of the Tunica vaginalis to the
wall of the scrotum.
 Allows Testes to “swing freely
 “Bell-Clapper deformity”
 Two variations
 Intravaginal Torsion
 Extravaginal Torsion-Exclusively in neonates
Torsion Testicle
 Incidence- 1:4000 males before age 25
TESTICULAR TORSION
 DIAGNOSIS: High degree of suspicion
 CLINICAL DIAGNOSIS
 Blood Flow:
 ULTRASOUND - color doppler
 Radionucleotide
Torsion Testicle

 REPRESENTS SURGICAL EMERGENCY

 Requires immediate orchidopexy
 Contralateral side should be repaired at the
same time
Testicular Salvage rates
 < 6 hours – 90-100% salvage rate
 12-24 hours – 20-50%
 > 24 hours – 0-10%
Torsion Testicle

 Differential includes
 Appendiceal torsion
 Orchitis
 Epididymitis
Appendiceal Torsion
 Onset of Symptoms:
 Subacute
 Age
 Prepubertal
 Tenderness
 Localized to upper pole
 UA
Negative
 Cremasteric reflex
 Positive
 Treatment
 Bed rest/scrotal evalvation
 Surgical
Torsion of Testicular appendix
 Appendix Testes
 Remnant of Mullerian duct (92%)
 “Blue dot” sign
 More common in children than testicular torsion
 Appendix Epididymis
 Remnant of Wolffian duct (23%)
 Present as Subacute pain
 Absence of systemic/Urinary tract symptoms
Blue Dot sign
Epididymitis

 DEFINITION:
 Inflammation, Pain, Swelling of epididymis
 Acute: Symptoms usually lasting < 6 weeks
 Chronic: Symptoms usually lasting > 6 weeks
 May be acute sub-acute chronic
 EPIDEMIOLOGY:
 Most common cause of acute scrotal pain
 Age: 16-30 y/o & 51-70 y/o
 Incidence parallels incidence of Chlamydia & GC
Epididymitis
 ETIOLOGY:
Retrograde infection from the urinary tract.
Sexually active – Chlamydia, Gonorrhea, E.coli
Older men and children- E.coli
Non-infectious – post surgery, drugs

 SIGNS/SYMPTOMS:
Scrotalpain- slow onset
+- Dysuria, frequency, Discharge, Fever
Tenderness and swelling epididymis
Epididymitis
 Natural History/Complications
 Abscess
 Epididymis and testicular infarction
 Chronic inflammation/disability
EPIDYDIMITIS
Diagnostic Studies
 Urinalysis
 May reveal pyuria
 Urine Culture
 Responsible organisms
 Urethral Swab
 Gram Stain
 Culture
 PCR-Gonorrhea/Chlamydia
Epididymitis
 Treatment
 < 35 y/o
 Ceftriaxone 250 mg IM
 Doxycyxline 100 BID x 14 days
 > 50 y/o
 Treat responsible organism
 Ciprofloxin/Quinilones
 TMP/SMZ
 Orchitis
 DEFINITION:
 Inflammation or infection of the testicles
 may be related to epididymitis
 Extension to testes
 Etiology:
 bacterial (E. coli, K. pneumoniae, P. aeruginosa,
Staph. or Strep)
 viral (EBV, coxsackievirus, arbovirus,
enterovirus, MUMPS VIRUS)
ORCHITIS & MUMPS
 Most common cause of orchitis
 Approximately 20% of prepubertal patients with mumps
develop orchitis.
 4 out of 5 cases occur in prepubertal males(younger than 10
years).
 Mumps orchitis follows the development of parotitis by 4-7
days.
 Mumps orchitis presents unilaterally in 70% of cases (fertility
usually maintained)
 In 30% of cases, contralateral testicular involvement follows by 1-9
days.
ORCHITIS
 SIGNS & SYMPTOMS:
 similar to epididymitis,
 hematuria, ejaculation of blood
 Pain,
 entire testes swollen- exquisitely tender
 Systemic- fever chills, malaise
Orchitis - Treatment
 GENERAL:
 BED REST,
 SCROTAL SUPPORT ANALGESICS,
ANTIEMETICs

 VIRAL etiology- Supportive care

Orchitis- Treatment

 BACTERIAL etiology:
 <35 y/o and sexually active,
 antibiotic coverage for sexually transmitted pathogens
(particularly gonorrhea and chlamydia)
 Ceftriaxone and either doxycycline or azithromycin is
appropriate.
 >35 y/o
 with bacterial etiology require additional coverage for
other gram-negative bacteria
 fluoroquinolone ( not for gonorrhea)
 TMP-SMX
Section 3

PAINLESS SCROTAL MASSES

PAIN LESS SCROTAL MASSES
 Varicocele
 Hydrocele
 Hernia
 Testicular Tumors
 Spermatocele
 Scrotal Edema
Varicocele
•Patient presents with mass of scrotum
that feels like “bag of worms”
•Most commonly left sided due to
drainage of L gonadal vein into the left
renal vein at an acute angle and
anatomic variants which cause back
pressure
•Clinically benign Except in the setting of
infertility
•40% of men with infertility have
varicocele.
•Surgical removal may be necessary
• Why might this cause infertility?
Varicocele
Hydrocele

 DEFINITION:
 Fluid filled mass between tunica
vaginalis & testicle
ETIOLOGY
failure of patent processus vaginalis to
close & failure of peritoneal fluid to be
re-absorbed
EPIDEMIOLOGY
Common in newborns 1-6/100 boys
Rarer in Adult males 1/100
 When persistent or fluctuating
Hydrocele seen after age of 1 a
communication is present- (known
as communicating Hydrocele)
HYDROCELE
RISK FACTORS
 Premature and low-birth-weight infants
 Indirect inguinal hernia
 Primary testicular/intrascrotal pathology
 Trauma
 Surgery
 Increased intra-abdominal pressure
 Lymphatic obstruction
 Ventriculoperitoneal shunt
 Peritoneal dialysis
 Ehlers-Danlos syndrome
 Non communicating forms may result from trauma, infection or neoplasm
Hydrocele
 Physical Exam
 Transilluminating mass-waxes and
wanes
 May associated with a indirect hernia
 Consider ultrasound due to possibility of
neoplasm causing Hydrocele
 Management
 Expectant- watch and wait
 Surgical resection
Hydrocele
 C

NON-COMMUNICATING
COMMUNICATING
NORMAL
HERNIA:
 DEFINITION:
 ETIOLOGY:
 EPIDEMIOLOGY:
HERNIA:RISK FACTORS
Being male.
Family history.
Certain medical conditions: cystic fibrosis
Chronic cough..
Chronic constipation. Straining during bowel movements
Excess weight: moderately to severely overweight puts extra pressure on
abdomen.
Pregnancy: This can both weaken the abdominal muscles and cause increased
pressure inside your abdomen.
Certain occupations: Having a job that requires standing for long periods or
doing heavy physical labor increases risk of developing an inguinal hernia.
Premature birth: Infants who are born early are more likely to have inguinal
hernias.
History of hernias: one inguinal hernia, it's much more likely develop another
— usually on the opposite side.
Hernias: EXAM
Hernias
Hernias
Hernias
Hernias
 CLINICAL COURSE:
 NORMAL: REDUCIBLE
 Complications:
 INCARCERATION
 Not easily manually reduced
 STRANGULATION
 Surgical Emergency- herniorrhaphy
 Blood supply to hernial contents (omentum/intestines)
is compromised  tissue death
 Spermatocele

 DEFINITION:
 Usually asymptomatic, small mass of
the epididymis
 Equivalent of a Berry aneurysm of the
epididymis
 Benign
 DIAGNOSIS:
 normally confirmed with ultrasound
however only (definitive diagnosis is
made through biopsy or aspiration
returning spermatozoa- not necessary)
 TREATMENT:
 Surgical excision reserved for chronic
pain or extensive enlargement
 CRYPTORCHIDISM
 DEFINITION:
 Undescended or“Hidden
testis”
 EPIDEMIOLOGY:
 Incidence-
 0.7-1% at age 1.
 ETIOLOGY:
 Uncertain
 COMPLICATIONS:
 Can lead to infertility and
has a higher incidence of
malignancy .
 Tx- Orchiopexy
TESTICULAR TUMORS

 EPIDEMIOLOGY:
 Incidence low: 4/100,000
 Prevalence: 3.7/100,000

 Most common cancer in men between ages of

15-35
 Excellent prognosis with early detection
Who gets testicular cancer?
 Men who are more likely to get testicular cancer:
 Are white
 Have a father or brother who had testicular cancer
 Have a testicle that did not come down into the scrotum
even if surgery was done to remove the testicle or bring it
down
 Have small testicles or testicles that aren't shaped right
(most testicles are round, smooth and firm)
 Have Klinefelter's syndrome
What are the signs of testicular cancer?
 A hard, painless lump in the testicle (this is
the most common sign)
 Pain or a dull ache in the scrotum
 A scrotum that feels heavy or swollen
 Bigger or more tender breasts

 Back Pain
 Dyspnea
Testicular Cancer

 Histology:
 2 groups
 Nongerminal (5%)
 Leydig or sertoli cells

 GERMINAL (95%)
 Seminoma, Embryonal,
tertatoma,
choriocarcinoma, yolk
sac tumors
Testicular Cancer
 Germinal tumors usually metastasize thru
lymph system except for choricocarcinoma
which metastasize thru the vascular system.
 TREATMENT AND PROGNOSIS
 varies with type of tumor.
 The earlier its found the better the outcome!
 Virtually 100% CURE if found before metastasis
 >80% if metastasized
 chemotherapy
Testicular Self Examination
 Check your testicles
one at a time. Use
one or both hands.
 Cup your scrotum
with one hand to see
if there is any
change.

Testicular Self Examination
 Place your index and
middle fingers under a
testicle with your
thumb on top.
 Gently roll the testicle
between your thumb
and fingers.
 Feel for any lumps in
or on the side of the
testicle. Repeat with
the other testicle.
Testicular Self Examination
 Feel along the
epididymis for swelling