Disorders of the male genetalia Flashcards
Disorders of the scrotal contents
Clinical examination of scrotal lumps and swellings
A lump or swelling in the scrotum may be:
- A solid or cystic mass arising from a component of scrotal contents or spermatic cord. These include testis, epididymis, epididymal appendage, vas deferens and pampiniform venous plexus
- A collection of fluid in the tunica or processus vaginalis (hydrocoele)
- An indirect inguinal hernia extending along the embryological path of testicular descent into the scrotum
Common causes of acute pain in the scrotum
Inflammation of the epididymis and testis
Epididymitis
- Bacterial epididymitis is the most common inflammatory disorder of scrotal contents
- urinary tract infection with coliforms (in the 50–65 age group) or a sexually transmitted infection with Chlamydia or Neisseria gonorrhoeae (common in the 15–30 age group)
- Epididymitis incorrectly called orchitis or epididymo-orchitis. Testis rarely infected, but inflammation surrounding epididymitis causes testicular tenderness.
- Treatment of acute epididymitis is initially with bed rest for pain relief and at least a month of an appropriate broad-spectrum antibiotic
Common causes of acute pain in the scrotum
Inflammation of the epididymis and testis
Tuberculous epididymitis
- Tuberculosis may involve the epididymis via bloodstream spread from a pulmonary or other focus.
- A tuberculous urinary tract infection can spread to the epididymis, with swelling as the presenting complaint.
- Typically, the whole length of the epididymis is thickened, non-tender and ‘cold’.
- In contrast to bacterial epididymitis, the epididymis can be readily distinguished from the testis on palpation.
- If untreated, the testis may also become involved.
Diagnosis requires analysis of serial early morning urine specimens (EMUs) for mycobacteria or, more reliably, histological examination of percutaneous needle biopsies. If tuberculosis is confirmed, a search must be made for pulmonary and urinary tract disease
Common causes of acute pain in the scrotum
Orchitis
- Orchitis (or-KIE-tis) is an inflammation of one or both testicles. It is usually caused by a bacterial infection or by the mumps virus.
- Bacterial orchitis can be caused by sexually transmitted infections (STIs), particularly gonorrhea or chlamydia
- Primary bacterial orchitis is rare and may result from pyogenic infection in the genital tract or elsewhere. Tertiary gummatous syphilis may involve the testis, producing diffuse non-tender enlargement.
- This is now rare and there is usually a history of primary and secondary lesions. Sometimes a gumma is found unexpectedly during investigation of a suspected testicular tumour.
- Viral orchitis is most often caused by mumps. In post-pubertal males, bilateral mumps orchitis produces infertility in 50%; elevated follicle-stimulating hormone (FSH) blood levels following orchitis usually indicate the patient is infertile.
Common causes of acute pain in the scrotum
Hydrocoele
- Primary hydrocoeles develop in adulthood, particularly in the elderly, by slow accumulation of serous fluid, presumably by impaired reabsorption.
- These can reach a huge size, containing several hundred millilitres of fluid but the lesions are otherwise asymptomatic.
- The swelling is soft and non-tender and the testis cannot usually be palpated. The presence of fluid is confirmed by transillumination.
Note that a secondary hydrocoele may develop in response to testicular tumour or inflammation. In most, the hydrocoele is small and the testis can easily be palpated to reveal the primary abnormality
Management:
- everting the sac and oversewing the edges (Jaboulay procedure) or plicating the sac (Lord’s method). If the sac is thick, it is best excised.
Common causes of acute pain in the scrotum
Fournier’s scrotal gangrene
- Form of necrotising fasciitis of genitalia and perineum and does not involve the testes.
- There is often consequent systemic sepsis.
Treatment is urgent and includes intravenous antibiotics and surgical excision of all necrotic tissue, with the wound left open to heal by secondary intention.
Common causes of acute pain in the scrotum
Testicular tumours
WHO histopathological classification of testicular tumours:
- Germ cell tumours (90%)
- Seminoma (48%)
- Non-seminomatous GCT (42%)
- Teratoma (most common)
- Embryonal carcinoma
- Yolk sac tumour
- Choriocarcinoma
- Mixed NSGCT
- Mixed GCT
Sex cord/gonadal stromal tumours
- Leydig cell tumour
- Sertoli cell tumour
- Mixed
Miscellaneous non-specific stromal tumours
- Ovarian epithelial tumours
- Tumours of the collecting ducts and rete testis
- Lymphoma, leukaemia, secondary metastases
Common causes of acute pain in the scrotum
Investigation and treatment of testicular tumours
- scrotal ultrasonography.
- staging investigations are usually performed next, including chest X-ray or CT
- blood levels of tumour markers (which must be measured before treatment)
Tumour markers:
- Human chorionic gonadotrophin (beta-hCG) is secreted by syncytiotrophoblastic cells and levels may rise in any tumour type, particularly poorly differentiated germ cell tumours
- Alpha-fetoprotein (AFP) is produced by yolk sac elements. About 75% of patients with metastatic teratoma have elevated AFP levels but this marker is not expressed in seminoma
- Lactic dehydrogenase (LDH) is elevated in more than half the patients with metastatic seminoma.
Common causes of acute pain in the scrotum
Surgical exploration and management of seminoma
- Orchidectomy is the only appropriate treatment for the primary tumour and is usually performed as part of the diagnostic process.
- The surgical approach is via an inguinal incision to avoid involving scrotal skin.
- The spermatic cord is temporarily clamped to prevent venous spread of tumour cells and the testis is brought out for inspection and palpation.
- If the testis is obviously malignant, orchidectomy is performed
Management of seminoma:
- For stage 1 seminoma, i.e. in testis, some oncologists advise no further treatment after orchidectomy, although carboplatin-based chemotherapy is recommended.
- Seminoma very radiosensitive and radiotherapy can also play a role for the primary, although it is not by the European Association of Urologists in view of the high cure rate from standard treatment.
- stages IIa and b radical radiotherapy to the ipsilateral (same side) para-aortic and iliac nodes gives a cure rate of about 95%, chemotherapy is an alternative
Common causes of acute pain in the scrotum
Surgical exploration and management of teratomas and other non seminomatous cell tumours
25% of patients with stage I disease would relapse within a year of orchidectomy without further treatment. Radiotherapy has no curative role in these types of tumour. There are three options for further treatment for stage I disease:
- Immediate chemotherapy( EP (etoposide and cisplatin) or BEP (bleomycin, etoposide and cisplatin)
- Retroperitoneal lymph node dissection
- Surveillance and treatment if metastases occur
Common causes of acute pain in the scrotum
Torsion of the testis or epididymal appendage
- extravaginal torsion which presents as a hard, swollen testis. Later in childhood, the testis becomes suspended in a near vertical position, anchored by the spermatic cord and by attachments to the posterior scrotal wall. This attachment prevents rotation
- Minor anatomical variations can produce a narrow-based pedicle with a horizontal (‘bell-clapper’) testicular lie, that allows the testis to twist about its axis within the tunica (intravaginal torsion).
- When this occurs, pampiniform plexus veins become compressed causing venous congestion. After a few hours, venous infarction occurs unless torsion is corrected
Common causes of acute pain in the scrotum
Management of suspected testicular torsion
- Differentiating between acute epididymitis and torsion can be difficult. If a firm diagnosis cannot be reached, surgical exploration is mandatory.
- Investigations are of little value: radionuclide studies and Doppler ultrasound examination may be employed to show testicular blood flow but results can be misleading.
