Male Reproductive System

Question 1

Priapism: Overview

Answer 1

• prolonged and painful erection for several hours (≥2-4 hours), not associated w/ sexual stimulation or desire
• pt may awaken w/ an erection
• bimodal distribution w/ peak incidence in children 5-10 years and adults 20-50 years
• can be idiopathic or caused by certain meds and disease states (secondary priapism)
• Most common cause in adults (25%) is meds, such as intracavernosal injections to tx erectile dysfunction
• Males w/ sickle cell disease are at very high risk (35-45%) of ischemic priapism

Other RF:
- high doses of erectile dysfunction drugs
- cocaine
- quadriplegia

TWO types: ischemic and nonischemic
** Ischemic priapism is considered a urologic emergency!

Question 2

Paraphimosis: Overview

Answer 2

• occurs when foreskin cannot be returned back to its original position because of swelling of head (glans) of penis; glans is swollen, reddened, and painful
• highest incidence is among uncircumcised infants and toddlers
• if glands become red, swollen, and painful, it may not return back to its original state
• REQUIRES EMERGENCY TREATMENT! because may cause ischemic changes
• a small slit in the foreskin (w/ topical anesthesia) can help relieve pressure
• in severe cases, a circumcision may be needed
• considered a urologic emergency → Refer to ED!

Question 3

Testicular Cancer: Overview

Answer 3

• teenage to young adult male c/o nodule, sensation of heaviness ora ching, one larger testicle, and/or tenderness in one testicle
• can present as a new onset of a hydrocele (from tumor pressing on vessels)
• usually painless and asymptomatic until metastasis
• More common in white males, 15-30 years
• rare in African Americans

Question 4

Testicular Cancer: Overview

Answer 4

• teenage to young adult male c/o nodule, sensation of heaviness ora ching, one larger testicle, and/or tenderness in one testicle
• can present as a new onset of a hydrocele (from tumor pressing on vessels)
• usually painless and asymptomatic until metastasis
• More common in white males, 15-30 years
• rare in African Americans

Question 5

Prostate Cancer

Answer 5

• Older to elderly man
• complains of new onset of low-back pain and rectal area/perineal pain or discomfort accompanied by obstructive voiding sx such as weaker stream and nocturia
• may be asymptomatic
• more common in older (>50 years), obese, and African Americans, + men w/ fam hx of prostate CA (father, brother)

Question 6

Torsion of the Appendix Testis (Blue Dot Sign)

Answer 6

• school-age boy c/o abrupt onset of blue-0colored round mass located on testicular surface
• mass resembles a “blue dot”
• appendix testis is a round, small (0.03 cm), pedunculated, polyp-like structure that is attached to testicular surface (on the anterior superior area)
• blue dot is caused by infarction and necrosis of appendix testis d/t torsion
• Cremasteric reflex is present< NOT testicular torsion
• Torsion of the appendix testes rarely happens in adults
• Most cases occur in children ages 7-14 years (mean age is ~10.5 years)

Question 7

Testicular Torsion: Overview

Answer 7

• A male (usually adolescent) reports waking up in the middle of the night or in the morning w/ abrupt onset of an extremely painful and swollen red scrotum
• usually <12 hrs in duration
• some have inguinal pain or lower abdominal pain as presenting complaint
• frequently accompanied by nausea and vomiting
  -affected testicle/scrotum, located higher and closer to the body than the unaffected testicle
• cremasteric reflex is MISSING!
• majority of cases, 2/3, occur between ages of 10-20 years
• SURGICAL EMERGENCY! Refer to ED!

Question 8

Fournier’s Gangrene: Overview

Answer 8

• rare, rapidly progressing polymicrobial necrotizing fasciitis of external genitalia and perineum

RF:
- diabetes
- trauma to the urethral/penile area
- use of sodium-glucose cotransporter-2 (SGLT2) inhibitors (e.g., canagliflozin, dapagliflozin, empagliflozin); ↑ risk for this infection

S/Sx
- abrupt onset of severe pain, redness, and swelling of skin in perineum
- spreads rapidly
- skin will turn black (gangrene)
- can include scrotum and penis or labia in females

SURGICAL EMERGENCY! Requires surgical debridement and IV antibiotics

Question 9

Normal Findings: Spermatogenesis (Spermarche)

Answer 9

• Ideal temp for sperm production is 1º C to 2º C (33.8º F-35.6º F) lower than core body temp
• sperm production begins in late puberty (Tanner stage IV) and continues for entire lifetime
• sperms are produced in seminiferous tubules of testes
• sperms require 64 days (~3 months) to mature

Question 10

Normal Findings: Testes

Answer 10

• Cryptorchidism (undescended testes) ↑ risk of testicular cancer
• production of testosterone/androgens is stimulated by release of luteinizing hormone
• Spermatogenesis is stimulated by both testosterone and follicle-stimulating hormone
• the left testicle usually hands lower than the right

Question 11

Normal Findings: Prostate Gland

Answer 11

• heart-shaped gland growing throughout life cycle of male
• produces prostate-specific antigen (PSA) and prostatic fluid
• prostatic fluids (alkaline pH) helps sperm survive in vagina (acidic pH)
• prostate grows throughout a man’s life
• up to 50% of 50-year-old men have BPH, an enlargement of prostate

Question 12

Normal Findings: Epididymis

Answer 12

• coiled tubular organ located at posterior aspect of testis
• storage area of immature sperm (sperm takes 3 months to mature)
• resembles a “beret” on the upper pole of the testes

Question 13

Normal Findings: Vas Deferens (Ductus Deferens)

Answer 13

• tubular structures that transport sperm from epididymis toward urethra in preparation for ejaculation
• tubes are cut/clipped during a vasectomy procedure

Question 14

Normal Findings: Cremasteric Reflex

Answer 14

• testicle is elevated toward body in response to stroking or lightly puinching the ipsilateral inner thigh (or thigh on the same side as testicle)
• cremasteric reflex is absent w/ testicular torsion

Question 15

Normal Findings: Transillumination - Scrotum

Answer 15

• useful for evaluating for undescended testicle (cryptorchidism), hydrocele, spermatocele, and other types of scrotal mass
• direct a beam of light behind one scrotum (turn off room light); hydrocele will transilluminate (serous fluid inside scrotum) and will have a larger glow than unaffected side
• testicular tumor will not transilluminate (solid tumor blocks light)
• Varicocele (“bag of weorms”) will not transilluminate

Question 16

Testicular Cancer
1. Definition/Etiology
2. Clinical Presentation
3. Physical/objective Findings
4. Lab/Diagnostics
5. Treatment Plan

Answer 16

1. Most common tumor in males aged 15-30 years
   - more common in white males
2. • teenage to young adult male
     - c/o nodule
     - sensation of heaviness or aching
     - one larger testicle
     - tenderness in one testicle
     - may present a new onset of hydrocele (from tumor pressing on vessels)
     - usually painless and asymptomatic until metastasis
3. • affected testicle feels” heavier” and more solid
     - may palpate a hard, fixed nodule (most common site is lower pole of testes)
     - 20% of cases will have a concomitant hydrocele
4. • US of testicle reveals solid mass
     GOLD STANDARD: Testicular biopsy
5. • Refer to urologist for biopsy and management
     - Surgical removal (orchiectomy)

Question 17

Testicular Torsion
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan

Answer 17

1. When spermatic cord becomes twisted, the testis’s blood supply is interrupted
   - permanent testicular damage results if not corrected within first few hours (<6 hrs)
   - if not corrected within 24 hrs, 100% of testicles become gangrenous and must be surgically removed
   - more common in males w/ “bell clapper deformity,” which causes the testicle to lay more sideways than longitudinally
   - adolescent or adult male
2. • sudden onset of severe testicular pain
     - has extremely swollen red scrotum
     - some may have acute hydrocele (severe edema)
     - c/o severe N/V
     - affected testicle is higher than normal testicle
     - Cremasteric reflex is missing**
3. • Call 911 ASAP!
     - Preferred test in ED is doppler US with color flow study
     - Treatment can be manual reduction or surgery w/ testicular fixation using sutures

Question 18

Prostate Cancer
1. Definition/Etiology
2. Clinical Presentation/Objective Findings
3. Labs/Diagnostics
4. Treatment Plan

Answer 18

1. • most common CA in men (incidence)
     - African American males have higher risk of prostate CA
     - Average age of diagnosis: 71 years

RF:
- >50 years
- African American
- obesity
- positive family hx (1º relative will double risk)

• Routine prostate CA screening (digital rectal exam [DRE] w/ PSA is not recommended
• Study shows that absolute risk reduction of prostate CA deaths w/ screening is very small
• Individualized management, based on pt’s risk factors and age

2. • Painless and hard fixed nodule (or indurated area) on prostate gland on an older male, detected by DRE
3. • ↑ PSA >4.0 ng/mL
     - Diagnostic test: Biopsy of prostatic tissue (obtained by transurethral US)
     - Screening Test: Not recommended; if pt wants to be tested, order PSA level /w DRE; if limited life span (<10 years), not recommended
4. • Refer to urologist if PSA >4.0 ug/mL; suspect prostate CA
     - Individualize screening is based on RF; discuss risk (bleeding, infection, impotence, procedures, and psychological trauma) vs benefits
     - Most CA are not aggressive and are slow growing; watchful waiting/monitoring by urologist is common
     - If symptomatic (nocturia, weak stream, hesitancy, dribbling), alpha-blockers (terazosin/Hytrin) are FIRST-LINE therapy → * Initiate drug therapy w/ antiandrogens (Proscar), hormone blockers (e.g., Lupron), and others

Question 19

Benign Prostatic Hyperplasia
1. Definition/Etiology
2. Clinical Presentation
3. Objective Findings

Answer 19

1. • Seen in 50% of men >50 (up to 80% of men >70 years)
     - rarely in those younger than 40
     - Rule out prostate CA
     - Use the American Urological ASsociation (AUA) urinary sx score/International Prostate Symptom Score (IPSS) questionnaire to assess the severity of the pt’s BPH sx
2. • older men
     - c/o gradual development (years) of urinary obstructive sx
     - weak urinary stream
     - postvoid dribbling
     - feelings of incomplete emptying
     - occasional urinary retention
     - Nocturia is very common
3. • PSA is elevated (norm is 0-4 ng/mL)
     - Prostate that is symmetrical in texture and size (rubbery texture) is enlarged
     - Lifestyle changes may help ↓ sx and include reduction of caffeine and alcohol intake, avoidance of fluids before bedtime, and avoidance of diuretic meds (if possible)

Question 20

Benign Prostatic Hyperplasia
4. Medications

Answer 20

FIRST LINE: Alpha-adrenergic antagonists
- Tamsulosin (Flomax)
- terazoasin (Hytrin) 5 mg
- doxazosin (Cardura)

5-alpha-reductase inhibitors (binds to prostate gland directly)
- Finasteride (Proscar) → inhibits type 2 5-alpha-reductase (blocks androgen receptor) and acts directly on the prostate gland to shrink it (temporarily) while on meds; if pt stops taking Proscar, the size of prostate gland returns back to its original size
- shrinks by 50% while on Proscar (so PSA must be doubled or multiplied by 2)
- Category X drug (teratogenic); should NOT be touched w/ bare hands by reproductive-aged females (adversely affects male fetus)

Avoid drugs that worsen symptoms
- anticholinergics and sympathomimetics (cause urine retention)
Ex: antihistamines, decongestants, cold meds, caffeine, atropine, antipsychotics, and TCA

Herbal
- Saw palmetto (mild improvement for some)
- does NOT work for everyone

• Duration of treatment ranges from a few months to daily for many years
• Watch for an adverse effect of alpha-blockers, which is orthostatic hypotension
• Advise pt that they may have dizziness d/t low BP
• Pts w/ HTN and BPH can use alpha-blockers that ↓ BP ( terazosin, doxazosin)
• Instruct pts to take medication at bedtime
• Tamsulosin may have less effect on BP than the other alpha-blockers
• If hypotension is a problem, discontinue and start on a trial of finasteride (Proscar)

** Male w/ BPH and HTN: start w/ alpha-blocker that affects BP (Hytrin, Cardura) first; works by relaxing x smooth muscles on prostate gland and bladder neck

Question 21

Chronic Bacterial Prostatitis
1. Definition/Etiology
2. Clinical Presentation
3. Objective Findings
4. Labs/Diagnostic
5. Medications

Answer 21

1. Chronic (>6 weeks) infection of prostate
   - some men report hx of acute UTI or acute bacterial prostatitis
   - others are asymptomatic
   - more common in older men
   - caused most commonly by: E. coli and Proteus
   - Nonbacterial prostatitis has same sx but is culture negative
2. • Elderly man w/ hx of several weeks of suprapubic or perineal discomfort
     - accompanied by irritative voiding sx
     - dysuria
     - nocturia
     - frequency
     - NOT accompanied by systemic sx
     - Some men are asymptomatic
3. • Prostate may feel normal (or slightly “boggy”) to palpation; not tender
     - UA: normal (unless pt has prostatitis, epididymitis, cystitis)
4. • UA, urine culture and sensitivity (C&S), PSA
     - PSA goes up w/ BPH, after sexual intercourse, infection, or inflammation
     - Transurethral US can measure prostate volume
5. • Ciprofloxacin (Cipro) 500 mg PO BID x 4 weeks
     - Alternatives: Trimethoprim-sulfamethoxazole (Bactrim DS) one tablet PO BID x 1-3 months
     - Refer to urologist

Question 22

Acute Prostatitis
1. Definition/Etiology
2. Clinical Presentation
3. Objective Findings
4. Labs/Diagnostics
5. Treatment/Medications

Answer 22

1. • Acute infection of prostate
     - Infection ascends into urinary tract
     - most common non-sexually transmitted cause is Enterobacteriaceae (E. coli, Proteus)
     - if condition occurs in a male <35 years of age, it is treated like gonococcal or chlamydial urethritis
2. • Adult to older man c/o sudden onset of fever
     - chills w/ suprapubic and/or perineal pain/discomfort
     - pain sometimes radiates to back or rectum
     - accompanied by UTI sx such as dysuria, frequency, and nocturia w/ cloudy urine
     - DRE reveals extremely tender prostate that is warm and boggy
     - pt may have an accompanying infection of bladder (cystitis) or epididymitis
3. • Gently examine prostate; prostate will be extremely tender and warm
     ► Warning!!! Vigorous palpation and massage of an infected p[rostate can cause bacteremia
4. • CBC: Leukocytosis w/ shift to the left (presence of band cells)
     - UA: large amount of WBC (pyuria), hematuria
     - Urine C&S: if possible, also obtain urine after gentle prostatic massage
5. Based on age and presumptive organism
   - Age <35 years (or high risk for STD): Ceftriaxone 250 mg IM and doxycycline 100 mg BID x 10 days
   - Age >35 years or unlikely sexual transmission: Ciprofloxacin or ofloxacin PO BID or levofloxacin (Levaquin) PO daily x 10-14 days (minimum); some experts recommend 4-6 weeks of therapy

• Antipyretics, stool softener w/out laxative (Colace), sitz baths, hydration
• Pt should be hospitalized if septic or toxic
• Learn to distinguish b/t chronic prostatitis and acute prostatitis
• chronic is of gradual onset; prostate can feel normal w/ DRE (older males)
• Acute prostatitis presents as sudden onset; prostate is swollen and very tender (younger males)
• SSRIs cause erectile dysfunction in men
• SSRI that has the highest risk of ED is paroxetine (Paxil)**

Question 23

Acute Bacterial Epididymitis
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment/Medications

Answer 23

1. bacteria ascend urethra (urethritis) and reach epididymis, causing infection
   - AKA bacterial epididymo-orhitis
   - R/O testicular torsion (can mimic condition)
   - sexually active males <35 yo → more likely to be infected w/ STD (chlamydia, gonorrhea)
   - Males >35 yo → usually d/t gram- E. coli
2. • adult to older man c/o acute onset of swollen red scrotum, hurts
     - unilateral testicular tenderness w/ urethral discharge
     - scrotum is swollen and erythematous
     - induration of posterior epididymis
     - sometimes accompanied by hydrocele
     +/- s/sx of URI
     - may have systemic sx such as fevers
     - Discharge: green-colored purulent or serous clear (e.g., chlamydia, viral, chemical)
     - Positive Prehn’s sign: relief of pain w/ scrotal elevation
3. • CBC: Leukocytosis
     - UA: Leukocytes (pyuria), blood (hematuria), nitrates
     - Urine C&S
     - Urine nucleic acid amplification test (NAAT) for gonorrhea and chlamydia
4. • Age <35 yo (or suspect STD) → Doxycycline PO BID x 10 days + ceftriaxone 250 mg IM x 1; do NOT forget to treat sex partner
     - Age >35 yo → Ofloxacin (Floxin) 300 mg PO x 10 days or levofloxacin (Levaquin) 500 mg PO x 10 days; caution pt regarding risk of tendon injury and discourage vigorous LE exercise while on fluoroquinolone
     - Treat pain w/ NSAIDs (ibuprofen, naproxen) or acetaminophen w/ codeine (severe pain)
     - employ scrotal elevation
     - scrotal ice packs
     - bed rest for few days
     - give stool softeners (e.g., docusate sodium or Colace) if constipation
     - Refer to ED if septic, severe intractable pain, abscessed, and so forth

Question 24

Positive Prehn’s sign

Answer 24

relief of pain w/ scrotal elevation

Question 25

Erectile Dysfunction
1. Definition/Etiology
- Organic
- Drug-induced
- Psychogenic

Answer 25

1. • inability to produce an erection firm enough to perform sexual intercourse
     - several kinds of male sexual dysfunction
     - incidence ↑ w/ age
     - men 50-59 (18%), 60-69 (25%), 70-79% (37%), 80-89 (80%)
     - men ≥50 → more likely r/o organic causes
     - check med hx, CONTRAINDICATED is nitrates

• Organic Causes → Inability to have a satisfactory erection
• can be caused by aging, neurologic (diabetic neuropathy, MS, spinal cord damage)
• vascular or hormonal (hypogonadism), or other disorders
• Drug-induced
• SSRIs (esp paroxetine [Paxil], antipsychotics, recreational drugs, alcohol [large amount], beta-blockers, thiazide diuretics); if smoker, advise smoking cessation
• Psychogenic causes → Spontanously has early-morning erection or normal nocturnal tumescence or can achieve a firm erection w/ masturbation
• can be caused by performance anxiety, depression, relationship issues, stress
• Reduced libido → affects 4-15% of men, ↑ w/ age

*Check cremasteric reflex; if missing, RULE OUT neurologic causes

Question 26

Erectile Dysfunction
2. Labs
3. Treatment/Medications + adverse effects
4. Contraindications

Answer 26

2. • R/O diabetes (FBG, A1C), thyroid disorder (TSH), morning serum testosterone
3. • FIRST LINE: treat w/ phosphodiesterase type 5 inhibitor drug class
     * Sildenafil citrate (Viagra):
     - 24/50/100 mg; take 1 dose 30-60 mins before sexy
     - duration of 4 hours
     - use only one dose Q24 hrs
     ► Another use is for pulmonary HTN (brand name Revatio)
     ► Do NOT combine Viagra w/ Revatio or guanylate cyclase-C meds such as riociguat (Adempas) → will cause severe hypotension
     ► Careful w/ alpha-blockers, hx of MI in past 6 months, or unstable angina; risk of hypotension
     ► Do NOT use w/ drugs that prolong QT interval (macrolides)
     ► Advise pt to take med on empty stomach and avoid fatty foods for optimal effectiveness; food and fats delay drug action
     !! WARNING !! - can ↓ blood flow to optic nerve, causing sudden vision loss; has occurred in pts w/ diabetes, heart disease, HTN, or other preexisting eye problems

• Vardenafil (Levitra) → 1 dose of 30-60 mins before sex, duration is 4 hrs
• Tadalafil (Cialis) → 5-20 mg; can be taken several hours before sex d/t long duration (8up to 36 hrs); may also be prescribed as a daily dose for combined BPH and ED (5-10 mg)

Adverse effects
- headache
- facial flushing
- dizziness
- hypotension
- nasal congestion
- priapism
- changes in vision

Other treatments
- vacuum-assisted erection devices
- penile self-injection (intracavernosal injection of alprostadil)
- penile implant
- CBT (for psychogenic causes)

4. • Concomitant nitrates (↑ hypertensive effects)
     - use caution w/ alpha-blockers, recent post-MI, post-CVA, major surgery, or any condition which exertion is contraindicated
     - avoid combining w/ grapefruit juice or alcoholic drinks

Question 27

Peyronie’s Disease
1. Definition/Etiology
2. Clinical Presentation/Labs
3. Treatment

Answer 27

1. • an inflammatory and localized ds of penis resulting in fibrotic plaques on the tunica albuginea → penile pain that primarily occurs during erection
     - may resolve spontaneously in small cases, but nearly half cases worsen over time
     - psychological issues because it affect man’s ability to have erection, which can be distressing
2. • palpable nodules
     - penile deformity (crooked penile erections)

Labs: none; clinical diagnosis

3. Refer to urologist
   - Surgical correction if needed

Question 28

Balanitis
1. Definition/Etiology
2. Clinical Presentation
3. Treatment

Answer 28

1. • Candidal infection of glans penis
     - when foreskin (prepuce) is involved → called balanoposthitis
     - more common in uncircumcised men, diabetes, and/or immunocompromised men
     - use of SGLT2 inhibitors for diabetes management, such as canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance), ↑ risk of balanitis, UTIs, and vaginal yeast infection
2. • redness, pain, tenderness, or pruritis of glands and/or foreskin that developed over 3-7 days
     - PE of penis will show redness and shallow ulcers w/ curd-like discharge on glans penis
3. • OTC azole creams (clotrimazole 1% or miconazole 2%) BID daily for 7-14 days
     - if partner has candidiasis, treat at the same time

Question 29

Cryptorchidism

Answer 29

Testicle that doe snot descent spontaneously by 4 months of age
- up to 30% of premature infants are bone w/ undescended testes
- can affect or only one testicle
- 70% will descend spontaneously by 12 months of age
- markedly increases risk of testicular CA
- usually corrected during infancy
- look for empty scrotal sac

Question 30

Phimosis
1. Physiologic
2. Pathologic

Answer 30

1. seen in almost all newborn males
   - considered normal
   - foreskin should NOT be red or swollen
   - avoid forcible retraction → causes tearing, which will cause scarring and development of pathologic phimosis
2. when foreskin is truly nonretractable; foreskin cannot be pushed back from the glans penis d/t inflammation
   - in adults, d/t chronic inflammation and edema of foreskin
   - can complicate sexual function, voiding, and hygiene
   → Refer to urologist

Question 31

Paraphimosis`

Answer 31

• when foreskin cannot be returned back to its original position d/t swelling of head (glans) of the penis
• glans is swollen, reddened, and painfuil
• highest incidence among uncircumcised infants and toddles
• if glans become red, swollen, and painful, it may not return back to its original state
  ** Requires emergency treatment because may cause ischemic changes
• a small slit in foreskin (with topical anesthesia) can help relieve pressure
• in severe cases, a circumcision may be needed
  *** Considered a UROLOGIC EMERGENCY! → Refer to ED!

Question 32

Varicocele

Answer 32

• varicose veins in scrotal sac (feels like “bag of worms”
• new-onset varicocele can signal testicular tumor (20%) or a mass that is impeding venous drainage

NEEDS US of scrotum!
- can contribute to male infertility of large enough (↑ temp of affected testicle)

Tx: Surgical removal of varicosities if infertile
- Most benign varicoceles are left-sided

Unilateral R-sided varicoceles may be indicative of a tumor inside the chest, abdomen, or pelvis that is compressing a large vein, such as vena cava
- another abnormal finding is a varicocele that does not reduce or drain in the supine position
- benign varicoceles ↓ in volume when the pt is supine d/t blood draining (gravity) from the abnormally dilated scrotal veins

Question 33

Hydrocele

Answer 33

• serous fluid collects inside tunica vaginalis
• during scrotal exam, hydroceles are located superior and anterior to testes
• most hydroceles are asymptomatic
• more common in newborns; most cases resolve spontaneously
• rill glow w/ transillumination
• glow is larger on affected scrotum compared w/ unaffected scrotum
• if complaints of testicular pain and scrotal swelling or new-onset hydrocele in an adult or enlarging hydrocele → order scrotal Doppler US to R/O tumor, testicular hematoma, rupture, testicular torsion, orchitis, or epididymitis
• Refer to urologist!

Question 34

Spermatocele

Answer 34

• a spermatocele (or epididymal cyst) is a fluid-filled cyst containing nonviable sperm
• will transilluminate d/t filled w/ fluid
• can be palpated as a separate smooth and firm lump at the head of the epididymis, which lies above and behind each testicle
• does NOT affect fertility
• treated only if they cause pain, discomfort, or embarrassment (Surgical excision)
• US is imaging test of choice