Disorders of the Male Genitalia

The Origin of a Scrotal Lump

The first objective is to determine whether the swelling arises in the groin, the spermatic cord or the scrotum, and is achieved by palpating the cord at the scrotal neck. In a hernia, the cord is broader than normal and the hernia can be shown to communicate with the abdominal cavity by a cough impulse or by reducing the hernia. Spermatic cord swellings (varicocoele or cyst) are usually easily recognised (examine with the patient standing). In purely scrotal lumps, the spermatic cord is normal in diameter.

Testicular and Epididymal Lumps

With a scrotal abnormality, an attempt should be made to palpate testis and epididymis separately, and to determine their relationship to the lump. If the testis is enlarged or has a lump within it, this is a tumour until proven otherwise. Patients with testicular swellings caused by lymphoma may have systematic symptoms and 10% have bilateral tumours. Any testicular pathology may cause a little fluid to accumulate in the tunica vaginalis, producing a small secondary hydrocoele , but this rarely interferes with testicular palpation.

Lumps in the epididymis (cysts, chronic epididymitis or, rarely, tuberculous granulomata) are discrete from, but attached to, an otherwise normal testis. Tiny focal lumps in the epididymis are rarely clinically important. Infective lesions (i.e., abscesses) cause diffuse and usually painful thickening of the epididymis, whereas epididymal cysts are almost always located at the upper pole. Epididymal cysts are filled with clear fluid and therefore transilluminate. Transillumination (see Fig. 33.1 ) is demonstrated by shining a strong beam of light through the scrotum in a partly darkened room. If the lesion is fluid-filled, it will glow (except in the case of blood). About 10% of cysts in the epididymis, and most in the cord, are filled with an opalescent fluid containing spermatozoa ( spermatocoeles) , which can also transilluminate. Scrotal ultrasound can confirm the diagnosis.

Acute Pain ( Box 33.1 )

In acute scrotal pain, testicular torsion must be excluded, since the torted testis can be saved if an operation is performed promptly; an exploratory operation is mandatory if torsion cannot be confidently excluded. Torsion occurs mainly in adolescents but occasionally in young adults. Recurrent, incomplete (intermittent) torsion may cause transient episodes of severe testicular pain. In these cases, the anatomical relationship of the testis to the tunica vaginalis is often abnormal so the testes lie horizontally rather than vertically when standing. These ‘bell-clapper’ testes are susceptible to torsion. The main differential diagnosis at all ages is acute epididymitis. Torsion of an epididymal appendage (hydatid of Morgagni) produces symptoms similar to testicular torsion in children but less severe; surgical exploration is usually still required to exclude it. A traumatic haematocoele also causes acute pain but the trauma or surgery that preceded it points to the likely diagnosis.

Chronic Pain

Chronic scrotal pain is often caused by inflammation . It can be related to previous surgery (i.e., vasectomy, hydrocoele repair). Patients present weeks or months after the vasectomy operation, complaining of localised tenderness at the operation site or a general ache in one side of the scrotum. If there is a small tender lump caused by a stitch granuloma, this is usually cured by excision. Sperm leakage ( sperm granuloma ) following vasectomy may also cause chronic pain. Pain is a feature of chronic bacterial epididymitis, which usually follows an acute episode.

Case History

Epididymitis

Bacterial epididymitis is the most common inflammatory disorder of scrotal contents. It is usually secondary to urethral infection that ascends via the vas deferens. The source is usually a urinary tract infection with coliforms, such as Escherichia coli (in the 50–65 years age group), or a sexually transmitted infection with Chlamydia or Neisseria gonorrhoeae (common in the 15–30 years age group). Epididymitis is often incorrectly called orchitis or epididymoorchitis . The testis is rarely infected, although the inflammation may cause testicular tenderness.

In epididymitis, pain usually begins acutely. It may present as a surgical emergency and be clinically indistinguishable from testicular torsion. On examination, the affected side of the scrotum and its contents are swollen, oedematous and tender, and the scrotal skin can be red and warm. It may be difficult to palpate the testis and epididymis separately once infection is established. In boys and young men, epididymitis must never be diagnosed in the absence of urinary symptoms, a proven urinary infection or urethritis. Such an ‘acute scrotum’ must be explored to exclude torsion (see p. 451).

Treatment of acute epididymitis is initial bed rest and pain relief and 2 to 4 weeks of an appropriate broad-spectrum antibiotic. The infecting organism is often not identified but attempts should be made to do so using urine or blood cultures. Current guidance recommends a 14-day course of oral doxycycline and a single intramuscular injection of ceftriaxone for patients at risk of Chlamydia and N. gonorrhoeae . Oral levofloxacin, ciprofloxacin or ofloxacin are recommended for epididymitis caused by gram-negative organisms (i.e., E. coli ). Persistent or chronic epididymitis may cause the patient to suffer chronic scrotal tenderness. Chronic epididymitis may also result from inadequate antibiotic treatment of an acute episode.

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, nontender and ‘cold’, with a beaded cord (i.e., involvement of the vas in the spermatic cord). In contrast to bacterial epididymitis, a tuberculous 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 for mycobacteria or, more reliably, histological examination of percutaneous needle biopsies. Patients will have sterile pyruria (white cells in the urine in the absence of bacterial infection) and a raised erythrocyte sedimentation rate on blood testing. Where available, polymerase chain reaction urine testing can provide a rapid diagnosis of tuberculosis. If tuberculosis is confirmed, a search must be made for pulmonary and urinary tract disease (see Ch. 38 ).

Orchitis

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 nontender enlargement. This is now rare and there is usually a history of primary and secondary lesions.

Viral orchitis is most often caused by mumps . In postpubertal males, bilateral mumps orchitis produces infertility in 50%; elevated follicle-stimulating hormone (FSH) blood levels following orchitis may indicate subfertility. Mumps orchitis manifests 4 to 6 days after the onset of parotitis, with unilateral or bilateral enlarged, tender testes and an inflammatory hydrocoele. Treatment is directed at symptomatic relief. Other viruses affecting the testis include Coxsackie, human immunodeficiency virus (HIV) and Epstein–Barr. Lymphatic filariasis can be a cause of orchitis in endemic parts of Africa and Asia, and is associated with hydrocoele, scrotal oedema and genital elephantiasis.

Primary Hydrocoele

A hydrocoele is an excessive collection of fluid within the tunica vaginalis, that is, in the serous space surrounding the testis. Like the peritoneal cavity, the tunica normally contains a little serous fluid, which is produced and reabsorbed at an equivalent rate ( Fig. 33.2 ).

Case History

In infants and children, a hydrocoele is usually an expression of a patent processus vaginalis (PPV). In some, the scrotal swelling disappears overnight, and is known as a communicating hydrocoele . Provided there is no hernia, hydrocoeles in boys below the age of 1 year usually resolve spontaneously. For older children, ligation of the PPV is required; surgical repair is recommended if the hydrocoele fails to resolve by age 2 years.

Primary hydrocoeles may 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 and may feel heavy or uncomfortable when large. The swelling is soft and nontender 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 a testicular tumour or inflammation. In most, the hydrocoele is small and the testis can easily be palpated to reveal the primary abnormality.