2. Embryology
Descent of testes at 32-40 wks gestation
Descends within processes vaginalis
Outpouching of peritoneal cavity
Tunica vaginalis is potential space that remains after
closure of process vaginalis
3. Anatomy
Spermatic cord –testicular vessels, lymph, vas deferens
Epididymis - sperm formed in testicle and undergo maturation, stored in
lower portion
Vas Deferens – muscular action propels sperm up and out during
ejaculation
Gubernaculum –
fixation point for testicle to tunica vaginalis
Tunica Vaginalis – potential space
Encompasses anterior 2/3’s of testicle
Tunica albuginea is inner layer opposing testis
5. Male External genitalia
Scrotum
Penis
Male internal genitalia
o Testes
o Epididymis
o Ductus deferens (Vas
deference)
o Ejaculatory duct
o Urethra.
o Spermatic cord
o Accessory organs are:-
seminal, prostate & bulbo-
urethral glands
Anatomy
6. Causes of Pain and Swelling
Pain
Testicular torsion
Torsion of appendix testis
Epididymitis
Trauma
Orchitis and Others
Swelling
Hydrocele
Varicocele
Spermatocele
Tumor
7.
8. Torsion
Inadequate fixation of testes to tunica vaginalis at
gubernaculum
Torsion around spermatic cord
Venous compression to edema to ischemia
9. Epidemiology
Accounts for 30% of all acute scrotal swelling
Bimodal ages – neonatal (in utero) and pubertal ages
65% occur in ages 12-18yo
Incidence 1 in 4000 in males <25yo
Increased incidence in puberty due to inc weight of testes
10. Predisposing Anatomy
Bell-clapper deformity
Testicle lacks normal
attachment at vaginalis
Increased mobility
Tranverse lie of testes
Typically bilateral
Prevalence 1/125
11. Torsion: Clinical Presentation
Abrupt onset of pain – usually testicular, can be lower
abdominal, inguinal
Often < 12 hrs duration
May follow exercise or minor trauma
May awaken from sleep
Cremasteric contraction with nocturnal stimulation in REM
Up to 8% report testicular pain in past
12. Torsion: Examination
Edematous, tender, swollen
Elevated from shortened spermatic cord
Horizontal lie common (PPV 80%)
Reactive hydrocele may be present
Cremasteric reflex absent in nearly all (unreliable in <30mo
old) (PPV 95%)
Prehn’s sign elevation relieves pain in epididymitis and not
torsion is unreliable
13. Diagnosis – “Time is Testicle”
Ideally -- prompt clinical diagnosis
Imaging
Don’t waste time!
Color doppler – decreased intratesticular flow
False + in large hydrocele, hematoma
Sens 69-100% and Spec 77-100%
Lower sensitivity in low flow pre-pubertal testes
Nuclear Technetium-99 radioisotope scan
Show testicular perfusion
30 min procedure time
Sens and spec 97-100%
14. Management
Detorsion within 6hr = 100% viability
Within 12-24 hrs = 20% viability
After 24 hrs = 0% viability
Surgical detorsion and orchiopexy if viable
Contralateral exploration and fixation if bell-clapper deformity
Orchiectomy if non-viable testicle
Never delay surgery on assumption of nonviability as
prolonged symptoms can represent periods of intermittent
torsion
15. Torsion: Special Considerations
Adolescents may be embarrassed and not seek care until
late in course
Torsion 10x more likely in undescended testicle
Suspicious if empty scrotum, inguinal pain/swelling
16. Torsion of Appendix Testis
Appendix testis
Small vestigial structure,
remnant of Mullerium duct
Pedunculated, 0.3cm long
Other appendix structures
Prepubertal estrogen may
enlarge appendix and cause
torsion
17. Torsion of Appendix Testis
Peak age 3-13 yo (prepubertal)
Sudden onset, pain less severe
Classically, pain more often in abd or groin
Non-tender testicle
Tender mass at superior or inferior pole
May be gangrenous, “blue-dot” (21% of cases)
Normal cremasteric reflex, may have hydrocele
Inc or normal flow by doppler U/S
19. Torsion of Appendix Testis
Management supportive
analgesics, scrotal support to relieve swelling
Surgery for persistent pain
no need for contralateral exploration
20. Liam a Kabarak University student, is finishing his last football game as team
gets ready for the 2nd half. Liam gets up from a sit, he feels a twinge of pain in
the right side of his scrotum. On his way back to the locker room, he can’t stand
up straight. In the shower, he examines his scrotum but doesn’t see any bruising
or swelling. However, his right testis is higher than his left, and it’s so tender he
can barely get dressed. He is walking hunched over and feels nauseated. The
coach notices Liam protective, slow gait and sees him stop to vomit in the trash
bin. “What’s going on, Liam? You played a great game tonight.” “Oh, sorry,
Coach. I am just a little sick to my stomach,” replies Liam. “And this is
embarrassing, but my right testicle is killing me. I don’t remember getting hit
there, but it is so painful I can’t touch it.” His coach says, “Liam, you are going
straight to the hospital for possible emergency surgery . Call your parents.” Why
does his coach send Liam to the hospital for a possible emergency surgery?
Clinical correlate:
A Serious Game of Twister
21. Epididymitis
Inflammation of epididymis
Subacute onset pain, swelling localized to epididymis,
duration of days
With time swelling and pain less localized
Testis has normal vertical lie
Systemic signs of infection
inc WBC and CRP, fever + in 95%
Cremasteric reflex preserved
Urinary complaints: discharge/dysuria PPV 80%
23. Epididymitis
Sexually active males
Chlamydia > N. gonorrhea > E. coli
Less commonly pseudomonas (elderly) and tuberculosis
(renal TB)
Young boys, adolescents often post-infectious (adenovirus)
or anatomic
Reflux of sterile urine through vas into epididymis
50-75% of prepubertal boys have anatomic cause by imaging
24. Epididymitis Diagnosis
Leukocytosis on UA in ~40% of patients
PCR Chlamydia + in 50%, GC + in 20% of sexually active
95% febrile at presentation
Doppler scan show increased flow
If hx consistent with STD, CDC recommends:
Cx of urethral discharge, PCR for C and G
Urine culture and UA
Syphilis and HIV testing
26. Epididymitis Treatment
Sexually active treat with Ceftriaxone/Doxycycline or
Ofloxacin
Pre-pubertal boys
Treat for co-existing UTI if present
Symptomatic tx with NASIDs, rest
Referral all to GU for studies to rule out VUR, post urethral
valves, duplications
Negative culture has 100% NPV for anomaly
27. Orchitis
Inflammation/infection of testicle
Swelling pain tenderness, erythema and shininess to overlying
skin
Spread from epididymitis,
hematogenous, post-viral
Viral: Mumps, coxsackie,
echovirus, parvovirus
Bacterial: Brucellosis
28. Mumps Orchitis
Extremely rare if vaccinated
20-30% of pts with mumps, 70% unilateral, rare before
puberty
Presents 4-6 days after mumps parotitis
Impaired fertility in 15%, inc risk if bilateral
29. Trauma
Result of testicular compression against the pubis bone,
from direct blow, or straddle injuries
Extent depends on location of rupture
Tunica albuginea ruptures (inner layer of tuncia vaginalis) allows
intratesticular hematoma to rupture into hematocele
Rupture of tunica vaginalis allow blood to collect under scrotal
wall causing scrotal hematoma
Doppler often sufficient to assess extent
Surgery for uncertain dx, tunica albuginea rupture,
compromised doppler flow
36. Hydrocele
Mass increases in size during day or with crying and
decreases at night if communicating
If non-communicating and <1 yo follow
If communicating (enlarging), scrotum tense (may impair
blood flow) requires repair
Unlikely to close spontaneously and predisposes to hernia
37. Varicocele
Collection dilated veins in
pampiniform plexus
surrounding spermatic cord
More common on left side
R vein direct to IVC
L vein acute angle to renal vein
~20% of all adolescent males
38. Varicocele
Often asymptomatic or c/o dull ache/fullness upon standing
Spermatic cord has ‘bag of worms’ appearance that
increased with standing/valsalva
If prepubertal, rapidly enlarging, or persists in supine
position rule out IVC obstruction
Most management conservatively
Surgery if affected testis < unaffected testis volume
39. Spermatocele
Painless sperm containing
cyst of testis, epipdidymis
Distinct mass from testis
on exam
Transilluminates
Do not affect fertility
Surgery for pain relief only
40. Acute Idiopathic Scrotal Edema
Scrotal skin red and tender
underlying testis normal
no hydrocele
Erythema extends off
scrotum onto perineum
Empiric tx, cause unknown
Antihistamine, steroids
Resolves w/in 48-72hrs
41. Testicular Cancer
Most common solid tumor in 15-30 yo males
20% of all cancers in this group
Painless mass
Rapidly growing germ cell tumors may cause hemorrhage
and infarction
Present as firm mass
Typically do not transilluminate
Diagnostic imaging with U/S initially
50. Testicular Cancer
Presentation
Typically painless intratesticular mass discovered on self
examination
Age 15-35
Albeit some tumor subytpes cluster in infancy and some at later
age (60’s)
51. Testicular Cancer
Investigations
Labs
B-HCG
Produced by choriocarcinoma & in some Seminomas
Alpha-fetoprotein
Produced by Yolk Sac, Embryonal Carcinoma & Teratocarcinoma
LDH
Correlates with tumor volume
Imaging
Scrotal U/S
CT Abdo and Pelvis: assess for retroperitoneal mets
CXR
+/- CT Head
