Testicular Conditions

Epididymo-orchitis

This is inflammation of the epididymis (and the testes)

Causes

Bacteria, e.g., chlamydia, gonorrhea, E. coli

Viruses, e.g., mumps (in teenage males)

Drugs e.g., amiodarone

Symptoms

Acute onset tender swelling (confined to epididymis)

Dysuria, sweats, fever

Management

Treat the underlying cause, e.g., antibiotics if due to an STI

Testicular torsion

This refers to twisting of the spermatic cord, usually in adolescents

It can cut off the blood supply to the testes resulting in ischaemia

Symptoms

Acute onset testicular pain

Absence of the cremasteric reflex

Abdominal pain, nausea and vomiting

Prehn’s sign seen (where raising the testicle does not reduce pain)

Key tests

Can be diagnosed clinically if the history and exmination is comvincing

Ultrasound can be used if diagnosis unclear

Management

This is a surgical emergency – aim to treat within 6 hours

Orchidectomy (removal of testes) is required if the testicle is non-viable

Hydrocele

This is a fluid collection within the tunica vaginalis covering the testis and scrotum.

It occurs in infants due to incomplete closure of the processus vaginalis.

It can also occur in adults as the presenting feature of testicular cancer.

Symptoms

Non-painful, soft scrotal swelling limited to the scrotum (can get “above it”)

It can be transilluminated, unlike solid tumour

Hydrocele will appear a soft red whereas a tumour is opaque to the light

Key tests

In adults, can use ultrasound to exclude tumour

Management

Usually requires surgical fixation to close the processus vaginalis

Varicocele

This refer to dilation of a spermatic vein due to blocked venous drainage.

It usually occurs on the left, as the gonadal vein drains into the renal vein before the IVC, in comparison to the right side.

It is sometimes seen if a patient has a left-sided renal cell carcinoma.

Symptoms

Scrotal swelling which gives a dull ache, but can be asymptomatic

Key tests

Doppler ultrasound

Management

Does not require treatment unless it is symptomatic

Embolisation if painful (this diverts blood away from an enlarged vein in your scrotum using a coil to block the vein)

Cryptorchidism

This is a failure of one or both testicles to descend into the scrotum.

As a result, the higher temperature within the abdomen suppresses sperm production.

This leads to atrophy and significantly increases the risk of testicular cancer.

Symptoms

Absent testes in the scrotum (can be bilateral)

Predisposes to infertility later in life

Management

Orchidopexy, a procedure which moves the undescended testicle into the scrotum and permanently fix it there, usually performed before the age of 18 months

Testicular Cancer

This is most common cancer in young males which arises from germ cells or sex cords.

Most tumours are malignant germ cell tumours

Risk Factors

Undescended testis

Infertility

Having a relative with testicular cancer

Symptoms

Present as a solid non-tender mass which cannot be transilluminated

Can give rise to a secondary hydrocele causing pain

Can present with established metastases in the lungs or abdominal masses

Key tests

1st line is Ultrasound

Check tumour markers AFP, LDH, β-hCG – these are elevated in germ cell tumours

Tumours are usually not biopsied due to risk of disseminating the tumour cells 

CXR and PET-CT scan can be used for staging of the cancer

Management

Radical orchidectomy (complete removal of the testes) and chemo/radiotherapy

Germ Cell Tumour

This is the most common type of testicular cancer occurring in ages 15–40.

The germ cell tumours are usually divided into two main types:

Seminoma

This is a malignant tumour of big cells which look like spermatogonia.

They have a clear cytoplasm and central nuclei.

These are very responsive to radiotherapy and metastasise late.

Therefore, they are relatively easier to treat and have a good prognosis

Non-seminoma

This includes a variety of tumours, which metastasize early

Sex-Cord Tumour

This is a (usually benign) proliferation of sex-cord cells and is split into 2 types: 

Lymphoma

This is a proliferation of white blood cells, usually large B-cells

It is the most common testicular mass in men above the age of 60 years