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Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022
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Image from Wikimedia Commons | OpenStax College.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
The testicular anatomy is demonstrated above.
The testicles constitute a paired organ system that is responsible for endocrine and reproductive function in males.[1] On average, each testis is about 4-5 cm long, 3 cm wide, and 2.5 cm deep, with a volume of 15-25 mL. The two predominant cell types within the testicle are Leydig cells and Sertoli cells (the production grounds for testosterone and spermatogenesis, respectively). The testicles are contained within layers of fascia, which in turn are contained within the scrotal sac; this affords a degree of protection against the external trauma to which they are vulnerable. Additionally, the testicles are sensitive to temperature and can be affected by conditions such as varicoceles. This presentation briefly reviews causes of testicular pathology, as well as diagnosis and treatment of each pathologic condition.
Image courtesy of Josh Palka, DO.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 14-year-old male high school student presents to the emergency department (ED) with left-lower-quadrant abdominal pain of acute onset, which wakes him up from sleep. He vomited twice en route to the hospital. On examination, the abdomen is soft and nontender. Genital examination reveals a swollen right hemiscrotum with horizontal lie and an absent cremasteric reflex; elevation of the scrotum does not relieve the patient's pain. Scrotal ultrasonography (US) is immediately performed, with the results shown above.
In view of the patient's age and the classic presentation, which of the following conditions is he most likely to have?
Testicular torsion
Scrotal hematoma
Scrotal hernia
Testicular cancer
Image courtesy of Josh Palka, DO.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: A. Testicular torsion.
Testicular torsion is a urologic emergency that necessitates prompt intervention and carries a risk of testicular loss if prompt evaluation is not sought. (The image shows a testicle that was outside the 6-hour ischemia window and required orchiectomy.) Some reports have stated that as many as 42% of testicular torsions end in orchiectomy; thus, prompt evaluation and management are vital.[2]
The classic presentation consists of the acute onset of severe scrotal pain with swelling. Nausea and vomiting are also common.
Whenever a surgical patient is found to have a testicular torsion intraoperatively, a bilateral orchidopexy should be performed if the testicle is viable. If the testicle is nonviable, an ipsilateral orchiectomy should be performed in conjunction with a contralateral orchidopexy. If an operating room (OR) is not immediately accessible, manual detorsion can be performed in the ED by externally rotating the testicle (the "opening book" technique); however, surgical exploration must still be carried out as soon as possible.
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
The above image illustrates a "bell-clapper" deformity. This deformity is found in approximately 12% of males and is thought to be a harbinger of testicular torsion. In a bell-clapper deformity, the tunica vaginalis abnormally attaches proximally to the spermatic cord, causing increased mobility of the testicle and thus an anatomic predisposition to intravaginal torsion. Inciting events for testicular torsion have not been fully elucidated but are known to include cold temperature, changes in temperature that activate the cremasteric reflex, and the onset of puberty.
A high degree of suspicion should be maintained with regard to patients who report intermittent testicular pain that resolves; they may be suffering from intermittent torsion.[3] Studies have shown that 30-50% of patients with previous attacks of self-limited scrotal pain will suffer from acute testicular torsion. These patients should be carefully selected for elective bilateral orchidopexy.
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Prepubertal patients who present with acute-onset scrotal pain may also be suffering from torsion of the appendix testis or appendix epididymis. Torsion of an appendage (shown) is the most common cause of the acute scrotum in prepubertal children.[4] On examination, the famed "blue dot" sign is visible in the upper pole of the testis through stretched scrotal skin.[5] On scrotal US, an abnormal appendage is rarely seen; however, hypervascularity to the epididymis, sometimes confused for epididymitis, is often apparent. As a rule, torsion of an appendage is self-limited and is treated with conservative anti-inflammatory therapy, but if testicular torsion cannot be excluded, surgical exploration is required. Most appendages will degenerate or calcify in 2 weeks without complications.
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 22-year-old man presents to the ED after being struck in the scrotum with a ball during a baseball game. He complains of severe pain in the scrotum and vomits once while being examined. Scrotal US is performed, with the results shown above.
Which of the following findings is visible in the right testicle (the left is included for comparison)?
Testicular torsion
Testicular degloving
Testicular fracture
Testicular dislocation
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: C. Testicular fracture.
The above scrotal ultrasonogram shows a fractured testis with a disrupted tunica albuginea and testicular contents surrounded by tunica vaginalis (arrow).
Because of the anatomic location of the testes and their mobility within the scrotum, testicular trauma is uncommon.[6] Testicular injuries can be divided into the following three broad categories on the basis of the mechanism of injury: (1) blunt trauma (as many as 75% of cases), (2) penetrating trauma, and (3) degloving trauma (rare).
Testicular fracture (or rupture) refers to a rip or tear in the tunica albuginea that results in extrusion of the testicular contents. In equivocal cases, scrotal US can be performed. Prompt surgical exploration and repair of the tunica albuginea are vital. When exploration and repair are carried out within 3 days of the injury, testicular salvage rates exceed 90%.
Image courtesy of Josh Palka, DO.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 55-year-old man presents to the clinic with complaints of scrotal swelling over the past several months, which continues to worsen. He denies experiencing pain or skin irritation. The swelling transilluminates with light. On careful examination, the spermatic cord is palpable and feels normal. Scrotal US is ordered, with the results shown above.
Which of the following is visible on the scrotal ultrasonogram?
Inguinal indirect hernia
Spermatocele
Hematocele
Hydrocele
Image courtesy of Radiopaedia.org | Case contributed by Dr M Osama Yonso.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: D. Hydrocele.
The image demonstrates normal-appearing testes with surrounding fluid from a hydrocele.
A hydrocele is a fluid collection that develops within the tunica vaginalis of the scrotum or along the spermatic cord. In adults, hydroceles are most commonly caused by excessive fluid production by the visceral tunica albuginea without adequate reabsorption of this fluid by the parietal peritoneum around the testis.[4] In children and adolescents, and sometimes in adults, hydroceles may represent persistent developmental connections (of the processus vaginalis) along the spermatic cord. US is the modality of choice for distinguishing hydrocele from hernia, spermatocele, or tumor.
Hydroceles pose little risk of significant clinical consequences, especially those developing in infancy, which can resolve spontaneously. For adults, surgical correction is indicated to address discomfort or cosmetic issues. For children and adolescents, surgery is indicated if the hydrocele persists beyond age 1 year or enlarges during this observation period. For some adult patients, aspiration, with or without sclerotherapy, is a less invasive technique that may be considered; however, this approach has a higher recurrence rate than open hydrocelectomy does.
Image courtesy of Josh Palka, DO.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 25-year-old man presents with a 2-month history of a dragging sensation on the left side of his scrotum. The patient describes the pain as aching in quality. He denies having sustained any trauma. He states that he is sexually active but has not experienced any penile discharge or dysuria. Examination reveals a large swelling that feels like a bag of worms. When the patient is asked to perform a Valsalva maneuver, the scrotal swelling and pain increase. Scrotal US is performed, with the results shown above.
Which of the following diagnoses is confirmed by the ultrasonogram?
Varicocele
Spermatocele
Hematocele
Seminoma
Image courtesy of Josh Palka, DO.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: A. Varicocele.
A varicocele is an abnormal enlargement of the veins of the pampiniform plexus. Patients may report scrotal pain or a feeling of heaviness. Physical examination remains the primary method of varicocele detection, and the characteristic finding is the palpation of what is referred to as a "bag of worms." If, however, the physical findings are equivocal, Doppler US can be performed, typically revealing large anechoic, tubular structures adjacent to the testicle (see slide 10). Varicoceles are the most common correctable cause of subfertility in males.[7]
Varicoceles are more common on the left side than on the right, presumably because of the 90° insertion of the testicular vein into the left renal vein. Treatment of varicocele is reserved for patients seeking evaluation for infertility or poor testicular development or for symptomatic patients undergoing either surgery or embolization.
Image courtesy of Radiopaedia.org | Case contributed by Dr Kewal Arunkumar Mistry.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 17-year-old male patient presents to the ED with a 2-day history of pain and swelling to the left testis. The patient states that it burns when he urinates and that he thinks he has a fever. On examination, his left hemiscrotum is red, swollen, and tender. A urine specimen is obtained, and US with color-flow Doppler is performed, with the results shown above.
Which of the following does the ultrasonogram show?
Testicular fracture
Testicular torsion
Seminoma
Epididymo-orchitis
Image courtesy of Radiopaedia.org | Case contributed by Dr Kewal Arunkumar Mistry.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: D. Epididymo-orchitis.
Acute epididymitis is a clinical syndrome consisting of scrotal pain, swelling, and inflammation of the epididymis that last less than 6 weeks.[8] In most cases, the testis is also involved, with the condition then being referred to as epididymo-orchitis. Among sexually active men younger than 35 years, epididymitis is most frequently caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In older men, bacteriuria secondary to obstructive urinary disease (eg, benign prostatic enlargement) is more common. In prepubertal boys with acute orchitis, mumps infection should be considered. US findings considered diagnostic of acute epididymitis are (1) an enlarged testicle with variable echotexture (shown) and (2) increased blood flow (see slide 12). Most cases of epididymitis can be managed with antibiotics on an outpatient basis.
Image courtesy of Josh Palka, DO.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 39-year-old man presents to the ED with a history of a gradual increase in the size of his right testicle over a period of 3 months. He reports no pain or trauma, and he has no dysuria or urinary frequency. Physical examination reveals an enlarged, painless, firm right testis. Scrotal US is ordered and reveals a hypoechoic mass that raises concerns about possible malignancy.
Which of the following is the most common testicular tumor?
Nonseminoma
Seminoma
Choriocarcinoma
Yolk sac tumor
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: B. Seminoma.
The above computed tomography (CT) scan, obtained in a patient with metastatic seminoma, demonstrates a large retroperitoneal lesion (arrow) that is displacing the kidney and encompassing the aorta.
Testicular tumors are the most common solid malignant tumors in males aged 20-40 years.[9,10] Characterizing and staging testicular cancer requires pathologic analysis of the primary tumor after radical orchiectomy. Laboratory tests should include alpha fetoprotein, beta human chorionic gonadotropin, and lactate dehydrogenase, as well as liver enzymes and renal function. Additionally, if the patient does not have lymphoma, radiographic imaging (radiography or CT of the chest and CT of the abdomen and pelvis) is warranted to assess for metastatic disease.
Image courtesy of Ed Uthman, MD.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Before the discovery of cisplatin chemotherapy, metastatic testicular cancer was a fatal diagnosis. Today, however, testicular cancer is the model for successful management of malignant solid tumors. Depending on the patient's staging and pathologic diagnosis, a multidisciplinary approach combining surgery, chemotherapy, and radiotherapy (in the setting of seminomas) is employed.[11] If the patient is interested in fathering children, then the possibility of sperm donation should be discussed. Though dependent on staging, 5-year survival rates as high as 98% have been achieved.
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 10-month-old male presents to your office with the findings shown above. Unable to palpate the right testicle, you refer the patient to urology, where, again, the testicle cannot be palpated.
Which of the following is NOT a correct next step?
Examination under anesthesia
Diagnostic laparoscopy
CT of the abdomen
Orchidopexy
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: C. CT of the abdomen.
The above image demonstrates a first-stage testicular artery endoligation, performed during a planned two-stage Fowler-Stephens laparoscopic orchidopexy.
Cryptorchidism, in which the gonads fail to descend into the scrotal position, is among the most frequently encountered genitourinary problems in pediatric urology.[12] If the primary care provider is unable to palpate a testicle within the scrotum, the patient is commonly referred to a specialist. Palpation is possible for about 70% of undescended testicles; the rest require diagnostic laparoscopy. (Imaging is not recommended for undescended testicles.)[12] Patients who present with bilateral nonpalpable testicles should undergo further assessment for differences (disorders) of sex development.[12]
If testicular descent has not occurred by 6 months of age, cryptorchidism is treated with orchidopexy.[12] Fertility will be near normal in children with one undescended testis, but infertility will occur even after orchidopexy in nearly two thirds of those with bilateral cryptorchidism.[13]
Image courtesy of Josh Palka, DO.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
A 65-year-old man with a history of diabetes presents to the ED with complaints of dysuria and an acutely swollen left scrotum. Scrotal US (above) is performed. The patient is febrile, tachycardic, and toxic appearing. Lab work reveals leukocytosis and an elevated lactic acid level.
Which of the following is a risk factor for the patient's disease state?
Sarcoidosis
Diabetes
Eczema
Asthma
Image courtesy of Medscape.
Testicular Disorders: Trouble Doesn’t Always Come in Pairs
Dave Holson, MD; Josh Palka, DO | July 18, 2022 | Contributor Information
Answer: B. Diabetes.
Scrotal abscesses can result from bacterial entry to the scrotum via microtrauma to the scrotal skin or surgical intervention. Intrascrotal abscess development can also occur if a perforated testicular abscess forms a pyocele (as shown above). The patient in question underwent surgical drainage, with return of foul-smelling purulent material. The risk factors most commonly associated with scrotal infections include diabetes, chronic alcohol use, and other diseases that leave patients in an immunocompromised state. Fournier gangrene, the most severe type of genital infection, must be addressed with prompt surgical intervention and broad-spectrum antibiotics.[14]
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Contributor Information
Authors
Dave Holson, MD
Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine
Director, Department of Emergency Medicine, Queens Hospital Center
New York, NY
Disclosure: Dave Holson, MD, has disclosed no relevant financial relationships.
Josh Palka, DO
Detroit Medical Center
Detroit, MI
Disclosure: Josh Palka, DO, has disclosed no relevant financial relationships.
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References
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Palmer LS, Palmer JS. Management of abnormalities of the external genitalia in boys. Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, Wein AJ, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2020: Chap 146.
Dresner ML. Torsed appendage. Diagnosis and management: blue dot sign. Urology. 1973;1(1):63-6. PMID: 4792289
Morey AF, Zhao LC. Genital and lower urinary tract trauma. Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, Wein AJ, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2020: Chap 101.
Cayan S, Shavakhabov S, Kadioglu A. Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 2009;30(1):33-40. PMID: 18772487
Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009;79(7):583-7. PMID: 19378875
Stephenson AJ, Gilligan TD. Neoplasms of the testis. Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, Wein AJ, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2020: Chap 34.
Dearnaley DP, Huddart R, Horwich A. et al. Managing testicular cancer. BMJ. 2001;322(7302):1583-8. PMID: 11431302
Testicular cancer. Version 2.2022. National Comprehensive Cancer Network. January 4, 2022; Accessed: July 8, 2022. Available at: https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf.
Kolon TF, Herndon CD, Baker LA, et al. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol. 2014 Aug;192(2):337-45. PMID: 24857650
Barthold JS, Hagerty JA. Etiology, diagnosis, and management of undescended testis. Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, Wein AJ, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2020: Chap 148.
Schaeffer AJ, Matulewicz RS, Klumpp DJ. Infections of the urinary tract. Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, Wein AJ, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2020: Chap 12.
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