Health

CLINICAL REVIEW: Scrotal and Testicular Problems

Written By: Sam Savage

Published Date: September 18, 2005 Last Edited: September 18, 2005

The essentials

* Most problems arising within the scrotum are benign.

* Carry out emergency surgical exploration in suspected torsion.

* A large tense hydrocoele may mimic an inguinal hernia.

* Any suspicious testicular lesion must be seen urgently by a specialist.

* Varicocoeles can cause poor sperm quality.

1. Causes of scrotal and testicular pain

Many men present with lumps, bumps or pain in the scrotal area. Hernias will also cause swelling in the scrotum. Most problems arising within the scrotum are entirely benign but some conditions, such as tumours or torsion of the testicle, need an accurate diagnosis to be made at initial presentation or require early or immediate referral. It is interesting that scrotal pain is becoming an increasingly common symptom in young men.

Chronic testicular or epididymal pain

In many cases, chronic scrotal discomfort presents in a similar way to prostatic-type pain, with epididymal tenderness in the absence of overt infection.

The condition is commonly found in men who have had previous surgery or who have suffered some sort of trauma to the scrotum. There are no investigations or simple tests that will give a specific diagnosis.

However, an ultrasound scan will help in reassuring the patient that there is no underlying abnormality, since this can allay any anxiety about the possibility of cancer. This is important, because concern about malignancy often plays a part in chronic testicular pain.

Any thickening or fluid collection detected in the epididymis should be further investigated to rule out chronic bacterial inf ection. Tuberculosis is a rare but real possibility that is serious but easily overlooked.

In addition, it is often necessary and appropriate to exclude the presence of an STI or a urinary tract infection. Once these possibilities have been excluded, it is often worthwhile offering treatment with long-term quinolone antibiotics – my recommendation is to use ciprofloxacin for at least three weeks.

However, chronic testicular or epididymal pain can be a difficult condition to treat, and this empirical approach is not always successful. While it is true that physical problems such as epididymal cysts or varicocoeles may cause scrotal pain, it is also the case that in many men the co-existence of a physical abnormality and pain are not linked.

Acute epididymitis

Acute epididymitis tends to present with severe, often bilateral, testicular pain and inflammation that develops over a number of hours or days. In young men the condition is often linked to an STI, particularly with the gonococcus. In older men, a urinary tract infection will more often be the cause.

The differential diagnosis of acute epididymitis is important. This is because in younger men it may be impossible to distinguish the sudden onset of this condition from a testicular torsion. In any case where testicular torsion is suspected, an immediate referral to hospital for a specialist review is needed.

Treatment

The treatment of acute epididymitis is generally doxycycline given for about six days. Alternatively a quinolone antibiotic such as ciprofloxacin can be used, but in this case at least two weeks’ treatment is necessary.

In older men who do not have any risk factors for STI, a broad- spectrum antibiotic may be the best initial course of action. This can be started while awaiting the results of an MSU. Also in the older patient, investigation of possible bladder outflow problems may be appropriate once the initial infection has settled down.

Acute epididymitis causes pain and inflammation

Key points

* Some problems arising within the scrotum such as suspected torsion or tumour require urgent specialist assessment.

* Chronic scrotal discomfort presents with epididymal tenderness in the absence of overt infection.

* There are no investigations or tests that will give a specific diagnosis.

* An ultrasound scan helps exclude any underlying abnormality.

* In younger men it may be impossible to distinguish the sudden onset of acute epididymitis from a testicular torsion.

2. Testicular torsion and Fournier’s gangrene

In some men the testis suffers from hypermobility, with an excess of tissue lying within the sac of the tunica vaginalis. This situation may favour torsion of the testicle.

The classic testicular torsion occurs in a teenage boy with a sudden onset of severe testicular pain associated with abdominal discomfort or nausea. However, this is not exclusively a problem of young men, as the condition may occur in neonates or in men in their forties.

High-resolution Doppler ultrasound may be able to differentiate torsion from acute infection, but it is often impossible to exclude torsion by clinical examination, even when aided by ultrasound. If there is doubt, then emergency surgical exploration should always be carried out.

Avoiding testicular atrophy

To avoid testicular atrophy, timing is critical. Nearly all testicles suffering a torsion that is untwisted and fixed within six hours of the onset of pain will survive. Most of those treated after a delay of 12 hours or more will suffer at least some testicular atrophy.

Both testicles should be fixed at the time of surgery, because the unaffected testicle is also at risk of torsion.

Intermittent torsion may occur, with the patient presenting with typical symptoms, but spontaneously improving before any intervention is carried out. In these cases a decision to operate and permanently fix both testicles is made on clinical grounds.

The testicular appendix

It is possible for the testicular appendix – the hydatid of Morgagni – to tort in children and adolescents, and this presents with acute pain. This small developmental remnant sits just anterior to the head of the epididymis.

A small tender spot may be palpable, and ultrasound can confirm the diagnosis, assuming the boy will let anyone near his tender scrotum. It is a benign and self-limiting condition, but it can be difficult to rule out testicular torsion.

Inflammatory conditions of the testis such as tuberculous, granulomatous or syphilitic orchitis are rarely seen in the UK.

Fournier’s gangrene

This is a necrotising fasciitis involving the genital region and perineum and is due to a mixed aerobic and anaerobic bacteria. Escherichia coli, bacteriodes and clostridia are frequently identified. It may follow a number of events including epididymo- orchitis, perianal abscess or surgery to the area.

Thrombosis of subcutaneous blood vessels occurs, followed by gangrene of the skin. Surgical debridement is invariably required, and orchidectomy results in 10-30 per cent of cases.

Fournier’s gangrene is a form of necrotising fasciitis

Key points

* Hypermobility of the testicle increases the risk of torsion of the testicle.

* Torsion is not exclusively a problem of teenage boys.

* Exploration is needed if in doubt, because clinical examination cannot exclude torsion.

* Testicles suffering from torsions that are untwisted and fixed quickly will survive.

* Torsion of the testicular appendix may occur in children and adolescents and presents with acute pain.

3. Benign lumps and bumps in the scrotum

The diagnostic key to making an accurate diagnosis of testicular lumps and bumps is determining whether the examining fingers can get above the lump. If it is possible to establish that the fingers can reach around and above the swelling, then it is arising from the scrotum. If this is not possible, then it is a hernia.

There is one rare exception to this, and that is sometimes a large tense hydrocoele may mimic an inguinal hernia. An ultrasound is the diagnostic test of choice, and has the added advantage that it may even pick up pre-clinical lesions.

Pilar (sebaceous) cysts occur frequently in the skin of the scrotum, are harmless and usually only need reassurance. Occasionally a request for their removal is made because they cause embarrassment or for cosmetic reasons, especially if they are large.

A much rarer and often unsightly condition is scrotal calcinosis, where multiple calcified nodules occur within the scrotal skin. They are not associated with any abnormality of calcium metabolism.

Epididymal cysts

Swellings of the epididymis are common and will be found in a high percentage of men who have ultrasonography for whatever reason. They may contain serous fluid or spermatozoa.

Most epididymal cysts do not cause pain, but men can become so alarmed on finding them that reassurance may be an essential part of management. Although epididymal cysts may be easily removed, a significant number of men will be left with obstructive azoospermia on the side of the operation, and some patients will develop troublesome post-operative scrotal pain.

As a rule I will not operate on scrotal cysts unless they are of a significant size or the man does not plan to have any more children. If pain is the main problem, this can often be relieved by performing a fine needle aspiration of the cyst.

Hydrocoeles

The normal state is to have potential space around the testis lined by mesothelial cells, with a tiny amount of fluid that allows the testis to move freely. If this fluid increases significantly, a hydrocoele will develop.

This is a different situation to the so-called ‘infantile hydrocoeles’ that still communicate with the peritoneal cavity.

Hydrocoeles \are usually idiopathic, but may arise after trauma, infection or any surgery that affects the lymphatic drainage of the testis or, rarely, a tumour. But if the testis within the hydrocoele causes any concern or is cosmetically unacceptable, then surgery to invert or plicate the sac is a simple matter. The success rate is high and there is no effect on fertility.

Epididymal cysts are common but can cause alarm

Key points

* If the fingers can get above the lump, it arises in the scrotum and is not a hernia.

* An ultrasound is the diagnostic test of choice, and may even pick up pre-clinical lesions.

* Epididymal cysts may be easily removed, but there can be undesirable consequences.

* Hydrocoeles are usually idiopathic, but may arise after trauma, infection or obstruction of the lymphatics.

4. Scrotal and testicular tumours

Most GPs dread missing a testicular tumour in a young man. Urologists realise this, and are happy to see any doubtful cases on an urgent basis. Although testicular cancer is rare overall, it is still the commonest cancer in men under the age of 40.

The classical presentation of testicular cancer is a painless lump in the body of the testis, although some men will notice the lump after an injury or an infection. Most early testicular cancers can be cured by surgery alone, but any delay in diagnosis increases the need for chemotherapy and its intensity.

Types of testicular cancer

Tumours of the testis fall into three groups: nonseminomatous (or teratomas), seminomas and lymphomas. Lymphomas are less common but need to be considered in the elderly.

Until relatively recently there was doubt about the place of ultrasound in the diagnosis of tumours of the testis. Modern high- resolution scanning will give an accurate answer if a man presents with a scrotal lump.

In our institution we have seen a series of men in whom small tumours that are undetectable by the examining physician have been accurately diagnosed by ultrasound. Our research suggests that Doppler ultrasound can tell malignant from benign lesions by their neovascular pattern.

Treatment

Treatment varies depending on the clinical stage and risk factors associated with each tumour. In the UK, radiotherapy to the para- aortic nodes is given to most seminoma patients even without evidence of spread, to reduce the risk of microscopic metastases growing later.

For patients who have organ-confined nonseminoma tumours, either observation or modified platinum-based chemotherapy will be recommended. All patients with metastatic disease are treated with cytotoxic chemotherapy.

Cancers of the epididymis are very rare. Any solid lump detected outside the testis is likely to be inflammatory, but nonetheless must be referred for specialist assessment.

High resolution ultrasound may show small testicular tumours that are undetectable on physical examination

Key points

* Most early testicular cancers can be cured by surgery alone.

* There are three types of testicular tumours: teratomas, seminomas and lymphomas.

* Doppler ultrasound can tell malignant from benign lesions by their neovascular pattern.

* Treatment involves para-aortic radiotherapy.

5. Varicocoeles and other problems

A varicocoele is the only scrotal swelling which does not fit the rule of ‘can you get above it?’

Varicocoeles are much more common on the left side because the testicular vein on the left drains into the renal vein, whereas on the right it goes straight into the vena cava. For reasons that are not clear, the one-way valves in the veins that stop reflux are more likely to become incompetent on the left.

Varicocoeles and poor sperm quality are associated. This is thought to be linked to an abnormally high testicular temperature. Varicocoeles are very common, and seem to occur more often where there is a family history of varicose veins. Although a varicocoele may present in later life in association with a renal tumour, this is rare.

Treatment

Treatment depends on the individual patient. Many Varicocoeles are completely asymptomatic and do not affect a man’s fertility. However, if a man is having discomfort or has a fertility problem, then treatment is justified. Traditionally, open surgery was used but this has a risk of inducing chronic pain.

It is our practice to perform a retrograde transfemoral embolisation, which is a local anaesthetic procedure. On the left side a success rate of some 80 per cent has been achieved.

For bilateral or recurrent varicocoeles, a laparoscopic approach will allow identification of all the abnormal veins at the internal ring, and this procedure can be done as a day case.

Miscellaneous problems

Rarely, infestations such as filariasis may affect the scrotum, causing elephantiasis. Idiopathic scrotal oedema and congestive cardiac failure may also cause scrotal swelling.

Skin cancer is rare in this area, but may affect the scrotal skin. The ‘Pott’s tumour’ seen in chimney sweeps was the first demonstration of environmental carcinogenesis. For obvious reasons, it is much less common now.

Varicocoeles are associated with poor sperm quality

Key points

* Varicocoeles are more common on the left.

* Varicocoele may present in association with a renal tumour, but this is rare.

* Retrograde transfemoral embolisation under local anaesthetic is an effective treatment.

* For bilateral or recurrent varicocoeles, a laparoscopic approach may be best.

Further resources

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