Disorders of the male genitalia

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Disorders of the male genitalia

Disorders of the scrotal contents

Introduction

Abnormalities of the scrotal contents include disorders of the testis or its coverings, the spermatic cord and inguino-scrotal hernias (see Ch. 32). Distinguishing between them usually requires only clinical examination. Diagnoses that must not be missed are testicular tumours and testicular torsion. Other problems include inflammation, hydrocoeles and cysts, maldescent and testicular trauma, as well as varicocoele. Male sterilisation and disorders of the penis are also covered in this chapter.

Clinical examination of scrotal lumps and swellings

A lump or swelling in the scrotum may be:

• A solid or cystic mass arising from a component of scrotal contents or spermatic cord. These include testis, epididymis, epididymal appendage, vas deferens and pampiniform venous plexus

• A collection of fluid in the tunica or processus vaginalis (hydrocoele)

• An indirect inguinal hernia extending along the embryological path of testicular descent into the scrotum

The important disorders of the scrotum and contents are summarised in Table 33.1, with their anatomical and clinical significance.

Table 33.1

Summary of disorders of the scrotum and its contents and their clinical features

The origin of a scrotal lump: The first objective is to determine if 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. In purely scrotal lumps, the spermatic cord is a normal 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. Testicular swellings due to lymphoma, leukaemia or granulomatous infections (e.g. tuberculosis or syphilitic gumma) may be softer but this is unreliable. 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 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 (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.

Fig. 33.1 Transillumination of a scrotal cyst
This 30-year-old man complained of a swelling in the right scrotum. On clinical examination there is a 3 cm soft rounded swelling at the upper pole of the epididymis. A confident diagnosis of epididymal cyst can thus be made

Scrotal pain

Acute pain (Box 33.1)

In acute scrotal pain, testicular torsion must be excluded since the torted testis can be saved if 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 torsion may cause transient episodes of severe pain or poorly defined lower abdominal 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.

Box 33.1 Common causes of acute pain in the scrotum

Torsion of the testis

• Sudden onset of unilateral scrotal pain with or without poorly localised abdominal pain

• In early cases, the testis is high in the scrotum and exquisitely tender, and the cord is thickened; later these signs are often obscured by oedema

• The opposite testis may lie horizontally (bell-clapper testis)

Torsion of the epididymal appendage (hydatid of Morgagni)

• Nearly always in children

• Sudden onset of unilateral scrotal pain; the testis hangs normally. There is a tenderness only at its upper pole and minimal overlying oedema

Acute epididymitis

• Moderate or severe scrotal pain and tenderness with marked redness and oedema

• Often preceded by symptoms of urinary tract infection; urine usually contains white cells, nitrites and organisms

Haematocoele following trauma or scrotal surgery (e.g. vasectomy)

• History may be diagnostic although torsion is sometimes precipitated by trauma

Case History

Fig. 33.2 Testicular hydrocoele
This man of 67 had a painless swelling of the left side of the scrotum for several years that was slowly enlarging. On examination, the swelling was confined to the scrotum and did not involve widening of the cord at the scrotal neck which might indicate a hernia. The testis was not palpable separately from the swelling, and the swelling transilluminated, confirming the diagnosis

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 below the age of 1 year usually resolve spontaneously. For older children, ligation of the PPV is required.

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 but the lesions are otherwise asymptomatic. The swelling is soft and non-tender 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 testicular tumour or inflammation. In most, the hydrocoele is small and the testis can easily be palpated to reveal the primary abnormality.

Management: For symptomatic patients, a hydrocoele operation can be performed by everting the sac and oversewing the edges (Jaboulay procedure) or plicating the sac (Lord’s method). If the sac is thick, it is best excised. Alternatives include observation alone or periodic aspiration (rarely performed) if the patient is unsuitable for surgery. If a testicular tumour is a possibility, a hydrocoele must not be aspirated as malignant cells can be disseminated via scrotal skin to its lymphatic field.

Hydrocoele of the cord

Rarely, a hydrocoele develops in a remnant of the processus vaginalis somewhere along the course of the spermatic cord. This hydrocoele also transilluminates, and is known as an encysted hydrocoele of the cord (see Fig. 33.3). In females, a multicystic hydrocoele of the canal of Nuck sometimes presents as a swelling in the groin. It probably results from cystic degeneration of the round ligament.

Fig. 33.3 Causes of a lump or swelling in the scrotum

Fournier’s scrotal gangrene

Fournier’s scrotal gangrene is a form of necrotising fasciitis of genitalia and perineum and does not involve the testes. There is often consequent systemic sepsis. The underlying causes are varied and include pre-existing primary hydrocoele, genitourinary trauma, either accidental or iatrogenic, perirectal abscess and urethral stricture. Predisposing factors include diabetes mellitus, corticosteroids, chemotherapy and alcohol abuse. The infecting organism is principally an anaerobe but there is often synergistic aerobic infection. Treatment is urgent and includes intravenous antibiotics and surgical excision of all necrotic tissue, with the wound left open to heal by secondary intention.

Epididymal cyst and spermatocoele

Multiple cysts can develop in the upper pole of the epididymis and present as a painless scrotal swelling (see Fig. 33.3). Epididymal cysts affect a slightly younger age group than hydrocoeles. The testis can be palpated separately from the cysts, which transilluminate.

Less common is a spermatocoele, a single cyst containing spermatozoa. Spermatocoeles usually occur in the head of the epididymis and may present like a third testis. They are clinically similar to epididymal cysts but may or may not transilluminate. Occasionally they occur in the spermatic cord and surgical excision may cause obstruction to passage of sperm. If a patient wishes to remain fertile and the cysts are bilateral, excision may be contraindicated.

Varicocoele

A varicocoele (see Figs 33.3 and 33.4) represents dilatation and tortuosity of the pampiniform plexus of the spermatic vein in the cord. The condition is much more common on the left (90%), so it may result from the different venous drainage of the two sides: on the left, the testicular vein drains into the high-pressure renal vein, whereas the right testicular vein drains directly into the inferior vena cava.

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