Testicular Conditions

Epididymo-orchitis

This is inflammation of the epididymis (and the testes)

Causes:

– Chlamydia or Neisseria Gonorrhea (seen in sexually active)

– E. Coli –> more in elderly as UTI spreads into reproductive tract

– Mumps –> seen in teenage males

– Drugs –> Amiodarone is non-infective cause of epididymitis

Symptoms:

– Acute onset tender swelling (confined to epididymis)

– Dysuria, sweats, fever

Management:

Antibiotics to clear infection.

If due to Chlamydia or non-gonococcal bacteria doxycycline 100mg for 10-14 days + ofloxacin for 14 days

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)

Tests:

Do not do tests if the clinical story is strong

– Ultrasound can be used if diagnosis unclear

Management:

Orchidectomy (removal of tests) or bilateral fixation of testes

Hydrocele

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

– Occurs in infants due to incomplete closure of the processus vaginalis, so fluid enters

– Also occurs 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

Investigations:

In adults, can use ultrasound to exclude tumour

Management:

Adults –> Lords/Jabouley Procedure

Children –> Trans-inguinal ligation of processus vaginalis

Cryptorchidism

This is a failure of the testicle to descend into the scrotum

The higher temperature within the abdomen suppresses sperm production leading to atrophy and significantly increases the risk of testicular cancer

Symptoms:

– Absent testes in the scrotum (can be bilateral)

– Infertility later in life

Management:

– Orchidopexy –> performed before age 18 months, to move undescended testicle into the scrotum and permanently fix it there

– If the surgery is delayed, then the sex chord cells that line the testes will start to degenerate almost irreversibly, hence need to perform surgery at a very early age

Testicular Cancer

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

– Most testicular tumours are malignant germ cell tumours, often detected late when metastasis has occurred

 

Risk Factors:

Undescended testis, infertility and having a relative with testicular cancer

 

Symptoms:

– These present as a solid non-tender mass which cannot be transilluminated

– Can give rise to secondary hydrocele causing pain

– Many present with established metastases, giving dyspnea (lung) or abdominal masses

 

There are many different types of testicular cancers:

a) Germ Cell Tumour

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

Risk factors:

– Cryptorchidism

– Kleinfelter syndrome

– Family history

 

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

i) Seminoma:

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

– They will have clear cytoplasm and central nuclei

– These are very responsive to radiotherapy and metastasize late

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

ii) Non-seminoma:

This includes a variety of tumours, which metastasize early

Subtypes of Non-Seminomas

Embryonal carcinoma:

This is a malignant tumour of immature cells that can secrete hormones

– This forms a mass which can bleed giving necrosis

– It is a very fast-growing cancer which metastasizes early

– Secretes AFP and b-hCG

 

Yolk sac tumour

This is a malignant tumour that is formed from the embryological yolk sac

– It is the most common testicular tumour seen in children

– Schiller-Dival bodies (mini-glomeruli) are seen on histology with raised AFP

 

Choriocarcinoma:

This is a malignant tumour of syncitiotrophoblasts and cytotrophoblasts

– It is likened to the spectrum of gestational trophoblastic diseases

– Secretes B-hCG is elevated  this can cause hyperthyroidism or gynecomastia as the alpha-subunit of hCG similar to FSH, TSH

 

Teratoma:

This is a neoplasm which may contain ectodermal tissue (hair, skin, teeth)

– Unfortunately, it is malignant in males but benign in females. Secretes B-hCG and AFP

 

Mixed:

This is of many cell types. The prognosis is based on the most dangerous component

b) Sex-Cord Tumour

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

Subtypes of Sex-cord tumours

Leydig cell tumour:

This is made up of Leydig cells which secrete testosterone.

– This will lead to early puberty in children and give signs of hyperandrogenism.

– It displays characteristic Reinke crystals on histology.

Sertoli cell tumour:

This is made up of Sertoli cells which line the tubules in testes.

c) 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

Investigations:

– 1st line is Ultrasound

– Check AFP, LDH, b-hCG –> These are elevated in germ cell tumours

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

Staging:

CXR and CT allow staging

Stage 1 – no metastases      

Stage 2 – local node      

Stage 3 – distant node       

Stage 4 – lung metastases

– Alpha-feto protein and B-hCG and useful tumour markers and help monitor treatment

Management:

 Radical orchidectomy (complete removal of the testes) + Radiotherapy