Disorders of the testis

Disorders of the testis & spermatic cord

Ectopy &cryptorchidism

In ectopy the testis has strayed from the path of the normal descent;

In cryptorchidism, it is arrested in the normal path of descent.
Ectopy may be due to an abnormal connection of the distal end of gubernaculum testis that leads the gonads to abnormal position.

The ectopic sites are as follow

1- superficial inguinal (most common).
2- perineal (rare).
3- femoral or crural (rare).
4- transverse or paradoxic both testes descend the same inguinal canal.
5- pelvic.

Cryptorchidism is a condition in which the testicle is arrested at some point in its normal descent anywhere between the renal & scrotal areas.
Unilateral arrest is more common than bilateral arrest.
At the time of birth (9 months gestation) the incidence of maldescent is 3.4% half of such testicle descend in the first month of life.
itis incidence in adults is 1%
in premature infants, it is 30% .
Categorisation : Palpable 80% and Non palpable 20%

Etiology

causes of maldescent testis is not clear may due to.
A –abnormality of the gubernaculum testis.
(cord like structure that extend from the lower pole of the testis to the scrotum).
B –intrinsic testicular defect.
making the testicle insensitive to gonadotropins. Best explanation for unilateral
C –deficient gonadotropic hormonal stimulation. Testicular descent is androgen mediated event
Best explanation of bilateral cryptorchidism, & more incidence of undescent testis in premature infant

.

Pathogenesis & pathology.

The scrotum is an effective temperature regulator for the testis, which are kept 1-2 `C cooler than body temperature.
The spermatogenic cells are sensitive to body temperature.
Studies of the ultrastructure of the cryptorchid testis found deleterious changes in the 1st year of life. By the age of 4 yr massive collagen deposition was evident.
So the testis has to be in the scrotum by the age of 6 months. Fortunately, the leydig cells are not affected by body temperature.

Clinical findings.

The cardinal feature is the absence of one or both testes from the scrotum. So the scrotum on the affected side is under developed.
The testis either non palpable or felt external to the inguinal ring.
The patient may also complain of pain from trauma to the testis due to abnormal position.
Adult pt with bilateral cryptorchidism may present with infertility.
Hormonal studies, ultrasound, MRI, & laparoscope aid in the diagnosis.


Complications.
1- torsion of the spermatic cord.
2- tumor, cancer is 25-30 times more common in misplaced testis than normal testis.
orchiopexy facilitate early detection rather than decrease the incidence of malignancy.
3- trauma,
4-Hernia
5- Subfertility
6-abnormal semen analysis.

Treatment.

Medical
success rate about 20% by using (hCG)or (GnRH) can used in bilateral case
Surgery
should be as early as 6 months
Palpable testis then orchiopexy
Non palpable testis then Inguinal exploration with possible laproscopy
Microvascular autotransplantation
.

Disorders of the spermatic cord

Varicocele

Dilatation & tortuousity of veins within the pampiniform plexus above the testis.

A left side Varicocele is found in 15% of young healthy men. In contrast the incidence of Varicocele in subfertile men approaches 40%.
It un usual in boys under 10 but became more frequent at beginning of puberty
Ites adverse influence increase with the time
Incompetent valves are more common in the left internal spermatic vein &right angle insertion of the left spermatic vein to the left renal vein

Presentation : mostly asmptomatic ,could be scrotal pain and swelling ,fertility problems

Assessment :history an examination in up right position
Grading:
Non palpable
Palpable
Palpable &visible
If still there is suspicion so we do uls see
If there is venous reflux by doppler
Testicular size


Sperm concentration & motility are significantly decreased in 65-75% of subject.
Infertility is often observed & can be reversed in high percentage of patients by correction of varicocele.
The effect of varicocele on testicle remain unclear several theories have been postulated.
1- hormonal imbalance due to decrease testosterone
secretion by leydig cell
2- reflux of potentially toxic renal & adrenal metabolites.
3- increase hydrostatic pressure which reduce the efficiency of blood return & testis hypoxia

.

.
4- increase scrotal temperature due to reflux of warm
corporeal blood into the pampiniform plexus
Tratment
Conservative if there no indication of surgery
Follow up
During adolescent ,testicular size should be checked annually .after adolescent ,repeated sperm analysis is to be recommended.

surgery

Indication
small testis
Symptomatic varcocele
Pathological spermiogram
Additional testicular pathology like mass
Bilateral palpable varcocele

Surgical ligation of the internal spermatic veins. Percutaneous methods like injection of sclerosing fluid may be of value.


Hydrocele

Collection of fluid within the tunica or processus vaginalis.

Although it may occur within the spermatic cord, its most often seen surrounding the testicle.
Causes
Primary :cause unknown associated with patency of processes vaginalis
It classified as follow
A-communicating :it connect with the peritoneal
B-Non-communicated :not connected with peritoneal





2- Secondary : the fluid accumulate secondary to the pathological process like infection ,tumor ,trauma . clear & yellow.
Clinical presentation
Sumptoms
Painless swelling
Embarrassment
Dysuria &frequency if due to infection
Examination
Position: swelling usually unilateral but can be bilateral
Colour &temperature normal



Tenderness :primary not tender but seconadary may be tender
Composition :fluctuant and have fluid thrill if large enough
Reducibility :can not reduced
Testis impalpable and transillumenate
Management
Primary
in children
Most neonatal hydrocele resolve in first 2 year of live if persist then repair

.

In adult

Surgical excision
Secondary
Treat the underlying cause.
Acute secrotum in children
Achild or adolescent present with acute secrotal pain swelling tenderness
Aetiology
Torsion testis
Torsion appendix testis
Epididymatis or epididmo-orchtis
Other like mumps orchitis,varcocele,secrotal odema or hematoma


Torsion of the spermatic cord

Torsion of the testicle is a twist of spermatic cord leading to strangulation of the blood supply it mostly occur between age of 10-30.
.
Unless treatment is given within first 4 hr testicular atrophy may occur.

Causes.

1- undescend testis.
2- trauma.
3- congenital anomalies of the tunica vaginalis or spermatic cord.
Voluminous tunica vaginalis that insert well up on the cord. This allow the testis to rotate within the tunica.
The initiating factor is spasm of the cremaster muscle which insert obliquely on the cord.

Clinical findings.

Sudden onset of pain
Followed by swelling, reddening of the scrotal skin, lower abdominal pain, & nausea & vomiting.
Past history of similar pain in 50%

Examination usually reveals

Absent cremastic reflex ( most important)
swollen, tender organ that is retracted upward
Horizontal lie of testes.
Pain may increase by lifting the testis. This differentiate torsion from epididimorchitis

Diagnosis

if certain :emergent surgery
if uncertain :uls with doppler study document blood flow &anatomy if absent vascularity then indicate torsion.
D.Dx
Acute epididymitis,
acute orchitis,
trauma.
Treatment.
Early surgical detorsion + fixation of the affected testis & the contralateral testis as prophylactic procedure should be done as early as 1st 6 hours