David J. Breland and Mark L. Rubinstein
TESTICULAR TORSION
Testicular torsion is a surgical emergency, and clinicians caring for adolescent males must have a high index of suspicion given the short window for salvage of the testicle. Common presentation includes abrupt onset of severe scrotal pain with associated nausea, vomiting, fever, and abdominal pain.1-3 Symptomatic males may describe prior transient episodes of scrotal pain consistent with intermittent torsion/detorsion.1 The exact etiology of torsion is unknown. However, a well-described anatomical abnormality called the “bell clapper” deformity can predispose to testicular torsion (see Figure 75-1). In this deformity, the tunica vaginalis completely surrounds the testicle, including the posterior aspect, and the absence of the normal posterior anchoring allows the testicle to twist freely. On physical examination, if the adolescent presents early, the testicle may have a horizontal lie with minimal swelling.1-3 Typically, the adolescent presents later, and the scrotum is swollen, tender, erythematous, and often difficult to examine.1-4 The cremasteric reflex is nearly always absent.1-3 Diagnosis can be made on physical examination or with the assistance of color Doppler ultrasound, which has a sensitivity of 89% to 100% and a specificity of 77% to 100%.2,4 Time is of the essence because testicular viability declines to zero after 24 hours.2-4Treatment involves prompt surgical exploration and detorsion. Given the high incidence of retorsion, as well as torsion of the contralateral testis, once detorsed, the affected testis and the contralateral testis are fixed to the scrotum in a procedure called scrotal orchiopexy.2,3
TORSION OF TESTICULAR OR EPIDIDYMAL APPENDAGE
Both the testis and the epididymitis have appendages (see Figure 75-2) that are remnants of the wolffian and müllerian ducts, respectively.3 The typical presentation of appendiceal torsion occurs in boys ages 7 to 12 years and includes pain that may be accompanied by nausea and vomiting.2 Palpation of the testis reveals tenderness over the superior or inferior pole of the testes with or without a palpable mass.5 The cremasteric reflex is usually present. The classic “blue dot” sign, if present, represents the infarcted appendage viewed through the scrotal skin.1,3,5 The diagnosis is usually made on clinical examination. If torsion of the testis cannot be ruled out, a color flow Doppler examination is indicated.5 Treatment is usually supportive, including analgesics, anti-inflammatory agents, and scrotal elevation.1 If pain persists for longer than 5 days, consultation by a pediatric urologist is recommended.3
FIGURE 75-1. A: The normal testicle. B: Bell clapper deformity in which the tunica vaginalis completely surrounds the testicle, including the posterior aspect, such that the normal posterior anchoring is absent. C: Early presentation of torsion with swelling and horizontal lie of the testicle. D: Torsion of the testicle.
TRAUMA
Trauma may be a cause of pain and swelling of the scrotum. When the presentation includes an overlying hematocele, surgical exploration and repair may be required for testicular salvage.5
FIGURE 75-2. Testicular appendages.
HERNIA AND HYDROCELE
Both hernias and hydroceles are related to congenital abnormalities in the inguinal canal. Inguinal hernias are further discussed in Chapter 405. Communicating hydroceles develop when fluid tracks down the inguinal canal into the tunica vaginalis. Hydroceles may also form from trauma, infection (eg, epididymitis and orchitis), testicular torsion, or tumors. Indirect hernias form when a loop of bowel passes through the inguinal canal. Both can present as a scrotal mass. However, on examination, hernias are usually firmer than hydroceles and do not transilluminate. Additionally, bowel sounds may be auscultated over hernias. The hydrocele is usually painless and can shift in size when the patient is supine. In most patients, a hydrocele will transilluminate showing the presence of fluid. When palpated, it may feel like a supple, fluid-filled cyst. Hydroceles are corrected electively. Hernias can become incarcerated and therefore are usually repaired surgically.1
SPERMATOCELE
Spermatocele refers to the accumulation of sperm within the head of the epididymis6 (see Figure 75-3). Spermatoceles, which are benign cysts, are commonly found on routine physical examination or by the adolescent himself and usually do not require intervention unless symptomatic.3 On palpation, they are predominantly smooth, soft, well circumscribed, and found on the superior aspect of the testicle. In addition, these cystic lesions may transilluminate.2
ORCHITIS
Orchitis rarely occurs in prepubertal males.5 The mumps virus is the most common cause of orchitis, but other viruses have been implicated (eg, coxsackivirus, echovirus, adenovirus, varicella). Mumps orchitis usually follows parotitis by about 4 to 8 days, but presentation up to 6 weeks later has been reported. The typical presentation includes edema, erythema, and tenderness of the testicle and may be associated with constitutional symptoms (eg, fever, nausea, lower abdominal pain).7 Bacterial orchitis is usually a consequence of the contiguous spread from an epididymal infection.5,7 Viral orchitis is treated supportively with rest and analgesia. Bacterial orchitis is treated with antibiotics and supportive care. Infertility is a rare complication of orchitis.7
FIGURE 75-3. Spermatocele.
VARICOCELES
A varicocele is a dilatation of the pampiniform venous plexus within the scrotum.2,6 There are several theories as to the etiology of varicoceles. One theory involves the presence of incompetent valves within the veins along the spermatic cord, resulting in the backup of blood.8 Another theory is the “nutcracker effect” wherein the left renal vein is compressed between the aorta and superior mesenteric artery, resulting in an increase in pressure, which is then transmitted to the left testicular vein.5,6 Support for this theory includes the fact that the vast majority of varicoceles are left sided.9 Right-sided varicoceles can be associated with tumors and should always be investigated further.2,6
Varicoceles may be graded on physical examination. A grade I (small) varicocele is detectable only when the patient performs a Valsalva maneuver, a grade II (moderate) varicocele may be palpated but is not visible on examination, and a grade III (large) varicocele is visible through the skin (eg, a “bag of worms”).8
Varicoceles are usually asymptomatic in adolescents but occasionally may cause a dull ache after long periods of standing. The clinical relevance of asymptomatic varicoceles in adolescents is controversial but is related to the risk of infertility.3 Varicoceles have been associated with both time-dependent testicular growth arrest and abnormal semen analyses in adolescents.6 Repair should be offered to adolescents with testicular growth arrest, abnormal semen analysis with high-grade varicoceles, bilateral varicoceles, and/or symptomatic varicoceles (eg, pain).3,5,6
EPIDIDYMITIS
Epididymitis is an inflammatory disease of the epididymis. Among sexually active adolescents, most cases of epididymitis are attributed to the retrograde extension of Chlamydia trachomatis10 organisms from the vas deferens; Neisseria gonorrhoeae is the second-most common organism. Patients may present with the gradual onset of scrotal pain and edema along with nausea, fever, abdominal or flank pain, and urethral discharge.3 On examination, the scrotum is often edematous and erythematous. Additionally, the epididymis is often tender to palpation. Fluctuance or fixation of the scrotal tissue around the epididymis is concern for the presence of a scrotal abscess. The lessening of pain with scrotal elevation (eg, a positive Prehn sign) may help to distinguish epididymitis from testicular torsion.11 Bilateral epididymitis may result in sterility due to occlusion of the ductules from peritubular fibrosis. Treatment includes appropriate antibiotic therapy for both the patient and his sexual partners. Patients who fail to improve during the initial 72 hours of outpatient management must be evaluated for the possibility of an abscess.10
TESTICULAR NEOPLASMS
Testicular neoplasms represent the most common solid tumor in males age 15 to 34 years. Histologic types that occur most frequently in adolescence are germ cell tumors and include seminoma, embryonal carcinoma, teratoma, and choriocarcinoma. Leydig and Sertoli cell tumors are of stromal origin and may occur at any age, including adolescence. Patients often present to the physician with painless scrotal swelling of gradual onset. Adolescents with testicular cancer are more likely than other adolescents to have had cryptorchism or testicular atrophy. Pain may be present if the tumor has hemorrhaged or become necrotic. When pain accompanies a tumor, it can lead to an erroneous diagnosis of an infectious or inflammatory process.1,12
Physical examination usually reveals a firm, irregular mass that is opaque to transillumination, but cystic or necrotic areas of the tumor can be soft on palpation. A hydrocele or varicocele may also be detected. The contralateral testis must be examined not only for comparison but also to rule out the presence of bilateral disease. The detection of cervical or supraclavicular lymph nodes may indicate an advanced stage of disease (ie, metastases). Other possible findings include gynecomastia and breast tenderness. Because stromal tumors tend to produce androgens and/or estrogens, the prepubertal boy may present with early virilization, whereas the pubertal boy may present with feminization.1,12
Testicular tumor markers, most commonly human chorionic gonadotropin and α-fetoprotein, are useful tests for certain histologic types and should be obtained before orchiectomy. The human chorionic gonadotropin is elevated in choriocarcinoma, nonseminomatous mixed germ cell tumors, and seminoma with syncytiotrophoblasts. The α-fetoprotein is elevated in nonseminomatous germ cell tumors, especially yolk sac tumors and embryonal carcinoma.1,12For further discussion, see Chapter 459.
Imaging of a scrotal mass is done using ultrasound or magnetic resonance imaging. Staging of a proven tumor requires chest and abdominal computerized tomography. Therapy is determined by staging and definitive histology and includes orchiectomy, retroperitoneal lymph node dissection, radiation, and chemotherapy. This results in an overall survival rate of more than 70%, with 95% of patients with stage I or II tumors achieving cure.12