Diseases of the Testes, Scrotum, and Intrascrotal Contents



Diseases of the Testes, Scrotum, and Intrascrotal Contents





5.1 Epididymitis/Epididymo-Orchitis

Cause: Males < 35 yr; condition is usually caused by STDs (Chlamydia, gc, ureaplasma). In older men, gram-neg bacteria more common. Coliforms are identified in homosexual men who practice anal intercourse (J Infect Dis 1987;155:134; J Urol 1979;12: 750). Acute epididymitis: less than 6-wk duration; chronic is 3 mo or longer duration.

Epidem: Rare in people < 18 yr; peak incidence is at 32 yr.

Pathophys: Inflammation localized to the epididymis or also involving testis

Sx: Usually gradual in onset and less than 6-wk duration

Si: Swollen, tender epididymis (with or without testis), possible scrotal wall erythema, nontender testis

Crs: Lasts 7-10 d if treated; improved with scrotal elevation, decreased activity

Cmplc: Abscess formation, testicular infarction, chronic pain, infertility


Diff Dx: R/o testicular torsion (most common during adolescence, torsion often presents with more acute onset and often associated with NV, loss of cremasteric reflexes, and testicular pain)

Lab: UA, c + s

Xray: Scrotal US may be helpful if abscess or torsion suspected. Testicular torsion is a clinical dx.

Rx: Men < 35 yr: recommended rx is ceftriaxone 250 mg im single dose plus doxycycline 100 mg po bid for 10 d. For acute epididymitis most likely caused by enteric organism, treat with ofloxacin 300 mg po bid for 10 d or levofloxacin 500 mg qd for 10 d.


5.2 Genital Condyloma

Cause: Usually an STD: Human papillomavirus (HPV) type 6 or 11 typically. HPV types 1 and 2 can cause skin and genital warts. Can also be caused by strains 30, 42, 43, 44, 51, and 52 less commonly. Types 6 and 11 responsible for 90% cases.

Epidem: Increasing in incidence worldwide. Warts may appear months to years after acquisition of HPV. Consistent condom use significantly decreases risk (Sex Transm Infect 1999;75:312). Previous chlamydial infection in both males and females is negatively associated with risk of genital warts. In males, risk factors include younger age, cigarette smoking, alcohol consumption, and greater number of lifetime partners. In females, risk factors include younger age, never having been married, unemployed, cigarette smoking, alcohol consumption (Sex Transm Infect 1999;75:312).

Pathophys: Natural hx marked by fluctuating crs of visible lesions, latency, and recurrence. Some lesions regress; some persist; others appear after rx. Most clinically apparent lesions resolve in months to years. Three types of lesions: cauliflower-like
condyloma acuminata usually involve moist surfaces, keratotic and small papular warts are usually on dry surfaces, and subclinical flat warts are found on any mucosal or cutaneous surfaces.

Sx: About 1- to 6-mo incubation; may cause pain

Si: Clinical infections present as lesion

Diff Dx: Penile cancer, molluscum contagiosum

Rx: CDC guidelines for condyloma: rx of genital warts should be

guided by preference of pt. Extensive rx, toxic rx, and procedures that result in scarring should be avoided. Goal of rx is removal of exophytic warts and amelioration of si/sx, not eradication of HPV (MMWR 1993;2:83). Rx options (Am J Med 1997;104:28) are as follows:

Cytotoxic Rx: eliminate genital warts by destroying affected tissue. (1) Trichloroacetic acid (TCA) causes chemical coagulation of condyloma; 80-90% solution applied directly to genital wart and repeated weekly if necessary; best on small moist warts. Side effects: discomfort, ulcers, and scarring (Sex Transm Dis 1993;20:344). Some (36%) pts develop new lesions in 2 mo (Genitourin Med 1987;63:390). Limit to area < 10 cm2. (2) Podophyllin is a plant compound that causes tissue necrosis by arresting cells in mitosis; 10-25% podophyllin can be applied weekly for up to 6 wk for 1-4 hr, then wash off. Half respond, but warts recur in 40%. Side effects: local skin reaction, including redness, tenderness, itching, burning pain, and swelling. Systemic side effects include bone marrow depression. Ineffective on relativity dry anogenital areas. (3) Podofilox is the major biologically active ligand of podophyllum resin: use 0.5% solution for topical application bid for 3 d, hold 4 d, and repeat 4-6 times as necessary. Limit to wart area ≤ 10 cm2. Appears to be more effective and works faster than podophyllin (Genitourin Med 1988;64:263) but recurrences are common. About 30% recurrence within 1 mo of rx (Obstet Gynecol 1991;77:735; Lancet 1989;1:831). Less successful for sessile warts or lesions on dry skin surfaces (Sex Transm
Infect 1999;75:192). (4) 5-fluorouracil (5 FU) inhibits cell growth by interfering with DNA and RNA synthesis; applied 1-3 times/wk for up to 10 hr; useful for meatal lesions; up to 75% clearance with recurrence < 10% (J Reprod Med 1990;35:384; Obstet Gynecol 1984;64:773). Side effects include local irritation.

Ablative Rx: (1) Cryotherapy involves liquid nitrogen employed for freezing and destruction of wart and small area of surrounding tissue. Effective in about 75% with recurrence in 21% (Int J Dermatol 1985;24:535). Can be painful. (2) Laser rx is a popular choice for rx of lesions that have not responded to other rx. Recurrence rates 6-49% (Obstet Gynecol 1984;64:773; 1980; 55:711; 1982;59:105; 1984;63:703). (3) Electrosurgery involves fulguration of tissue affected by genital warts. Loop electrosurgical excision involves electroexcision and fulguration. Requires local or general anesthesia depending on size of lesion. More effective than podophyllin or cryotherapy but has a similar recurrence rate (Genitourin Med 1990;66:16). Side effects include bleeding, scarring, infection. (4) Surgical excision yields 90% clearance rate and 20% recurrence rate (J Gynecol Surg 1995;11: 41; Br J Surg 1989;76:1067). (5) Interferon-alpha (IFN-alpha) is approved for intralesional rx of warts. Recombinant IFN-alpha2b 3 injections/wk for 3 wk, natural IFN-alpha 2 injections/wk for 8 wk. Clearance rates of 36-53%, recurrence rates of 20-25% (JAMA 1988;259:533; Arch Dermatol 1986;122:272; N Engl J Med 1986;315:1059). Side effects: flu-like sx, leukopenia, pain.

Newer Rx: (1) 5 FU/epinephrine injectable gel shows complete response in 25-71% varying with size of lesion; 3-mo recurrence rate of 39% in pts with complete response (Am J Med 1997; 102:28). (2) Solid-formulation podofilox: gel and cream forms appear to have response profiles similar to the solution; easier to use. (3) Imiquimod, an immune-response modifier, is potent inducer of IFN-alpha and enhances cell-mediated cytolytic activity against viral agents (Antiviral Res 1988;10:209); also induces a variety of cytokines (J Leukoc Biol 1995;58:365). Use of 5%
cream yields clearance rates of 50%. Can be left on for 6-10 hr and used 3 d/wk for 16 wk (JAMA 2000;283:175). Side effects include erythema, erosion, excoriation, and flaking. (4) Vaccine therapy: both prophylactic and therapeutic vaccines are under investigation.


5.3 Male Genital Tuberculosis (Tuberculosis of Epididymis, Testis, and Prostate)

Scan J Urol Nephrol 1993;27:425

Cause: Mycobacterium tuberculosis

Epidem: Most (80%) male genital tuberculosis (TB) is associated with coexistent renal disease (Rev Inf Dis 1985;7:511). Epididymal disease usually develops in young, sexually active males; up to 70% have a previous h/o TB (BJU 1989;64:305).

Pathophys: Epididymis appears to be bloodborne; usually starts in globus minor, which has greatest blood supply; may be associated with renal disease, but not universal. Epididymal disease may be first and presenting symptom of gu TB. Testis: almost always secondary to infection of the epididymis; 11% pts have renal lesion at autopsy (Urology 1982;20:43). May affect penis, epididymis, seminal vesicle, and prostate.

Cmplc: Prostatic abscess (Aust NZ J Med 2000;30:94)

Sx: Painful testis/epididymis

Si: Draining scrotal sinus, scrotal swelling, tender testis/epididymis, nodular prostate, tender prostate, decreased volume of ejaculate

Diff Dx: Epididymo-orchitis, prostate cancer, prostatitis

Lab: UA, c + s as for renal TB; culture of draining sinus for TB

Xray: KUB may show calcification of epididymis, prostate.

Rx: Chemotherapy, as for renal TB; epididymectomy if gross destruction/abscess formation of epididymis



5.4 Genital Filariasis

Cause: Wuchereria bancrofti accounts for 90% of cases. Brugia malayi and B. timori cause remainder. Onchocerca volvulus, a nonlymphatic parasite, can infect humans.

Epidem: Transmitted by mosquitoes; take a long time to mature— up to a year for onset of si. There is a 2-wk maturation in insect; infect via puncture holes; males and females in lymphatics produce microfilarial worms that migrate to peripheral blood in diurnal fashion where ingested by insect and complete cycle. Found primarily in tropical areas. Large number of pts infected with filariae remain asx (Lymphology 1976; 9:11).

Pathophys: Adult filaria block lymphatics; fibrotic nodules form around them in lymphatics or in subcutaneous locations (Onchocerca). Production of antigen-specific suppressor cells causes filaremia (N Engl J Med 1982;307:144).

Sx: Onset may be delayed to 51 yr after leaving area. Local swelling and redness of skin where microfilaria enter; fever. Pts with filarial fever sustain episodic fevers, lymphangitis, lymphadenitis, funiculoepididymitis, transient edema, small acute hydroceles and they are typically amicrofilaremic. Pts with chronic pathology have chronic hydroceles, fixed edema, elephantiasis, chyluria, lymph scrotum.

Crs: Chronic

Lab: Findings of Brugia or Wuchereria microfilaria in peripheral blood, chylous urine, or hydrocele fluid are diagnostic. Nearly half (40%) pos thin smears; thick smears better, or spin crit and look at buffy-coat smear under low power; eosinophilia. Specific serodiagnostic tests for W. bancrofti infection at CDC and ELISA for IgG4 ab against recombinant filarial ag appear promising (Am J Trop Med Hyg 1994;50:727).


Pathol: Bx of lymphatics/skin nodules (Onchocerca) shows adults.

Serol: Positive

Rx: (N Engl J Med 1985;313:133). Diethylcarbamazine (DEC). With high microfilarial counts, start with low doses of DEC (3 mg/kg body weight/d); increase gradually to avoid severe sx. Otherwise, 6 mg/kg body weight/d for total crs of 72 mg/kg body weight for W. bancrofti and 4 mg/kg body weight/d for total of 60 mg/kg body weight for B. malayi (Campbell’s Urology 1998;7:733; Acta Trop 1981;38:217). For genital elephantiasis: surgical rx to remove edematous and fibrotic tissue. Surgery for scrotal elephantiasis produces much more satisfactory results than that for elephantiasis of the legs. Aspiration followed by sclerotherapy with tetracycline provides an alternative for thin-walled hydroceles. Good skin care and prompt treatment of bacterial skin infections prevent the disease from progressing.


5.5 Fournier’s Gangrene (Necrotizing Fasciitis)

Semin Med 1984;4:69;1983;3:345; Surg Gynecol Obstet 1990;170: 49

Cause: Multiple organisms, including aerobes (Escherichia coli, Klebsiella, enterococci) and anaerobes (Bacteroides, Fusobacterium, Clostridium) (Surg Gynecol Obstet 1990; 1970:49; AUA Update 1986;5:6)

Epidem: Predisposing factors include DM, local trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery, such as circumcision or herniorrhaphy.

Pathophys: Infection most commonly arises from the skin, urethra, or rectal regions. Bacteria probably pass through Buck’s fascia of the penis and spread along the dartos fascia of the scrotum and penis, Colles’ fascia of the perineum, and Scarpa’s fascia of the anterior abdominal wall.


Sx: Pain and malaise

Si: Fever, tachycardia, hypotension, crepitus, gangrene, swelling, erythema of affected tissues

Crs: Onset usually abrupt and rapidly fulminating. Mortality rate of 20% (Surg Gynecol Obstet 1990;170:49; BJU 1990;65:524). Higher mortality in those with DM, alcoholics, and those with colorectal sources.

Cmplc: May require urinary diversion and/or fecal diversion; may require subsequent procedures to provide skin coverage of affected areas

Diff Dx: Perineal abscess

Lab: CBC, electrolytes, BUN and creatinine, type and cross

Xray: Plain film of abdomen may demonstrate subcutaneous air; scrotal US may also demonstrate air.

Rx: Fluid resuscitation, IV antibiotics (combination of ampicillin plus sulbactam or third-generation cephalosporin, such as ceftriaxone plus gentamicin plus clindamycin). Once resuscitated, emergent surgical débridement. Often need subsequent débridement in next 24-48 hr. Extensive tissue coverage is often needed when the infection is eradicated.


5.6 Cystadenoma of Epididymis



5.7 Adenomatoid Tumor



5.8 Epidermoid Cyst










Table 5.1 Differential Diagnosis of Benign Lesions of the Epididymis and Testis




































Cystadenoma of Epididymis


Adenomatoid Tumor


Epidermoid Cyst


Cause


Benign lesion originating from efferent ducts


Benign neoplasm of adnexal structures. Possible etiologies: reaction to injury/inflammation, mesothelial or endothelial origin


Benign neoplasm of the testis. May represent a benign monolayer teratoma


Epidemiology


May be seen in von Hippel-Lindau disease, bilateral lesions in 1/3 cases


Most common paratesticular tumor. Majority in head or tail of epididymis. Males in 20s-30s


Accounts for 1-2% of all testicular tumors. Half occur in 20s, remainder between teens and 30s. Right side more than left


Sx


Minimal or no discomfort, enlarged epididymis


Extratesticular solid mass; does not transilluminate


Usually painless, painless nodule/cyst


Dx


Scrotal US: epididymal mass that is partially cystic


Scrotal US: solid mass, does not transilluminate


Labs: serum markers (AFP, beta-HCG, and LDH if diagnosis is uncertain)


Scrotal US: well-circumscribed intratesticular cyst with hypoechoic center and circumferential echogenic whorls that do not shadow


Rx


Epididymectomy


Surgical excision


If confident of preoperative diagnosis: local excision and biopsy of adjacent testicular tissue to assess for testicular intraepithelial neoplasia to r/o mature teratoma. If diagnosis is unclear, radical orchiectomy


Abbreviations: AFP, alpha fetoprotein; beta-HCG, beta subunit human chorionic gonadotropin; LDH, lactate dehydrogenase.

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Aug 21, 2020 | Posted by in UROLOGY | Comments Off on Diseases of the Testes, Scrotum, and Intrascrotal Contents
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