38 Jasper Bondad1, Piotr L. Chlosta2, and Omar M. Aboumarzouk3, 4 1 Ninewells Hospital, Dundee, UK 2 Academic Urology Unit of Collegium Medicum, Jagiellonski University, Krakow, Poland 3 Glasgow Urological Research Unit, Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK 4 University of Glasgow, School of Medicine, Dentistry & Nursing, Glasgow, UK Benign testicular swellings tend to be asymptomatic the majority of the time, and good counselling and reassurance might be all that is needed. More often than not, the diagnosis of a hydrocele, epididymal cysts, and varicoceles can be reached by a clinical examination; however, an ultrasound can confirm the diagnosis as well as rule out a sinister cause such as a cancer. Symptomatic hydroceles or epididymal cysts are easily surgically treated, and a testicular torsion warrants emergency scrotal exploration and ‘untwisting’ followed by fixation. Symptomatic varicoceles can be embolised or surgically corrected by ligating the testicular vein. Keywords hydrocele; epididymal cysts; varicocele; testicular torsion; testicular pain; orchialgia Hydrocele is an abnormal collection of fluid between the two layers of tunica vaginalis, which surrounds the testis. It comes from the Greek words hydro and kele, meaning ‘water’ and ‘mass’, respectively. Depending on the cause of increase fluid in the sac, hydroceles can be divided into congenital, primary, or secondary. This is secondary to incomplete closure of the processus vaginalis leading to accumulation of fluid around the testis which is continuous with the peritoneal cavity. The processus may close above and below a short segment, giving rise to a ‘hydrocele of the cord’; it is a rare condition and an equivalent lesion exists in the female called hydrocele of the canal of Nuck where the cyst lies in relation to the round ligament. A hydrocele may be associated with a hernial sac, with obliteration of the intervening processus. Rarely, a hydrocele may extend through the internal ring to cause a retroperitoneal swelling (Figure 38.1). Figure 38.1 Various types of hernia and hydrocele. (a) Common hydrocele, (b) encysted hydrocele of the cord, (c) ‘double’ hydrocele, (d) hernia and hydrocele, (e) ‘hernia magna’, and (f) abdominoscrotal hydrocele. The fluid in primary hydrocele is lymph and is caused by either obstruction of drainage or decreased absorption of fluid. The lymphatic drainage of the testis is of great interest because the testicular tubules are immunologically deprived sites, keeping the haploid gametes safe from the immune defences of the body. Between the tubules, the lymphatic capillaries drain into the lymphatics of the cord, when these are obstructed, the intertubular spaces expand not the lumina of the tubules. There is always a little fluid between the layers of the tunica vaginalis in the adult; if the absorption is decreased, a hydrocele forms, however it is unknown why this occurs. Excessive production and accumulation of exudate fluid secondary to inflammation or malignancy within the sac is analogous to the secondary pleural or peritoneal effusion seen diseases in the pleural or peritoneal cavities. It can occur with epididymitis, orchitis, trauma, and can be a presenting symptom of cancer. Obstruction of the lymphatics of the cord by the filarial worm Wuchereria bancrofti can give rise to hydroceles, sometimes of prodigious size, endemic in countries like India and Myanmar [1]. Hydrocele can be seen in ascites and heart failure, and in men who have undergone radical retroperitoneal node dissection or radical removal of the kidney for cancer. An asymptomatic swelling in the scrotum which is translucent, fluctuant in two planes, if large enough difficult to palpate the testes encapsulated by the sac, and can more often palpate above the swelling. Symptoms can arise if the hydrocele ruptures or bleeds, forming a haematocele, usually secondary to trauma, or increases in size where it can cause pressure effects and cause the patient discomfort. Clinical examination is usually conclusive of the diagnosis, however, can be difficult to distinguish from a hernia, especially in children. The swelling is trans‐illuminable when a torch is shined behind it. An ultrasound can accurately establish the diagnosis, as well as determine if an underlying testicular cancer is present (Figure 38.2). If doubt remains, the fluid can be aspirated to allow the testis to be carefully palpated and if the findings are still inconclusive, then the testicle should be explored. Figure 38.2 Ultrasound of a hydrocele. The majority of hydroceles do not need treatment unless symptomatic. An old rule is to advise treatment if a man’s wife or his tailor complain. In the paediatric population, hydrocele repair is indicated for both congenital hydrocele and hydrocele of the cord [2–4]. However, it is recommended to monitoring vaginal hydroceles in infants because of its tendency to spontaneously resolve and on vaginal hydrocele which have shown decrease in size over a period of time. While in adults, surgery repair is the mainstay of treatment. Aspiration of a hydrocele is only advised for symptomatic relief of an elderly man unfit for surgery [2]. While injection of a hydrocele with a scleroscant can be painful and might not resolve the swelling, it can cause multiple smaller hydrocele saculations or an infection leading to a complex hydrocele (Figure 38.3). Figure 38.3 Ultrasound of complex hydrocele showing multiple large septate masses. Incisions for scrotal exploration is done through either a midline scrotal incision or a transverse incision. After the incision, the hydrocele is delivered out of the scrotum in its entirety. The sac is emptied of its fluid content through a small incision opposite the testis (to avoid injuring it), followed by lengthening of the sac incision and delivering the testis. The redundant tunica vaginalis can then be everted and closed behind the testicle (Jaboulay’s procedure) (Figure 38.4) or plicated with a series of interrupted absorbable sutures (Lord’s Procedure) (Figure 38.5). In long‐standing hydroceles, the sac is thick and stiff and needs to be cut away leaving a frill around the epididymis, which must be over sewn to achieve perfect haemostasis (Figure 38.6). Figure 38.4 Jaboulay’s ‘bottle’ operation for hydrocele. Figure 38.5 Lord’s plication for hydrocele. Figure 38.6 Radical cure of hydrocele. The surplus tunica vaginalis testis is excised and the edge over sewn to effect haemostasis. Haematoma is the main complication in the repair of hydrocele and perfect haemostasis must be achieved in every step of the procedure to prevent this from happening. Infections, injury to the testicle or structures of the cord, and recurrence of hydrocele are rare, but they are nonetheless potential risks. Epididymal cysts arise as diverticula of the vasa defferentia and contain clear fluid (Figure 38.7). If the cyst contains spermatozoa, it is called a spermatocele. The pathophysiology is unknown, however, are more commonly multiply occurring. Figure 38.7 Cysts of epididymis are diverticula of the vasa efferentia testis. The diagnosis is often clinical with a palpable cystic trans‐illuminable mass arising on the epididymis separate from the testes (above and behind the testis) and can be multilocular. It may be difficult to distinguish a hydrocele from a collection of cysts, especially when both are present in the same patient. An ultrasound can accurately make the diagnosis (Figure 38.8). Figure 38.8 Ultrasound of epididymal cyst. Treatment with an epididymal cyst excision is only indicated if they become bulky and bothersome with pain and discomfort. Alternative needle aspiration of the fluid can be done; however, they tend to recur. The testis is delivered through a transverse scrotal incision and the intact cyst is dissected from the rest of the epididymis. Good haemostasis along the way will help prevent the common complication of haematoma. Benign testicular cysts are uncommon and alternative diagnosis such as testicular malignancy should be excluded before making a benign diagnosis. They are of two varieties: simple cysts and epidermoid cysts. Simple cysts contain clear fluid, while epidermoid cysts are well circumscribed lesions filled with keratinized debris. Ultrasounds can accurately diagnose the lesions and distinguish it from malignant masses. Treatment is unnecessary unless they become symptomatic with pain or discomfort due to size, and in which case, enucleation or partial orchiectomy can be done. A urological emergency, testicular torsion was first described by Delasiauve in 1840 [5]. The twisting of the spermatic cord causes vascular compromise to the respective testis, initially with venous congestion and ultimately leading to arterial ischaemia and infarction. It has a bimodal distribution with the first year of life and around the pubertal age. It is thought to be more commonly occurring in cold weather [6]. There are two types of torsion, extravaginal and intravaginal. Seen in neonates and often occurs at the time of birth, the incomplete fixation of the gubernaculums to the scrotal wall causes the spermatic cord to twist, noticed as a firm mass in the scrotum but can also be diagnosed in utero with an ultrasound (Figure 38.9) [7–9]. Figure 38.9 Neonatal extravaginal torsion of the testis. This is seen in children and adults and is often caused by a congenital abnormality with a capacious tunica with an abnormally higher investment of the tunica vaginalis on the posterior wall of the scrotum, giving it the classical ‘bell clapper’ appearance (Figure 38.10). This will cause the cord to be the only pedicle of the testis which can easily twist. Because of its congenital nature, there is an increased risk of it occurring on both sides; bilateral torsion occurs in about 10% of cases. Figure 38.10 Intravaginal torsion of the testis. There are two distinct clinical pictures. Intermittent torsion whereby there is a clear history of warning attacks of testicular pain which have resolved spontaneously, possibly indicating a torsion‐detorsion episode. The other half has no warning and present with sudden pain and swelling in the testis. Associated symptoms include nausea, vomiting, fever, abdominal pain, and shock. Present cremasteric reflex and a nontender testis can exclude a testicular torsion. A hydrocele may be present due to the underlying testicular inflammation. The affected testis will be tender, often too tender to palpate properly, high riding, and may lie horizontally on clinical examination. Elevation of the testicle increases the pain, whereas relieves it in epididymo‐orchitis. There may also be scrotal erythema. A straightforward testicular torsion is a clinical diagnosis and investigations should not delay testicular exploration if the diagnosis is apparent. Ultrasound colour Doppler is useful in atypical presentations with a good specificity and sensitivity, which confirms the absence of the blood supply (Figure 38.11) [10, 11]. Figure 38.11 Doppler ultrasound showing lack of blood flow in the testicle. There are a number of ailments that can mimic torsion (Table 38.1); however, if there is any doubt, then scrotal exploration must not be delayed. Table 38.1 Differential diagnosis for testicular torsion. If the patient’s pain allows it, then a gentle attempt at detorting the testicle can alleviate the pain and can get the situation out of an emergency state, and then early fixation can be planned more electively. Through a midline scrotal incision, the affect testicle can be delivered. The tunica is opened to expose the epididymis and testicle. You may find a grossly distended black epididymis and a pale testis or the testicles might be dusky. Untwist the stalk and wait for 5–10 minutes. If the blood supply is re‐established, the testicle returns to its natural pink colour; alternatively, you can incise the tunica albuginea, and if it bleeds, it means the blood supply is not entirely thrombosed. Once viability is established, testicular fixation is done with a nonabsorbable suture between the tunica vaginalis and the tunica albuginea. As the most likely cause is a congenital variation that lead to the torsion, it is most likely present on the opposite testicle and therefore should also be fixed. If the testicle is no viable (i.e. infarcted), then it should be removed. In chronic torsion, where by the testicle has been torted for some days, there is no benefit from emergency exploring the scrotum because the testis will atrophy and fibrous to a hade nodule; however, fixation of the remaining testicle should be carried out. The more common appendage to tort is the appendix of the testis (hydatid of Morgagni) (Figure 38.12) [12]. Though it can mimic a testicular torsion, there is often less swelling with tenderness confined to the superior pole. Sometimes, a small area of ischaemia represented by a blue dot is seen at the scrotal skin. Torsion of the hydatid of Morgagni will warrant testicular exploration just like a testicular torsion. Figure 38.12 Torsion of the appendix testis. At six weeks of embryonal development, the primordial testis develops from the primitive genital ridge medial to the mesonephric ducts [13]. At around eight weeks, the mesonephric ducts gives rise to the epididymis and vas deferens, and the testes starts taken shape [13]. Division of the genital ridge and duplication of the mesonephric duct will give rise to an extra testicle. Contact of the mesonephric duct with the primitive testis initiates development of the epididymis and vas deferens. Based on the reciprocal development, various types of polyorchidism exists [14]. In Type I, the extratestis has no epididymis or vas. This occurs if the division separates from a small part of the genital ridge that is not in contact with the rete testis [14]. In Type II, the extratestis will have its own epididymis with no vas. This occurs when there is division through the genital ridge where it is attached to the mesonephric duct [14]. In Type III, the testis has its own epididymis and shares a common vas. This is the most common form and may result if the division of the genital ridge and a portion of the mesonephros. In Type IV, there is complete duplication of the testis, epididymis, and vas, resulting from simultaneous duplication of the genital ridge and mesonephric duct [14]. Usually asymptomatic and presenting as a lump, but it can present in association with inguinal hernias in 24%, cryptorchidism in 22%, torsion in 15%, and testicular cancer in 6.4% [13, 15]. Diagnosis can be confirmed with ultrasound (Figure 38.13) or magnetic resonance imaging (MRI). Spermatogenesis is normal in 50% of patients, and in the absence of suspected malignancy or torsion, patients can be left alone [15]. Figure 38.13 Ultrasound of third testicle. A varicocele is an abnormal dilation and tortuosity of the veins draining the testes and epididymis (Figure 38.14). A varicocele is often caused by absent or incompetent valves in the testicular vein. A more sinister cause should be excluded in new onset varicocele in adults, such as renal malignancy causing extramural obstructive pressure on the left testicular vein and venous obstruction from a retroperitoneal metastases from a cancer of the testis. Dissection of the gonadal vein during radical nephrectomy can also cause a varicocele. Figure 38.14 Venous drainage of the testis. A varicocele is more common on the left testis for various reasons. The left testicular vein is longer than the right, the left testicular vein anastomoses with the left renal vein at a right angle, the left testicular artery can compress the left testicular vein because of a variant anatomy, the descending colon can compress the left testicular vein, and the nutcracker phenomena caused by compression of the left renal vein by the aorta and superior mesenteric artery or compression of the left iliac vein by the left iliac artery [16]. A varicocele is present in 15% of men and is present in 19–41% of men with primary infertility and 45–81% of men with secondary infertility [16, 17]. Although a varicocele is a well‐known confounding factor for male subfertility, the pathophysiology behind this is uncertain. Routine repair of varicocele in subfertile men remains controversial. Some advocate that varicocele repair should not be offered as a form of fertility treatment because it does not improve pregnancy rates [18]. Others recommend a repair for those with a clinical varicocele, oligospermia, infertility for at least two years, and for unexplained infertility in the couple [19]. A recent review on varicocele and fertility have concluded that varicocele repair should be offered in young adults with impairment of seminal parameters because it is associated with a significant improvement of sperm concentration, motility and normal morphology, and is associated with improved pregnancy rates [20]. The majority of varicoceles are asymptomatic; however, some patients may complain of a swelling or a dragging heaviness discomfort in the scrotum or of pain or aching in the testicle. Physical examination can reveal a collection of dilated vein (Figure 38.15); however, on palpation, the classical ‘bag of worms’ is appreciated with a cough impulse and disappears when the patient lies flat owing to the emptying of the vein. In chronic cases the ipsilateral testis can be smaller due to atrophy. Table 38.2 depicts the standard grading system used. Figure 38.15 Varicocele visible through scrotum. Table 38.2 Varicocele grading system. Investigations are not required in the majority of cases; however a Doppler ultrasound can accurately make the diagnosis (Figure 38.16). Where embolisation is considered or in recurrent varicocele post‐treatment, a venogram can be obtained. Figure 38.16 Doppler ultrasound showing a varices. Reserved for symptomatic patients, such as those with pain, large varicoceles, dand elayed testicular growth compared to contralateral side if not affected. There are numerous modalities for the treatment of varicocele. Gaining access via the femoral veins, the testicular vein can be embolised injecting them with coils or a sclerosing agent. The testicular vein is isolated from the artery in the retroperitoneum and ligated during laparoscopic ligation (Figure 38.17). Figure 38.17 Laparoscopic clipping of testicular veins for varicocele. For an inguinal ligation, the external oblique is slit open through a small crease incision over the internal ring and the internal oblique and transversus are split in the line of their fibres giving access to the retroperitoneal fat. The testicular vessels are seen just as they curl round the inferior epigastric artery. The testicular artery is carefully dissected from the veins, which are divided between ligatures (Figure 38.18). Figure 38.18 High ligation of testicular veins through the inguinal approach. The spermatic cord is isolated as it emerges from the external ring, and all the veins are ligated outside the internal spermatic fascia, sparing the testicular artery (Figure 38.19). Figure 38.19 Low ligation of testicular veins at the external ring. Chronic testicular pain can give patients great grief. Causes for orchilgia such as a previous testicular injury, infection, torsion, and surgical operations (on the testicle or a vasectomy) are consevativly managed with pain relief measures. An ultrasound can exclude a cancer, a missed testicular injury or torsion, referred pain from a renal calculus, or a leaking aortic aneurysm. A small number of patients have a pain of unknown origin, which could be attributed to a deep‐seated psychological disorder, and surgical intervention only makes things worse. Orchiectomy in this situation is usually followed by a return of the pain on the other side [21]. This painful condition is sometimes seen in young men who become sexually excited without the opportunity to orgasm. The pathophysiology is unclear. On examination, the veins of the cord are tender and distended. The condition may be accompanied by so much pain radiated to the iliac fossa that can lead to a misdiagnosis of an appendicitis. The venous congestion is relieved by a warm bath.
Testes Benign Swelling
Abstract
38.1 Hydrocele
38.1.1 Aetiology
38.1.1.1 Congenital Hydrocele
38.1.1.2 Primary or Idiopathic Hydrocele
38.1.1.3 Secondary Hydrocele
38.1.2 Clinical Features
38.1.3 Investigations
38.1.4 Treatment
38.1.5 Operations for Hydrocele
38.1.6 Complications
38.2 Epididymal Cyst
38.2.1 Operative Technique
38.3 Benign Testicular Cyst
38.4 Testicular Torsion
38.4.1 Extravaginal
38.4.2 Intravaginal
38.4.3 Clinical Features
38.4.4 Investigation
38.4.5 Differential Diagnosis
Infants
Children and Adults
Scrotal haemorrhage
Acute epididymo‐orchitis
Fat necrosis
Incarcerated indirect inguinal hernia
Acute idiopathic scrotal oedema
Acute idiopathic scrotal oedema
Mumps and viral orchitis
38.4.6 Treatment
38.4.6.1 Scrotal Exploration
38.4.7 Torsion of a Testicular Appendage
38.5 Polyorchidism
38.6 Varicocele
38.6.1 Clinical Features
Grade 0
Impalpable, incidentally found on ultrasound scanning
Grade I
Palpable only on cough impulse/Valsalva manoeuvre
Grade II
Palpable in a standing position
Grade III
Visible through the scrotal skin
38.6.2 Investigations
38.6.3 Treatment
38.6.3.1 Embolisation
38.6.3.2 Surgical Ligation
38.6.3.3 Retroperitoneal Ligation
38.6.3.4 Subinguinal ligation
38.7 Orchialgia
38.8 Nux Amatoris
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