Only rarely is the testicle infected without spread from the epididymis; mumps is one example. The typical presentation of epididymitis is insidious onset of pain and swelling over hours to days, UTI symptoms, fever and erythema.13 Severe pain eventually prompts a visit to the clinic.

On physical exam, the epididymis is tender and swollen, and the scrotal surface may be erythematous. Even if the patient would allow you to try, the lesion would not transilluminate. A clinical test for epididymitis is the Prehn sign, in which the scrotum of a patient in the prone position is raised over the pubic bone. Pain that diminishes is considered to be positive for epididymitis.



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Differentiation between epididymitis, torsion (described below) and tumor is generally straightforward but can be quite difficult on occasion. History, systemic pathology and physical exam are the keys to making the appropriate diagnosis. Epididymitis specifically has an insidious onset, is painful, and may also include systemic pathology.14 Torsion has an acute onset, and tumors usually are not associated with pain.


Treatment includes antibiotics to address the appropriate pathogen. If a sexually transmitted source is suspected, treat with ceftriaxone (Rocephin) and azithromycin (Zithromax, Zmax). Otherwise, treat with ciprofloxacin (Cipro) or other agents likely to be effective against E. coli. Empiric treatment while waiting for culture results is appropriate. A negative result on urine culture is common. The patient should be instructed to lie prone with his scrotum elevated (a rolled-up towel under the scrotum is effective). Applying an ice pack will help quicken recovery and effectively reduce the pain.


Torsion


Testicular torsion is a result of a congenital defect that allows the testicle to rotate freely between the tunica albuginea and the tunica vaginalis. Normally, the testicle is safely anchored between the two layers and movement is limited. Torsion occurs when the testicle twists on the suspensory cord, which contains the vasculature, vas deferens and nerves that support it in the scrotum. Age of onset is usually between puberty and the early 20s.15 Torsion occurs less often in older men because the congenital defect would most likely have been manifested and treated at a younger age.


Clinically, the patient presents with acute-onset, severe testicular pain. Swelling will be significant. Classically, the testicle will be malrotated and riding high in the scrotum. Most cases of torsion occur when the patient rolls over in bed and the rubbing together of the thighs twists the testicle. A classic presentation is sudden onset of severe pain that wakes the patient and may be associated with vomiting. Trauma is an uncommon but possible cause. Differentiation between a torsion and infection is based primarily on the history — specifically, the rapidity of onset — and systemic findings.


Testicular torsion is an emergent surgical condition. Any patient in whom torsion is suspected needs an urgent scrotal US to definitively diagnose the condition. The absence of blood flow on Doppler US is diagnostic. If no ultrasound is readily available, it is reasonable to proceed directly to surgical management based on symptoms and examination alone.

A torsed testicle must be repaired within four to six hours in order to be saved. Detorsion can sometimes be accomplished manually. Manual detorsion allows surgery to be delayed, but surgery is still required to prevent future events. A surgically detorsed testicle is tacked to the scrotal wall (orchiopexy). The contralateral testis will be anchored as well because it is also at risk for torsion.11

Testicular cancer


Despite being the most common type of cancer among men aged 15 to 34 years, testicular cancer is quite uncommon. Significantly, testicular cancer is extremely curable in most men and is generally cited as one of the greatest medical success stories of this century. This success serves as an example of how to approach cancer treatment, as significant cure rates have been reached as a result of effective diagnostic techniques, improved tumor markers, effective multidrug chemotherapeutic regimens and modifications of surgical technique.16

Tumor types are divided into two primary categories — germ cell and non-germ cell. Germ cell tumors are by far the most common and account for 95% of testicular cancers. These tumors are further subdivided into seminoma (40%) and nonseminoma germ cell tumors (60%).2 Non-germ cell tumors account for only five percent of all testicular cancers, but they can be quite aggressive and more difficult to manage.


Patients will present with concern for a lump in the testicle. The nodule is painless in at least 90% of patients, and misdiagnosis is common: Testicular cancer is misdiagnosed in 25% of patients, and the average time from initial signs and symptoms to definitive treatment is three to six months.2

Other presenting features may include a sensation of “heaviness” in the testicle, lymphadenopathy in the pelvis and supraclavicular areas, gynecomastia and hemoptysis. As previously noted, 10% of testicular cancer patients will also have a hydrocele that masks the underlying tumor. For that reason, US evaluation is essential for the testicle that is not palpable on physical examination, especially in patients aged 15 to 40 years.


Once a tumor has been identified, treatment includes several steps: 


  1. Check tumor markers, including alpha-fetoprotein, beta-human chorionic gonadotropin and possibly lactate dehydrogenase and follicle-stimulating hormone. 

  2. Perform orchiectomy. There is no application for testicuar biopsy. The testicle is removed and sent to pathology to identify the type of tumor. 

  3. Get a CT of the abdomen and pelvis as well as a chest x-ray to further stage the cancer.

  4. Offer the option of banking sperm. Although fertility should be maintained by the remaining testicle, it can be stressed by surgery. Moreover, the remaining testicle may not be completely healthy to start with, and if radiation or chemotherapy is required, fertility can be jeopardized. 


Follow-up care includes CT, chest x-rays, complete blood count, basal metabolic panel and physical examination. The frequency with which these studies and examinations are done is based on the pathology report and staging of the tumor. Initially, some patients will require follow-up every three months, with visits and studies spreading out over time. After the initial monitoring phase, all testicular cancer patients will require annual checkups for the rest of their lives.2

The differential diagnoses for every patient with scrotal content concerns should include testicular cancer. If the diagnosis is not definitive or if the patient’s follow-up capability is questionable, US is a very specific diagnostic tool. 



Final steps


Because men are not always eager to see a health-care provider, their appearance in the clinic mandates a thorough evaluation and careful communication to address their anxiety. When scrotal-content concerns bring men in for evaluation, pain and fear of cancer are the most significant driving forces. Although testicular cancer is uncommon, it is still a major problem carrying significant morbidity and mortality.

After cancer has been ruled out with confidence, the patient needs to hear the words, “This is not cancer” loud and clear. Many times, the scrotal discomfort and lesion take on less significance for the patient once a testicular tumor has been ruled out.


Torsion and infections will require treatment and follow-up and typically have very favorable outcomes when treated promptly. Other scrotal lesions, including varicoceles, hydroceles and spermatoceles, can be simply monitored for changes or, in some cases, managed surgically — especially if fertility is an issue. Referral to urology is always appropriate when surgery is necessary or when further assessment is desired.

Craig Ensign, MPAS, PA-C, practices at the University of Utah School of Medicine, Division of Urology, in Salt Lake City, where William O. Brant, MD, is an assistant professor of surgery. 


References


  1. Rubenstein RA, Dogra VS, Seftel AD, Resnick MI. Benign intrascrotal lesions. J Urol. 2004;171:1765-1772.

  2. Tanagho EA, McAninch JW. Smith’s General Urology, 17th edition. New York, N.Y.: McGraw-Hill; 2008:375-381.

  3. Oliva E, Young RH. Paratesticular tumor-like lesions. Semin Diagn Pathol. 2000;17:340-358.

  4. Leung ML, Gooding GA, Williams RD. High-resolution sonography of scrotal contents in asymptomatic subjects. AJR Am J Roentgenol. 1984;143:161-164.
  5. Itoh M, Li XQ, Miyamoto K, Takeuchi Y. Degeneration of the seminiferous epithelium with ageing is a cause of spermatoceles? Int J Androl. 1999;22:91-96.

  6. Orlando MS, Schlecker BA, Wein, AJ. Benign diseases of the testicle and paratesticular tissues. AUA Update Ser. 1986;5:1-7.

  7. Skoog SJ. Benign and malignant pediatric scrotal masses. Pediatr Clin North Am. 1997;44:1229-1250.

  8. Rinker JR, Allen L. A lymphatic defect in hydrocele. Am Surg. 1951;17:681-686.

  9. Hermans BP, Foster RS, Donohue JP. Paratesticular masses. AUA Update Ser. 1998;17:290-295.

  10. Metin A, Bulut O, Temizkan M. Relationship between the left spermatic vein diameter measured by ultrasound and palpated varicocele and Doppler ultrasound findings. Int Urol Nephrol. 1991;23:65-68.

  11. Tanagho EA, McAninch JW. Smith’s General Urology, 17th edition. New York, N.Y.: McGraw-Hill; 2008:705.

  12. Tanagho EA, McAninch JW. Smith’s General Urology, 17th edition. New York, N.Y.: McGraw-Hill; 2008:210

  13. McPhee SJ, Papadakis MA, Rabow MW. Current Medical Diagnosis & Treatment 2012, 51st edition. New York, N.Y.: McGraw-Hill/Lange; 2012:918.

  14. Stewart A, Ubee SS, Davies H. Epididymo-orchitis. BMJ. 2011;342:d1543.
  15. Mellick LB. Torsion of the testicle: it is time to stop tossing the dice. Pediatr Emerg Care. 2012;28:80-86.

  16. Campbell MF, Retik AB, Vaughn ED, Walsh PC. Campbell’s Urology, 7th edition. Philadelphia, Pa.: W.B. Saunders Co; 1998:2411.


All electronic documents accessed August 7, 2012.