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• Pituitary failure, primary testicular failure, hypothyroidism and most other endocrine diseases
may contribute to impotence.
Pharmacological
Some drugs, in particular antihypertensive agents,
tranquillizers and oestrogens, may cause impotence.
Alcohol is also a common cause.
Psychogenic
Psychogenic impotence is usually of sudden onset,
and the patient continues to have nocturnal erections
and erections following masturbation, suggesting
there is not a physical cause.
Examination
After a thorough history looking at possible causes,
examination should consider the following:
Penis– malignant or premalignant lesions; penile
•
deformities (e.g. Peyronie’s disease).
Testes– signs of hypogonadism (small testes).
•
• Gynaecomastia and reduced body hair.
•
Rectal examination– large and/or irregular prostate.
luteinizing hormone, prolactin and thyroxine
should be excluded.
Treatment
Treatable medical causes are excluded, and hormonal disturbances are corrected when possible. Other
treatments include the following.
•
A phosphodiesterase type 5 (PDE5) inhibitor, such
as sildenafil or tadalafil, is taken 1 hour before
intercourse. It causes vasodilation of the corpus
cavernosum, but is contraindicated in patients on
nitrate therapy, for example for ischaemic heart
disease, since this combination can result in
severe hypotension; a thorough cardiac risk
assessment should be performed. Side effects also
include nasal congestion, flushing and dyspepsia.
PDE5inhibitors are successful in treating 75% of
patients.
Second line treatments include:
Alprostadil (prostaglandin E1), given by intrapenile
•
injection or by direct intraurethral application.
A vacuum condom with constriction ring or an
•
intrapenile inflatable prosthesis may be used.
Special investigations
A history and examination are conducted to determine
the cause. Other investigations include the following:
HbA1c estimation to detect diabetes.
•
• hormone screen: abnormalities in the blood levels
of testosterone, follicle-
stimulating hormone,
Additional resources
Case 118: A foreskin problem in a child
Case 119: An ulcerated prepuce
4848
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The testis andscrotum
Alexandra J. Colquhoun
Learning objectives
✓ To know the dierent causes of testicular maldescent and their
treatment.
✓ To have knowledge of testicular torsion, how it presents, its dierential
diagnosis and treatment.
✓ To know the dierent causes of scrotal lumps, their diering clinical
features and treatment, including the diagnosis and management of
testicular tumours.
covered by the tunica vaginalis. As expected from the
Abnormalities
oftesticular descent
embryology, abnormalities of descent are more common in premature infants (20% incidence) than in
full- term infants (2%).
Embryology
The testis arises from the mesodermal germinal ridge
in the posterior wall of the abdominal cavity. It links
up with the epididymis and vas deferens, which
develop from the mesonephric duct (see Chapter43).
As the testis enlarges, it undergoes caudal migration.
By the third month of foetal life, it is in the iliac
fossa; by the seventh month, it reaches the inguinal
canal; by the eighth month, it has reached the external
inguinal ring and by the ninth month, at birth, it has
descended into the scrotum. During this descent, a
prolongation of peritoneum, called the processus vaginalis, projects into the foetal scrotum; the testis slides
behind this and is thus covered in its front and sides by
peritoneum. The processus vaginalis becomes obliterated at about the time of birth, leaving the testis
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
Classication ofmaldescent
Testicular maldescent can be subdivided according to
whether or not the testis followed the normal course
of descent.
Ectopic testis (uncommon)
A testis that has strayed from the normal line of
descent is termed ‘ectopic’. The most common position is in the superficial inguinal pouch, which lies
anterior to the external oblique aponeurosis. The testis reaches this site after migrating through the external inguinal ring and then leaves the normal track of
descent to pass laterally. Other locations are the groin,
the perineum, the root of the penis and the femoral
triangle.
Undescended testis (common)
A testis that has followed the normal course of descent
but has stopped short of the scrotum is termed an
‘undescended’ or, more properly, an ‘incompletely
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descended testis’. It is a relatively common finding,
detected in 1in 25 boys at birth. The testicle may lie
anywhere from the abdominal cavity, along the inguinal canal, to the top of the scrotum. The vast majority
are due to a local defect in development. The affected
testis is always small and it is probable that this
imperfect development impairs descent rather than
that the imperfect descent impairs development. The
incompletely descended testis is usually accompanied by persistent patency of the processus vaginalis,
presenting as a congenital inguinal hernia. Unilateral
undescended testes are four times as common as
bilateral. The condition of an undescended impalpable testis is termed ‘cryptorchidism’, which can be unilateral or bilateral.
Most, if not all, testes that are going to descend do
so within the first few months of life. If the testis is not
in its normal scrotal position in early childhood, it is
very unlikely that it will be capable of spermatogenesis. However, the interstitial (Leydig
produce testosterone in response to luteinizing hormone, are functional, so that secondary sex characteristics develop normally.
1
) cells, which
Differential diagnosis:
theretractile testis
The most common mistake in diagnosis is to fail to
differentiate a true maldescent from a retractile testis.
The retractile testis is a normal testis with an excessively active cremasteric reflex, resulting in the testis
being drawn up to the external inguinal ring. It is a
common condition and often the parents think that
the testes have failed to descend; indeed, when the
scrotum is palpated the testes may not be felt.
However, careful examination will probably reveal
the testis at the external inguinal ring or at the root of
the scrotum and the testis can, by downward stroking
or by gentle traction, be coaxed into the scrotum. A
useful trick is to place the child in the squatting position for the examination; this often encourages a
retractile testis to descend into the scrotum. It is also
worthwhile asking the parents to examine the child
when he is relaxed in a warm bath, again, the retractile testis may then slip into its normal position.
1
Franz Leydig 1821–1908), German Zoologist and
Histologist, who also described eponymous cells in sh and
crustaceans.
If the testis is easily palpable in the groin and
remains easy to feel when the child tenses his abdominal wall muscles, it is lying in the ectopic position
and not in the inguinal canal – where it is usually
impalpable or, at the most, in a thin boy, detected as a
vague, tender bulge.
Treatment
The child with retractile testes is normal; reassurance
of the parents is all that is required.
The ectopic or undescended testis must be placed
in the scrotum if it is to function as a spermorgan. The optimum age for surgery has been revised
in recent times, and current recommendations are for
surgery around the age of 6 months. After that age,
definite changes in the testis can be seen on
microscopy, which may lead to impaired spermatogenesis. The operation, termed ‘orchidopexy’, consists
of mobilizing the testis and its cord, removing the coexisting hernial sac and fixing the testis in the scrotum
without tension.
producing
Complications ofmaldescent
• Defective spermatogenesis, causing sterility if
bilateral.
Increased risk of torsion.
•
• Increased risk of trauma.
•
Increased risk of malignant disease, even if surgi-
cal correction is carried out.
Inguinal hernia – persistence of the processus
•
vaginalis.
Scrotal swelling
Examination
When considering any swelling in the scrotum, the
following three questions should be considered in
turn (Figure48.1).
1
Can you get above the swelling? If not, the swelling
arises from the abdomen and is an inguinoscrotal
hernia.
2 Is it separate from the testis? If it is, and if it is cystic
on transillumination, the swelling is an epididymal cyst.
3 If it is not separate from the testis, is it cystic or
solid?
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1 Can I get above it?
If not, it is an
inguinal hernia
If so, it is a primary
scrotal swelling
2 Is it cystic?
No palpable testis –
hydrocele
3 Is it solid?
Confined to
testis –
tumour or
gumma (rare)
a If it is cystic, it is a hydrocele.
If it is solid, it is very likely to be a testicular
b
cancer.
Testis felt separate –
cyst of epididymis
Epididymis –
chronic epididymitis:
probably TB or
residium of
acute infection
Special investigation
Ultrasound of the scrotum should clarify the nature of
the swelling if there is clinical uncertainty and if a
tumour is suspected.
Figure48.1 Questions to resolve
the differential diagnosis of a scrotal
swelling.
Epididymal cysts
Epididymal cysts are common and due to cystic
degeneration of one of the epididymal or paraepididymal structures. They are often multiple, may be
bilateral, and produce a swelling in the scrotum that is
separate from the testis and should transilluminate.
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(a)
Vaginal
hydrocele
The swelling may be tense and so the cyst may feel
hard. The contained fluid may be water- clear or may
be milky and contain sperm; hence the old term ‘spermatocoele’. There is no way of differentiating clinically
between an epididymal cyst and a spermatocoele, and
the latter term is best abandoned.
Epididymal cysts are sometimes painful and their
bulk may occasionally be troublesome. If they
produce significant symptoms, excision may be
offered. Aspiration is usually unsuccessful because of
recurrence, and is discouraged due to the inherent
risk of introducing infection.
(b)
Congenital
hydrocele
(c)
Infantile
hydrocele
Hydrocoele
A hydrocoele is an excessive collection of serous fluid
in the processus vaginalis, usually the tunica.
Hydrocoeles may be classified as follows.
Primary or idiopathic hydrocoele
(Figure48.2)
This is usually large and tense. There is no disease of
the underlying testis. Primary hydrocoeles may be
subdivided into the following.
Vaginal hydrocoele. The vaginal hydrocoele is the
•
usual type of hydrocoele surrounding the testis
and separated from the peritoneal cavity. The
patient presents with a cystic transilluminable
swelling in the scrotum. On examination, the testis is difficult to feel and lies at the back of the
(d)
Hydrocele
of the cord
swelling which, owing to the anatomy of the
tunica, encompasses the anterior and lateral portions of the organ.
• Congenital hydrocoele. Congenital hydrocoele is
associated with a hernial sac, the still patent processus vaginalis. It opens into the peritoneal cavity
through a narrow orifice. When elevated, it gradually empties.
• Infantile hydrocoele. Infantile hydrocoele extends
from the testis to the internal inguinal ring but
does not pass into the peritoneal cavity.
•
Hydrocoele of the cord. Hydrocoele of the cord is
rare. It lies in, or just distal to, the inguinal canal,
separate from the testis and the peritoneum, and
represents a length of patent processus vaginalis
in which the upper and lower parts have closed.
Diagnosis is confirmed by the simple test of
downward traction on the testis, which pulls the
hydrocele of the cord down with it. The equivalent
in the female is a hydrocoele of the round ligament
within the inguinal canal, termed a ‘hydrocele of
the canal of Nuck’.
Figure48.2 (a–d) The anatomical
classication of hydrocoeles (the ring
at the upper end of each diagram
represents the internal inguinal ring).
2
Secondary hydrocoele
A secondary hydrocoele is usually smaller and lax and
the fluid collects because of inflammation in the
epididymis or testis, or an underlying testicular
cancer.
2
Anton Nuck (1650–1692), Professor of Anatomy and
Medicine, Leiden, the Netherlands.
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Treatment
Infants
Hydrocoeles in infants should be left alone because
most disappear spontaneously. If the hydrocoele persists after the first year, operative treatment is usually
advised. The sac is identified and excised, care being
taken not to damage any other structures in the cord.
Adults
In young adults, the possibility of tumour should be
borne in mind. Ultrasound examination will usually
differentiate a normal from an abnormal testis.
Many hydrocoeles are not troublesome, but
because of concern about the nature of the swelling
and the possibility of testicular cancer. Reassurance
in that situation usually suffices, but if the swelling
itself is troublesome, surgery can be offered. If a
hydrocoele is aspirated, recurrence is common, and
aspiration is seldom helpful. Various surgical options
are possible, involving obliteration or excision of the
hydrocele sac.
present
Acute infections ofthe
testis andepididymis
Acute infections usually arise as an ascending
infection via the vas deferens, spreading first to the
epididymis and then to the testis; occasionally, infection may be blood-
Blood- borne infection
The most common blood- borne agent to infect the
testis is the mumps virus, the testicular manifestation
of which usually follows within a week of the onset of
parotid gland enlargement. Occasionally, it may occur
in the absence of other manifestations. Diagnosis is
confirmed clinically and by the rising level of mumps
antibodies in the serum. Young adults are particularly
likely to be affected and there may be residual damage
to the testis and, if both sides are involved, fertility can
be impaired.
Ascending infection
Ascending infection is usually a consequence of
a preceding urinary tract infection (e.g. with
borne.
Escherichia coli) or a urethritis or prostatitis from a
sexually transmitted organism such as gonorrhoea
or Chlamydia, which result in epididymitis.
Epididymitis may also follow urethral stricture in
which straining causes reflux of urine up the vas, or
instrumentation of the urethra such as during
prostatectomy.
Clinical features
The patient will have a very painful swelling of the
epididymis, often with a secondary hydrocoele and
constitutional effects (pyrexia, headache and leucocytosis). There may be a history of dysuria, suggesting
a urinary tract infection, or urethral discharge, suggesting a sexually transmitted organism. Examination
of the urine may reveal the presence of organisms and
pus cells, but the urine need not be abnormal. Rectal
examination of the prostate may reveal coprostatitis.
existent
Treatment
Treatment is with an appropriate antibiotic given
over a prolonged course (4–6 weeks); ciprofloxacin
is a typical firstthe organisms most often encountered. Patients will
need to be fully counselled about ciprofloxacin associated potential collagensuch as tendon rupture and aortic dissection. If
frank abscesses have formed (verified by ultrasound), drainage is required. However, with early
adequate treatment, resolution is more likely. The
patient will often have residual swelling of the
epididymis, which may be rather firm, and differentiation from the tuberculous epididymitis may be
difficult unless the history of the previous acute
attack of tuberculosis is obtained. When epididymitis arises as a consequence of Chlamydia or other
sexually transmitted disease, it is important that the
sexual partner is also treated. In this situation, doxycycline is the antibiotic of choice.
line agent with good specificity for
related adverse effects,
Differential diagnosis
As with all acutely painful conditions of the testis, torsion must be excluded. If the patient is in their teens,
torsion is more likely; if in their twenties and sexually
active, epididymitis is more likely. If doubt exists,
urgent surgical exploration is mandatory.
Chronic infections ofthe
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testis
Gumma
Although once common, syphilis of the testis is now a
rarity. The testis is enlarged and is clinically difficult
to distinguish from a carcinoma. On penicillin therapy, gummas of the testis melt away.
Tuberculosis
This may occur in association with tuberculosis in
other parts of the genitourinary tract by ascending
infection, but more commonly is a consequence of
haematogenous spread.
Clinical features
The patient usually presents with swelling of the
epididymis. The vas deferens may be thickened and
feel nodular. A cold abscess may develop in relation to
the epididymis and rupture through the scrotum,
usually posteriorly, resulting in a chronic sinus. The
seminal vesicles may be enlarged and palpable on
rectal examination.
Diagnosis depends on isolating tubercle bacilli
from the urine or biopsy material, and/or evidence of
tuberculosis elsewhere.
The testis andscrotum 471
epididymis. It is probably impossible for torsion to
occur in an anatomically completely normal testis.
Untreated, the testis undergoes irreversible infarction
within a few hours and there is a typical transudation
of blood-
stained fluid into the tunica vaginalis.
Clinical features
Torsion of the testis is a surgical emergency, which
usually occurs in children or adolescents, typically
between 12 and 18 years of age, but it can occur in
neonates and in men in middle years. There may be a
history of mild trauma to the testis or of previous
attacks of pain in the testis due to partial torsion and
spontaneous untwisting. Cycling, straining, lifting
and coitus may be precipitants.
The history is of a sudden onset of severe pain in
the groin and lower abdomen, often accompanied by
vomiting. The abdominal pain occurs because the
nerve supply of the testis is mainly from the T10 sympathetic pathway. Rarely, the pain is limited to the
abdomen. Patients with torsion of the right testis have
been mistakenly operated on for acute appendicitis
because the testis has not been examined with care
or, more often, not at all.
Examination of the scrotum reveals a swollen testis,
painful to touch, sometimes lying high in the scrotum.
Elevation of the hemiscrotum on the side of the pain is
said to relieve the pain of epididymitis, but not of torsion,
the pain of which may be exacerbated (Prehn’s sign
3
).
Treatment
This is the same as for tuberculosis in other situations. If
a chronic sinus has developed, unilateral orchidectomy
is probably the best form of treatment, as the testis is
unlikely to be functional, is a continued source of infection and may lead to spread of the disease elsewhere.
Torsion ofthe testis
Aetiology
Usually, this is a torsion of the spermatic cord in a
congenitally abnormal testis, often maldescended or
hanging like a bell clapper within a completely investing tunica vaginalis. Occasionally, true torsion of the
testis occurs without involving the cord, when there is
an extensive mesorchium between the testis and
Differential diagnosis
The differential diagnosis is from acute epididymitis
and torsion of a testicular appendage; epididymitis
does not come on suddenly.
1
Epididymitis. The testis does not lie high in the
scrotum, there may be a systemic reaction with
pyrexia and leucocytosis and there may be a history of urinary infection with pus cells and organisms in the urine. A useful factor in differential
diagnosis is the age of the patient, as torsion of the
testis usually occurs before the age of 20whereas
epididymitis usually occurs after that age.
2 Torsion of a testicular appendage. Two embryologi-
cal remnants exist around the testis, the appendix
3
Douglas T Prehn (1901–1974), American Urologist.
Described the sign in 1934while working in a Naval hospital
in Brooklyn, NewYork.
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testis and the appendix epididymis, which may
themselves twist. They present in a similar fashion
to testicular torsion, but on examination the testis
does not lie high in the scrotum, and a dark blue
like swelling may be visible through the scrotal
peaskin (the so-
3
Strangulated inguinal hernia. Torsion may also
mimic a strangulated inguinal hernia.
Colour Doppler ultrasound of the testis may be helpful in diagnosis, provided it can be carried out rapidly
by an experienced operator, and only if it does not
delay surgical exploration.
called ‘blue dot sign’).
Treatment
If there is any doubt as to the diagnosis, it is best to
explore the testis as soon as possible, because every
hour increases the likelihood of irreversible damage
to the testis. If still viable, the testis is untwisted and
sutured to the tunica vaginalis. If infarcted, it is
removed. In every case, fixation of the other testis
should be performed at the same time, since any congenital anomaly is likely to be bilateral and torsion of
the opposite testis may, therefore, occur.
Varicocoele
This is a condition of varicosities of the pampiniform
plexus of veins. It usually occurs on the left, and manifests first in adolescence. It is present in nearly 10% of
men, the proportion increasing with age and being
higher in infertile men.
Its origin is said to be due to the drainage of the left
testicular vein at right angles into the left renal vein,
unlike the right testicular vein, which drains obliquely
into the inferior vena cava. Patients with varicocoele
have absent or incompetent valves at the junction
with the left renal vein.
Occasionally, a varicocoele can be secondary to
a tumour or other pathological process blocking
the testicular vein. The best known example of this
is a tumour of the left kidney involving the renal
vein and obstructing the drainage of the left testicular vein.
spermatogenesis, although surgical correction is not
associated with an increased live birth rate. On examination in the standing position, the varicose veins
within the scrotum feel like a ‘bag of worms’, but there
may be little to feel when the patient lies down.
Treatment
Usually, the varicocoele requires no treatment apart
from reassurance that the condition is not likely to
give rise to any dangerous complications. If the weight
of the varicocoele and testis causes an ache, closefitting underpants may help. If troublesome, the varicocoele can be cured radiologically by embolizing
the left testicular vein; less commonly surgical ligation and division of all the testicular veins that traverse the inguinal canal is required. There is no
evidence that treatment of a varicocoele has any
effect on male infertility.
Disorders ofthe scrotal
skin
Idiopathic scrotal oedema
Characteristically affecting prepubescent boys, this
inflammatory condition is characterized by an erythematous, oedematous swelling of the scrotal skin. It
may involve both sides of the scrotum, and can extend
into the groins. Unlike torsion, it is painless, and the
testis is normal on examination. Spontaneous resolution within a few days is usual.
Fournier’s gangrene
Fournier’s gangrene,4 or necrotizing fasciitis of the
scrotum, is a result of synergistic infection with several species of bacteria, both aerobic and anaerobic;
haemolytic streptococci, staphylococci, clostridia and
E. coli are common isolates.
The patient is often diabetic and catheterized; there
may be a history of minor trauma, perianal abscess or
surgery, although there is no obvious precipitating factor in half the cases. The patient develops sudden pain
in the scrotum, and rapidly becomes profoundly septic.
Clinical features
A varicocoele may cause a dragging sensation in the
scrotum. It can also be associated with defective
4
Jean Alfred Fournier (1832–1914), ‘Professeur des maladies
cutanées et syphilitiques’, Hôpital St Louis, Paris, France.
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This is a surgical emergency. Treatment involves
dose broad- spectrum antibiotics, critical care
highsupport and wide debridement of affected skin, with
repeated assessment under anaesthesia and further
excision if necessary. Due to potential large volume
skin loss, combined surgery with a urologist and plastic surgeon is recommended.
Carcinoma ofthe scrotum
Rare nowadays, this tumour is noteworthy as the first
described industrial malignant disease. Percival Pott
(1779) noted an association with chimney sweeps, in
whom chimney soot acted as a carcinogen when
ingrained into the scrotal skin. Later, it was described
in workers with mineral oils whose trousers were
soaked by the carcinogenic oils.
Presenting as an ulcerating growth, it is usually a
squamous carcinoma and is treated by wide excision
and block dissection of affected inguinal lymph
nodes.
Tumours ofthe testis
Testicular tumours are the most common solid malignancy in young adult men, although they are relatively uncommon, representing around 1% of
malignancies in men.
Aetiology
Undescended and ectopic testes are associated with a
three- fold increase in incidence of testicular cancer;
that risk is increased if the testis has not been brought
to lie in the anatomical position before the age of 13.
There is also an increased incidence in patients who
are infertile, and those who have had a previous contralateral testicular malignancy (12 times increased
risk). Other suggested risk factors include a family
history of testicular cancer and hypospadias.
Pathology
There are two main forms of malignant tumours of
the testis, seminoma and non- seminomatous germ
cell tumours (NSGCTs), of which teratoma is the main
5
Percival Pott (1714–1788), Surgeon, St Bartholomew’s
Hospital, London, UK.
type. Rarer tumours include sex- cord tumours and
lymphoma, which affects an older age group.
Seminoma
A seminoma arises from cells of the seminiferous
tubules, usually occurs between 30 and 40 years of
age and is relatively slow growing. Macroscopically,
the tumour is solid, appearing rather like a cut potato
on section. Microscopically, cells vary from welldifferentiated spermatocytes to undifferentiated
5
round cells with clear cytoplasm. Some 10% arise in
undescended testes.
Non- seminomatous germ cell
tumour
Non- seminomatous germ cell tumours occur in a
younger age group, the peak incidence being
20–30years. They are thought to arise from primitive
totipotential germ cells. Macroscopically, it has a
markedly cystic appearance and used to be called
fibrocystic disease. The cut surface may appear like a
colloid goitre, and areas of haemorrhage and infarction are common. Microscopically, the cells are very
variable and the tumour may contain cartilage, bone,
muscle, fat and other tissues.
Spread
• Local: the testis is progressively destroyed by the
tumour. Spread through the capsule is unusual,
but very occasionally in an advanced case there
may be ulceration of the scrotum.
• Lymphatic: to the para- aortic nodes via lymphatics accompanying the testicular vein. In advanced
cases, there may be enlargement of the supraclavicular nodes, especially on the left side.
Blood- borne: spread from NSGCT occurs rela-
•
tively early to the lungs and liver. In the seminoma,
this tends to occur late in the disease.
Clinical presentation
• As a lump in the testis.
•
As a hydrocoele.
• Sometimes as a painful rapidly enlarging swelling,
• As secondaries, usually metastatic deposits in the
lung (presenting as breathlessness), as a mass in
the abdomen due to involved abdominal lymph
nodes or as a cervical lymphadenopathy.
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Tumours of the testis usually present as a painless, swollen testicle, or a lump on a testicle that is hard and may
be associated with an overlying secondary hydrocele,
which sometimes contains bloodoften a misleading history of recent trauma, and rarely it
may present having undergone torsion.
Occasionally, gynaecomastia may be a presenting
feature, owing to the production of paraneoplastic
hormones.
stained fluid. There is
Special investigations
• Scrotal ultrasound may reveal a solid tumour with
or without the presence of a hydrocoele.
Tumour markers: NSGCTs usually produce α-
•
fetoprotein (AFP) and many produce β- human
chorionic gonadotrophin (βseminomas also produce β- HCG. These are useful
not only in making a diagnosis but also in subsequent follow-
• Computed tomography (CT) scans of the chest,
abdomen and pelvis are performed looking for
secondary spread in order to stage the disease.
up.
HCG); some pure
Treatment
If it is suspected that the testicular swelling is due to a
tumour, early surgical excision is mandatory. The
spermatic cord is exposed through an inguinal incision, occluded by an atraumatic clamp and the testis
delivered. The clamp prevents vascular dissemination of tumour cells. Orchidectomy is then performed
by ligating the cord and dividing it at the internal ring.
The use of intraoperative biopsy to confirm malignancy is now rare, given the accuracy of preoperative
scrotal ultrasound scanning. Inguinal, rather than
scrotal, exploration is performed to avoid exposure to
the scrotal lymphatics, which drain to the inguinal
nodes, unlike the spermatic cord, which drains to the
internal iliac nodes.
For organ confined disease, adjuvant treatment
with chemotherapy is often recommended to treat
occult micrometastatic disease. Seminomas are also
radiosensitive so adjuvant radiotherapy can be given
to the ipsilateral iliac and para- aortic lymph nodes for
this pathological disease type.
Patients who have metastatic disease on their staging CT scan are effectively treated with systemic
chemotherapy (bleomycin, etoposide and platinum).
Patients who exhibit persistent retroperitoneal lymphadenopathy after chemotherapy can be offered
retroperitoneal lymph node dissection with curative
intent. As chemotherapy is likely to render the patient
infertile, prior sperm banking is offered.
Prognosis
Node- negative cases have an extremely good prognosis of nearly 100% 5abdominal lymph node spread, there is still a 95%
5-
year survival and, with disseminated disease, long-
term survival is often achieved with chemotherapy.
year survival. Even with early
Male infertility
The majority of couples wishing to have children
achieve pregnancy within 2 years. However, 1in 10
couples suffers infertility, with the problem distributed evenly between each partner, with onecases due to factors in both the man and the woman.
Aetiology
Congenital disorder
• Chromosome abnormality, for example Klinefelter’s
syndrome
• Developmental anomaly, for example testicular
maldescent, absent vas deferens.
6
(XXY).
Physical problems
• Post- infection, for example following mumps
orchitis or mumps epididymitis.
Tra uma, with subsequent atrophy.
•
• Neurological, for example spinal injury, producing
erectile and ejaculatory dysfunction.
• Temperature, for example varicocele, tight- fitting
underpants.
Iatrogenic, for example vasectomy, damage dur-
•
ing orchidopexy or hernia repair.
Hormonal
• Pituitary insufficiency, for example from a pituitary tumour or craniopharyngioma.
• Liver failure, causing increased circulating oestrogens.
6
Harry Fitch Klinefelter (1912–1990), Associate Professor of
Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
third of
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