Porth's Essentials of Pathophysiology, 4e

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Genitourinary and Reproductive Function

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Spermatocele. A spermatocele is a painless, sperm- containing cyst that forms at the end of the epididymis. 15 It is located above and posterior to the testis, is attached to the epididymis, and is separate from the testes. Spermatoceles may be solitary or multiple and usually are less than 1 cm in diameter. They are freely movable and should transilluminate. Spermatoceles rarely cause problems, but a large one may become painful and require excision. Varicocele. A varicocele is characterized by varicosities of the pampiniform plexus, a network of veins supply- ing the testes 25 (Fig. 39-9C). The left side is more com- monly affected because the left internal spermatic vein inserts into the left renal vein at a right angle, whereas the right spermatic vein has a more oblique insertion into the inferior vena cava. In the standing male, this particular anatomy may cause higher pressures to be transmitted to the left scrotal veins and result in retro- grade reflux into veins of the pampiniform plexus. If the condition persists, there may be damage to the elastic fibers and hypertrophy of the vein walls, as occurs in formation of varicose veins in the leg. Sperm concentra- tion and motility are decreased in men with varicoceles. Varicoceles rarely are found before puberty, and the incidence is highest in males between 15 and 35 years of age. Symptoms of varicocele include an abnormal feel- ing of heaviness in the left scrotum, although many are asymptomatic. Usually, a varicocele is readily diagnosed on physical examinationwith the man in the standing and recumbent positions. Typically, the varicocele disappears in the lying position because of venous decompression into the renal vein. Scrotal palpation of a varicocele has been compared to feeling a “bag of worms.” Additional diagnostic methods include ultrasonography, radioiso- tope scanning, and spermatic venography. Treatment options for varicocele include surgical ligation or sclerosis using a percutaneous transvenous catheter under fluoroscopic guidance. It has been sug- gested that men with abnormalities in their semen and a varicocele show some degree of improvement in fer- tility after obliteration of the dilated veins. 25 However, the effectiveness of varicocele treatment in men from subfertile couples is still debated, especially when other assisted reproductive techniques (e.g., intracytoplasmic sperm injection [ICSI]) may be effective with as few as 20 sperm. 25 Aside from improving fertility, other rea- sons for surgery include the relief of the sensation of “heaviness” and cosmetic improvement. Testicular Torsion Testicular torsion is a twisting of the spermatic cord that suspends the testis. 26,27 Testicular torsion can be divided into two distinct types, extravaginal or intravaginal, depending on the level of spermatic cord involvement (Fig. 39-10). Extravaginal torsion, which occurs in fetuses or neo- nates, is the less common form of testicular torsion. 28 It occurs when the testicle and the fascial tunicae that sur- round it rotate around the spermatic cord at a level well

Torsion

Spermatic cord Testicular artery Epididymis

Testis

FIGURE 39-10. Testicular torsion with twisting of the spermatic cord that suspends the testis and the spermatic vessels that supply the testis with blood.

above the tunica vaginalis. The torsion probably occurs during fetal or neonatal descent of the testes before the tunica adheres to the scrotal wall. When the torsion occurs in utero, the baby is born with a large firm, non- tender testis. Usually the ipsilateral testis is ecchymotic. In these cases the torsed testis is rarely viable because of the time that has elapsed. In other cases the initial examination is normal, and acute scrotal swelling is recognized subsequently. In these cases, the torsed testis may occasionally be saved. The use of surgical treatment (orchiopexy [in which the testes is attached to the scro- tum] and orchiectomy [removal of the testis]) is contro- versial. There are multiple animal studies indicating that failure to remove the torsed testis may produce an auto- immune response that affects the normal testis. 28 Intravaginal torsion involves twisting of the sper- matic cord within the tunica vaginalis. It is a true surgi- cal emergency, and early recognition and treatment are necessary if the testicle is to be saved. 26–28 Intravaginal testicular torsion can occur at any age, but is more com- mon during adolescence. Torsion usually occurs in the absence of any precipitating event and is thought to be due to abnormal fixation of the testis within the tunica vaginalis, allowing the testis to twist, especially during periods of testicular growth such as puberty. The torsion obstructs venous drainage, with resultant edema and hemorrhage, and subsequent arterial obstruction. Males usually present in severe distress within hours of onset and often have nausea, vomiting, and tachycardia. The affected testis is large and tender, with pain radiating to the inguinal area. Testicular torsion must be differentiated from epi- didymitis, orchitis, and trauma to the testis. On physical examination, the testicle often is high in the scrotum and in an abnormal orientation. These changes are caused by the twisting and shortening of the spermatic cord. The degree of scrotal swelling and redness depends on the duration of symptoms. The cremasteric reflex, nor- mally elicited by stroking the medial aspect of the thigh and observing testicular retraction, frequently is absent.