Porth's Essentials of Pathophysiology, 4e

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Disorders of the Male Genitourinary System

C h a p t e r 3 9

Color Doppler ultrasonography is increasingly used in the evaluation of suspected testicular torsion. Treatment includes surgical detorsion and orchi- ectomy. Orchiectomy is carried out when the testis is deemed nonviable after surgical detorsion. Testicular salvage rates are directly related to the duration of tor- sion. Because the opposite testicle usually is affected by the same abnormal attachments, prophylactic fixation of that testis often is performed. Epididymitis Epididymitis is an inflammation of the epididymis, the elongated cordlike structure that is located along the posterior border of the testis and functions in the transport and storage of sperm 29,30 (see Fig. 39-4). The cause of epididymitis varies with age. Most cases of epididymitis in men younger than 35 years are due to sexually transmitted infections such as Chlamydia trachomatis and Neisseria gonorrhoeae . In men older than 35, epididymitis is generally caused by infec- tion with common urinary tract pathogens, such as Escherichia coli and Pseudomonas . In prepubertal children, the disorder usually is associated with con- genital urinary tract abnormalities and infection with gram-negative rods. Infections may reach the epididymis through the vas deferens, in which case the pressure associated with void- ing or physical strain may force pathogen-containing urine from the urethra or prostate up the ejaculatory duct and through the vas deferens into the epididymis. Infections may also reach the epididymis through the lymphatics of the spermatic cord. Risk factors for epi- didymitis in all men include sexual activity, heavy physi- cal exertion, and bicycle or motorcycle riding. Recent urinary tract surgery or instrumentation and anatomic abnormalities such as prostatic obstruction are risk fac- tors in older men. Epididymitis is characterized by unilateral pain and swelling, accompanied by erythema and edema of the overlying scrotal skin that develops over a period of 24 to 48 hours. Initially, the swelling and induration are limited to the epididymis. The distinction between the testis and epididymis becomes less evident as the inflammation progresses, and the testis and epididy- mis become one mass. There may be tenderness over the groin (spermatic cord) or in the lower abdomen. Symptoms of lower urinary tract infection, such as fever, frequency, urgency, and dysuria, may be present. Whether urethral discharge is present depends on the organism causing the infection; it usually accompanies gonorrheal infections, is common in chlamydial infec- tions, and is less common in infections caused by gram- negative organisms. Laboratory findings usually reveal an elevated white blood cell count. Urinalysis and urine culture are impor- tant in the diagnosis of epididymitis, with bacteriuria and pyuria suggestive of the disorder; however, the uri- nalysis may be normal. If the diagnosis remains uncer- tain, color Doppler ultrasonography may be useful, revealing increased blood flow to the affected testis.

Treatment of epididymitis includes bed rest, scrotal elevation and support, analgesics, nonsteroidal anti- inflammatory agents, and antibiotics. Bed rest with scro- tal support improves lymphatic drainage. 29,30 The choice of antibiotics is determined by age, physical findings, urinalysis, Gram stain results, cultures, and sexual his- tory. Sexual activity or physical strain may exacerbate the infection and worsen the symptoms, and should be avoided. If a sexually transmitted disease is suspected, it is important to ensure that the sexual partner receives treatment. Orchitis Orchitis is an infection of the testes. It can be precipi- tated by a primary infection in the genitourinary tract, or the infection can be spread to the testes through the epididymis, bloodstream, or lymphatics. 29 It can develop as a complication of a systemic infection, such as paroti- tis (i.e., mumps), scarlet fever, or pneumonia. Probably the best known of these complications is orchitis caused by the mumps virus. 31 Mumps orchitis is now rarely seen in children younger than 10, but is the most common complication of mumps infection in the postpubertal male, occurring in approxi- mately 20% to 30% of adolescent boys and young men with mumps. Although the incidence of mumps orchi- tis has dramatically declined since the introduction of childhood vaccination programs, a sharp increase in mumps and mumps orchitis has recently been reported in both the United States 32 and the United Kingdom. 31 It is also important to note that mumps remains epi- demic in many countries throughout the world, and the mumps vaccine is only used in 57% of the World Health Organization member-countries. 31 The onset of mumps orchitis is sudden; it usually occurs approximately 3 to 4 days after the onset of the parotitis and is characterized by fever, painful enlarge- ment of the testes, and small hemorrhages into the tunica albuginea. Unlike epididymitis, the urinary symp- toms are absent. The symptoms usually run their course in 7 to 10 days. The residual effects seen after the acute phase of the infection include hyalinization of the semi- niferous tubules and atrophy of the testes (seen in half of affected men). Spermatogenesis is irreversibly impaired in approximately 30% of testes damaged by mumps orchitis. If both testes are involved (which occurs in 10% to 30% of cases), permanent sterility can result, but is rare. 31 Androgenic hormone function is usually maintained in these cases. Neoplasms of the Scrotum andTestes Tumors can develop in the scrotum or the testes. Benign scrotal tumors are common and often do not require treatment. Carcinoma of the scrotum is rare and usu- ally is associated with exposure to carcinogenic agents. Almost all solid tumors of the testes are malignant. Scrotal Cancer. Cancer of the scrotum was the first cancer directly linked to a specific occupation when, in the 1800s, it was associated with chimney sweeps. 33