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U N I T 1 1
Genitourinary and Reproductive Function
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
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.
Spermatic
cord
Testicular
artery
Epididymis
Testis
Torsion
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.
