C h a p t e r 3 9
Disorders of the Male Genitourinary System
1005
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
