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a i l m e n t s o f t h e s c ro t u m Undescended testicles
A ridgeling stallion is one in which both testicles have remained at the back of the abdominal cavity and have not descended into the scrotum.
Such horses are almost always infertile. With mares, however, he behaves just like a normal stallion, since he still produces normal quantities of testosterone. If the animal is sold as a gelding, the new owner may experience problems, as a ridgeling stallion is inevitably less placid than a gelding. In this way undescended testicles can lead to great confusion and dissension.
In Ancient Rome men with two undescended testicles were not allowed to appear in court as witnesses. Roughly speaking, 20 per cent of cases involved two undescended testicles. The Ancient world did have some notion of surgery, but the range of operations was limited.
In fact in those days the choice was between being castrated brutally or with a razor-sharp knife. Moving undescended testicles to their appointed place was impossible. There is little point in treating undescended testicles with medication in the form of hormones and this is scarcely ever done these days. Too often hormones proved ineffective and an operation was subsequently needed anyway.
Over 80 per cent of undescended testicles can be seen or felt in the groin. If they can be neither felt nor seen, doctors speak of crypto -
orchidism, meaning literally ‘hidden testicle’. That usually means that the testicle has got stuck somewhere behind the abdominal cavity.
These make up some 20 per cent of the total. Tissue examination of undescended testicles shows irreversible abnormalities in the sperm-cell producing tissue from six months after birth onwards. It is therefore crucial to relocate the testicle as soon as possible, that is, in the scrotum.
This kind of procedure is called orchidopexy, and in it the testicle is inserted and secured in the scrotum. If the seminal cord is short this can be a particularly awkward operation.
Cryptoorchidism is also found in animals. In cats the abnormality is fairly rare (0.7%), but in dogs it occurs regularly (between 0.8% and 11%, depending on the breed). It is most common in small breeds such as poodles, Yorkshire terriers, dachshunds, Chihuahuas, Maltese terriers, toy schnauzers and shelties. Dogs with this abnormality are excluded from breeding. As in humans, if left untreated the sperm quality is anyway exceptionally poor. There are some animals in which crypto orchidism is normal. In almost all marine mammals, with their streamlined shape, the testicles are located in the abdominal cavity, and the same applies to elephants and hippopotami.
In humans, if the testicle cannot be felt, keyhole surgery is first carried out to check whether the testicle has been formed at all. If the 119
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testicle is located high up behind the abdominal cavity, the distance is too great to bring it down together with its stalk. In that case a clamp is put on the stalk, that is, on the artery and vein, after which the blood supply is taken over by the small artery belonging to the seminal duct.
This is followed six months later by a second procedure in order to transfer the testicle to the scrotum, a procedure which can also be performed by keyhole surgery.
Being born with a testicle lodged behind the abdomen involves an increased risk of testicular cancer, which is not decreased by timely relocation in the scrotum. In addition it quite frequently happens that no connection is found between such a testicle and the epididymis, which of course means that no sperm cells can be expected from the testicle concerned. It is important in all cases to pinpoint the position of both testicles on the ‘testicular map’ immediately after birth. It is highly improbable that a testicle which has first been located in the scrotum will move to a position behind the abdominal cavity. The
‘testicular map’ is important in the diagnosis of a ‘retractile testicle’.
For a short period after birth the previously explained cremaster reflex is not yet present. The reflex goes on increasing until puberty, quite frequently causing boys’ testicles to be pulled into the groin. If there is no ‘testicular map’ and there is doubt whether the diagnosis should be
‘undescended testicle’ or ‘retractile testicle’, it sometimes helps to examine the child while he is lying in a warm bath or squatting.
Multiple testicles
Men with no testicles, one testicle or two are nothing out of the ordinary, but men with three are rare. A story is told of a monk who was unable to keep his vow of chastity because of having three testicles, while an eighteenth-century account describes a man with multiple testicles, a condition known medically as polyorchidy, who was capable of sexual intercourse up to his hundred and twenty-fifth year. Others were reputedly capable of ejaculating twenty times in one night.
Ambrosius Paré, one of the giants of medical history, believed that extra testicles were a common phenomenon, and many surgeons shared his view. Undoubtedly these were almost always spermatoceles that were mistaken for additional testicles.
In a medical career of nearly thirty years I have only ever encountered one case of multiple testicles. The boy in question had three – a case of triorchidy, which can take various forms. There may be an extra testicle without an epididymis or seminal duct (a), an extra testicle with an epididymis but without a seminal duct (b), an extra testicle with an epididymis attached to the seminal duct of a testicle located below (c), 120
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The various
forms of poly-
orchidy.
and an extra testicle with an epididymis and an extra seminal duct.
These are different kinds of tissue faults between the sixth and eighth week in the development of the embryo, the period during which it is decided whether one is going to look like a girl or a boy as regards external sexual characteristics.
Most patients with polyorchidy present with a painless swelling.
The most common location for the abnormality is on the left. In most men the diagnosis is made between the ages of fifteen and 25, and in 80 per cent of cases tissue examination of removed additional testicles showed a reduced or non-existent production of sperm cells.
M. Hakami and S. H. Mosavy described a man with fertile sperm in whom the third testicle was discovered only after a vasectomy on both sides.
Inguinal hernia
The testicles are formed at the spot where the kidneys are situated, high up behind the abdominal cavity. From there they descend through the inguinal canal into the scrotum. On that journey – the baby boy is still in his mother’s womb – they take the front of the abdominal membrane with them. When things proceed normally this bulge in the abdominal membrane closes, so that there is no open connection left with the abdominal cavity. The remnant of abdominal membrane in the scrotum surrounds the testicles for the rest of the individual’s life as a double-layered protective membrane.
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If that hernial sac does not close around birth, then there is a chance that the intestine of the newborn infant will descend as far as the scrotum, creating a so-called innate hernia, which sometimes manifests itself as a sizeable swelling. Of course a hernia requires surgery – in boys with a scalpel, in adults mostly by means of keyhole surgery.
Adults in whom the abdominal membrane has closed properly may suffer a hernia because of an increase in pressure due, for example, to chronic coughing or a great deal of heavy lifting. Often the intestines bulge into the groin but do not reach the scrotum. The doctor can ascertain whether there is a hernia by having the man blow against the back of his hand while standing and himself feeling the inguinal canal with his finger from the scrotum.
Torsio testis
Acute, intense pain on one side of the scrotum indicates a twisted stalk ( torsio) of the testis. This seems to happen to one man in 4,000 annually. The testicles do not lie loose in the scrotum: they are attached to it by a wide band which prevents the testicle from turning vertically on its axis. There are
some men, mostly aged between ten and 30, in whom the band is too long and often too narrow. One day they may have the unfortunate experience of one of their testicles starting to turn: this is impossible to mistake, since the victim feels sudden intense pain in the scrotum, spilling over into the groin. The scrotum becomes red or purple, and patient is often nauseous. In a physical examination the observant doctor will notice in a case of torsion the cremaster reflex, the retraction of the testicles in the direction of the groin when the inside of the thigh is stroked. It can happen that a torsion disappears spontaneously after a short time, and with it the pain. Even then it is advisable to consult a doctor, since the phenomenon will undoubtedly recur one day, and it’s doubtful whether expert help will be on hand.
The fact is that torsio testis can have unpleasant consequences. As a result of the twisting of the testicle pressure is put on the veins and the artery. The flow of blood is interrupted and, if the situation continues for more than a few hours, the tissue in the testicle will die off for want of oxygen. The speed with which that happens depends on the extent to which the testicle has turned on its own axis. Sometimes it may have turned 360 degrees, in which case the process will be very rapid. The sperm-producing cells particularly are sensitive to a lack of oxygen, while those that make testosterone, the Leydig cells, survive longer. If a twisted testicle is untwisted within about four hours there need be no further repercussions. This need not, by the way, require an operation; an expert doctor may in the first instance attempt to solve 122
a i l m e n t s o f t h e s c ro t u m the problem manually. He or she should keep in mind the image of a heavy book, say a massive King James Bible, which has to be opened –
outwards.
Occasionally a torsio testis is not recognized and the pain and swelling are attributed to an inflammation of the epididymis, so subsequently a completely wrong treatment is applied, usually with anti -
biotics. This results in the completely unnecessary loss of an important organ. When in doubt, the best thing to do is to operate immediately, possibly after a duplex echograph. In this kind of operation the other testicle is immediately included, that is stabilized, to ensure that the problem will never be repeated on that side.
Inflammation of the epididymis
Pain in the scrotum with a sudden onset and which is often intense can also be caused by epididymitis, or inflammation of the epididymis. This kind of caused is produced by a bacterium that has spread from the urinary tracts to the seminal duct and from there to the epididymis.
Nowadays in younger people this is almost always chlamydia tracho -
matis, which is transmitted through sex. In the case of an inflammation of the epididymis, an extremely painful swelling develops at the back of the testicle, and soon afterwards the scrotum becomes hard and swollen. Anyone continuing to suffer in silence runs the risk of the testicle itself and hence fertility being affected. Inflammation of the epididymis is easy to treat with antibiotics, but if there is any doubt about the cause the gp will generally send his or her patient along for a urine culture to check what micro-organism has caused the inflammation of the urinary tracts. Experience shows that many men with an inflamma -
tion of the epididymis are not treated in time, or for long enough or with the wrong antibiotic, with the result that the infection may spread to the testicle itself, causing epididymo-orchitis. Complications include abcesses and the risk that after ‘recovery’ one is left with a ‘shrivelled testicle’.
It is also important that the patient rest as far as possible, and it is sensible to support the scrotum with a flannel containing ice, or an ice-pack.
Hydrocele
As has been said, after the closure of the hernial sac a remnant of the abdominal membrane carried along on the descent continues to surround each of the testicles as a double-layered sheet. Between those two layers there is normally a small quantity of liquid, which allows the testicle as it were to dance. Sometimes too much liquid is produced between the two layers, which can lead to a very large, uncomfortable 123
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Hydrocele.
hydrocele
swelling called a hydrocele. If such a hernia becomes troublesome, for example, when cycling or during sexual intercourse, an operation is called for.
This cabaret song by Hans Dorrestein gives a humorous slant on hydroceles and sex:
Geriatric Sex
Sex for us wrinklies shows the wear and tear,
reflects the elderly wife.
God, when will he come, the poor old sod?
His prick’s grown like a goat’s hoof with no hair.
Sex for us wrinklies shows the wear and tear,
his scrotum’s like a pouffe that’s full of air.
After forty years it isn’t odd,
growing as close as peas in a pod,
but when this is over I won’t care,
sex for us wrinklies shows the wear and tear.
Hydrocele may be triggered by a previous inflammation of the epididymis, a trauma, or in vary rare cases testicular cancer, though in the majority of cases the cause remains obscure. It may be removed either via the groin or via the scrotum. In the latter case an incision is made 124
a i l m e n t s o f t h e s c ro t u m in the skin and the next layer, the tunica dartos. Bleeding vessels are held with a fine pincette and cauterized. If the hydrocele is very large, it is first lanced and emptied by suction. The tunica vaginalis is cut open lengthways, so that the testicle itself can be taken out. The redundant layer is removed and folded back behind the epididymis. Because the wall of the hydrocele is turned inside out, the chance of relapse is small.
Because of the abundant blood there is a high risk of bleeding after this operation, and partly because of this a pipe is frequently left in through which blood can drain away.
Spermatocele
The weird idea of ‘growing an extra ball’ is particularly common with spermatocele. This is because a hydrocele is as it were attached to the testicle, which as a result appears to grow bigger and bigger, while a spermatocele can be felt separately from the testicle, always at the level of the head of the epididymis. A weak spot may occur in the wall of the tubes between the testicle and the epididymis, a bulge develops and sperm cells accumulate in it. Such spermatoceles are very common: most middle-aged men have one or two. There are generally small, do not hurt and can do absolutely no harm. However, sometimes they grow to such proportions that it becomes difficult to go on walking with them. Anyone who consults a specialist and is told that an operation is proposed would be well advised to ask whether that operation is really necessary. There is a risk of damage to the artery to the tes ticle, inflammation and bleeding may occur, and moreover there is no guarantee that very shortly there will not be a recurrence of spermatocele.
In order to prevent that the whole epididymis would have to be removed: with men who still want to have children it is completely disastrous to start operating.
Varicocele
To understand how a varicose vein or varicocele emerges it is necessary to know something about the blood supply to the testicles, or rather the drainage of blood. Venal blood leaves the testicles via the left and right testicular veins ( vena spermatica interna). The right-hand vessel discharges into the inferior vena cava, which transports low -
oxygen blood back to the heart. In the case of the left-hand testicular vein the situation is slightly different: it discharges into the left-hand renal vein, which transports blood purified in the left kidney to the vena cava. Since no organ, including a testicle, likes used blood, which contains waste matter, there are, especially in the left testicular vein, valves 125
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that prevent the blood from flowing back to the testicle. If those valves do not function properly it is possible that blood from the left renal artery will flow back, resulting in the formation of a varicose vein just above the left testicle, where there is a dense network of blood vessels (the ple
xus pampiniformis). This can lead to nagging pain, especially in men who stand up all day long. The accumulation of venal blood may cause the local temperature to rise, with possible harmful effects on fertility. But if the left testicle no longer functions properly, surely that won’t affect the right one? You’d certainly think not, but in practice in a number of cases of varicose veins venal blood flows back on the right-hand side too. This is because there are communication channels between the left and right side, but gravity undoubtedly also plays a part, since vari cose veins have never yet been observed in the scrotums of quad -
rupeds. Apart from that, varicose veins differ widely. Quite a few men, estimated at between 10 and 18 per hundred, have a varicose vein, but by no means everyone has a problem with it. Some 30 per cent of all men who consult a doctor because of involuntary childlessness have such a vein.
Making the diagnosis is generally quite simple. In half of patients the varicose vein is either visible to the naked eye or can be felt with the hand. In order to be able to assess the whole situation, the doctor will ask the patient to blow on the back of his hand briefly. A manoeuvre like this propels venal blood and causes the vein in the scrotum to swell considerably. If the doctor is not sure of his or her ground, he or she will ask for an ecograph of the scrotum. Surgery is by no means always called for in all cases of varicocele. With most men it is sufficient to advise the use of a tight-fitting pair of underpants. Only if the patient wishes to have children is treatment worthwhile. Researchers from Rotterdam showed recently in an excellent study that treating a varico -
‘Plugging’ the left
spermatic vein.
a i l m e n t s o f t h e s c ro t u m
Scrotal
lymphoedema
resulting from
filariasis.
cele significantly improves the chances of spontaneous pregnancy in the partner. There are three various possible treatments: surgically via an incision to the left of the navel, the groin or the scrotum, but also with an embolization in which a catheter is passed through the inguinal vein to the renal vein, after which a plug closure is inserted in the vena spermatica interna. The third possibility is a keyhole operation in which the vein is clipped. There is scarcely any difference between the success rates of the various treatments.
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