Testis and Penile disorders😍

Cryptorchidism

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  • Definition: Failure of the testis to descend.

Testicular Descent Triggers

  • Differential growth of abdominal wall: Most important.
  • Hormonal factors.
  • Pull of gubernaculum: Least important.

Normal Descent Timeline

  • Iliac fossa (6 months).
  • Inguinal canal (7 months).
  • Superficial ring (8 months).
  • Scrotum (9 months).

Features

  • Most common site: Inguinal canal.
  • Right > Left.
  • Bilateral → Cryptorchidism.

Complications (TESTIS Mnemonic)

  • Trauma.
  • Epididymoorchitis.
  • Sterility.
  • Torsion.
  • Indirect inguinal hernia (Most common).
  • Seminoma (Type of cancer).

Histological Changes

  • Decreased spermatogenesis.
  • Thickening of seminiferous tubules' basement membrane.
  • Decreased volume.
  • Increased risk of intratubular germ cell neoplasia.
  • Sertoli cells: More affected (spermatogenesis affected).
  • Leydig cells:
    • Less affected by temperature
    • Hyperplasia of Leydig cells.
    • (normal secondary sexual characteristics).

Fertility Consequences

  • decreased fertility (even after orchidopexy).
  • Unilateral cases: No change
  • Bilateral cases operated in adulthood: Azoospermic & infertile.

Associated Risk

  • Lifelong risk of cancer
    • Most common type: Seminoma.
    • Cancer risk:
      • Surgery before puberty: 2-3 times higher than general population.
      • Surgery after puberty: 5-6 times higher than general population.
  • Infertility

Undescended Testis Management

  • IOC: Diagnostic Lap > MRI
  • Time to Operate: 6-12 months
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  • Orchiopexy
    • Surgery to reposition testis into scrotal sac
    • Perform as early as possible, ideally before 18 months.
  • Bilateral Non-Palpable Testis:
    • β-hCG injection → No response → Anorchia
      (Increased testosterone, FSH, LH).
    • After 5-6 months:
      • Laparoscopy ± exploration.
  • Unilateral Non-Palpable Testis:
    • If intra-abdominal testis found:
      • Orchidopexy (Maneuver to bring testis down; 3-point fixation done).
    • Surgical exploration → Laparoscopy
    • Laparoscopy → Blind-ending vessels
      • → Monorchia (excise remnant).
    • Laparoscopy → Vessels exiting internal ring
      • → Inguinal exploration → Orchidopexy.
        • Orchidopexy
          • Manoeuvre to bring the testis down
          • 3-point fixation is done
    • If intra-abdominal testis with necrosis: Orchidectomy.
        • notion image

Ectopic Testis

  • Testis deviated from normal path of descent.
  • Most common site: Superficial inguinal pouch
  • Management: Orchidopexy.

Retractile Testis

  • Normal variant.
  • Testis in scrotum but can occasionally move into inguinal canal.
  • Management: Reassurance.

Synergistic Spreading Gangrene/
Necrotising Fascitis

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What it Is

  • Rare but serious bacterial infection.
  • Affects and spreads via the deep fascia (termed fasciitis).

Causing Organisms

  • Mixed pattern of bacteria:
    • Coliforms
    • Staphylococci
    • Bacteroides species
    • Anaerobic streptococci
    • Peptostreptococci
  • Both aerobic and anaerobic bacteria
    • anaerobic bacteria thrive because aerobic bacteria destroy living tissue.

Spreads & Progression

  • Signs of spreading:
    • Severe wound pain
    • Spreading inflammation
    • Crepitus (cracking/rattling sensation)
    • Odour
  • If untreated:
    • Widespread local gangrene
    • Systemic multisystem organ failure

Specific Types/Locations

  • Abdominal wall infections: 
    • Meleney's synergistic gangrene.
  • Scrotal infections: 
    • Fournier's gangrene.

Risk Factors

  • immunocompromised.
  • Diabetes Mellitus
  • Initiating cause:
    • May be minor wounds

Diagnosis

  • Finger Test (Primary Diagnostic Tool):
    • Infiltrate suspected area with local anaesthesia.
    • Make a 2-cm incision down to the deep fascia.
    • Positive Signs:
      • Lack of bleeding from incision.
      • Dishwater-coloured fluid seeping from the wound.
      • Gentle probing with gloved index finger at deep fascia dissects tissues with minimal resistance.
  • Tissue Biopsies:
    • Sent for frozen section analysis.

Treatment

  • Multifaceted approach:
    • Broad-spectrum antibiotic therapy
    • Surgical Debridement:
      • Wide excision of necrotic tissue
      • Laying open of affected areas
      • large areas of skin grafting later

Fournier’s Gangrene

Features

  • Necrotizing fasciitis in the perineal region.
    • Synergistic infection: Aerobic + Anaerobic bacteria.
  • Most common in immunocompromised patients (e.g., Diabetes Mellitus, alcoholics).
  • Testis is spared due to dual blood supply.

Management

  • Aggressive debridement.
  • Broad-spectrum antibiotics + IV fluids.
  • Hyperbaric oxygen (latest treatment).

Meleney's gangrene

  • Gangrene extending into the abdominal wall
      • notion image

Gas Gangrene

  • Clostridium perfringens

CF

  • Sudden onset of swelling and pain,
  • fever,
  • delirium,
  • crackles / crepitus
  • hypotension

Hydrocele

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  • Clinical Features:
    • Tense swelling,
    • testis not palpable separately,
    • brilliantly transilluminant.
      • Transillumination test is positive.
  • Accumulation of fluid in the tunica vaginalis.
  • Most common type: Vaginal hydrocele.
  • Primary:
    • Due to decreased absorption.
    • Most common type.
  • Secondary: 
    • Due to increased secretion secondary to
      • infections (most common),
      • trauma, or
      • tumors.
  • Surgery:
    • Smaller sac: Lord’s plication.
    • Larger sac: Jaboulay’s procedure (Eversion of sac)
    • Mnemonic: Small (smaller) Lord () do Large () Job (Jaboulay) for me

Varicocele

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  • Features: 
    • Dilated, tortuous pampiniform plexus of veins.
    • Mnemonic: Pampiniform plexus → Pambinepole
      • Increased temperature → infertility.
  • Left side > Right side
    • Reasons
      • Left testicular vein is longer.
      • Opens at right angles to the left renal vein.
      • Sigmoid colon can press on left testicular vein.
      • Left Renal Cell Carcinoma (RCC) can grow along the renal vein, causing secondary varicocele.
  • Majority are asymptomatic.
  • Infertility.
  • On Examination: "Bag of worms" consistency.
  • IOC: Doppler ultrasound.

Treatment:

  • Percutaneous embolization of gonadal veins (First-line).
  • If percutaneous treatment not possible/recurrence:
    • Surgical ligation (microsurgical varicocelectomy).

Note

  • After surgery → Testis Drained by cremasteric veins
 
A 50-year-old male presents with scrotal swelling that he has noticed recently. On examination, the testis can be palpated as a separate structure from the scrotal swelling. The swelling is also noted to show transillumination when examined with a light source. The patient reports no pain or discomfort associated with the swelling. What is the most likely diagnosis for this patient?
A. Spermatocele
B. Epididymal cyst
C. Secondary hydrocele
D. Primary hydrocele
 
Feature
Spermatocele
Epididymal Cyst
Primary Hydrocele
Secondary Hydrocele
Age group
Common in middle-aged men
Any age
Infants/young adults (idiopathic)
Adults (secondary to pathology)
Palpation
Separate from testis (posterior)
Similar
Surrounds testis, not separable
Surrounds testis
Content
Sperm-containing fluid (milky)
Clear serous fluid
Clear fluid
Clear/yellow fluid
Transillumination
Positive
Positive
Positive
Positive
Pain
Typically painless
Painless
Painless
May be painful if underlying cause
  • ➡️ Spermatocele and epididymal cyst are very similar, but spermatoceles are more common in middle-aged men and contain sperm.
  • All show transillumination
  • Separate from testis → Suggests extra-testicular swelling
    (rules out hydroceles, which surround the testis)

Testicular Torsion

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Risk Factors

  • Testicular inversion.
  • Torsion of cyst of Morgagni (leads to "Blue Dot Sign").
  • Undescended testis.
  • Bell Clapper testis (high attachment of tunica vaginalis).

Clinical Features

  • Acute scrotal pain & swelling
    • differential diagnosis: epididymo-orchitis
  • Prehn sign:
    • Pain increases with elevation of testis
    • unlike epididymo-orchitis where pain decreases
  • Deming sign positive:
    • Affected testis lies at a higher level.
  • Angel sign positive:
    • Transversely placed testis.
  • 720° twist (Double twist) indicates rapid ischemia.
  • Mnemonic:
    • Angel () and demon (deming) test (testicular) us.
    • Angel by our side (Angle → transversely) and demon away in sky (demon → up)
    • Angel parakkumbo blue (blue dot) bell (bell clappper) thungi kidakkum
    • Blue dot (sign) in Agni (morgagni) → fire

Torsion:

  • Twist in vascular pedicle.
  • Absent blood supply.

Epididymo Orchitis:

  • Inflammation.
  • Increased vascularity.

Doppler is IOC

  • Image shows a Twisted Pedicle.
    • Known as the Whirlpool Sign of Torsion.
        • notion image

Notes on Management

  • Twisting within <6 hours: ≈100% salvageable.
  • Twisting >24 hours: <20% salvageable.
  • Prophylactic orchidopexy is always done on the contralateral (other) side.

Fracture Shaft of Penis

Clinical Features

  • Tear in the corpora cavernosa.
  • Usually seen in erect penis (during sexual activity).
  • Popping sound followed by pain.
  • "Eggplant deformity" of penis.
      • notion image
  • Management: Hematoma evacuation & penile repair.

Phimosis

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  • Inability to retract foreskin.

Clinical Features

  • Asymptomatic.
  • Symptomatic:
    • Ballooning of foreskin.
    • Balanoposthitis.
    • Difficult micturition.
  • Management: Circumcision.

Paraphimosis

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  • Failure to reposition foreskin after catheterization → Constriction ring around the penis.
  • Management: Conservative reduction → Fails → Dorsal slit.

Peyronie’s Disease

 
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  • Calcific deposition in corpora → Penis bends to one side.
  • Clinical Features: Pain during intercourse.
  • Diagnosis: Clinical examination + MRI
  • Management: 
    • Intralesional collagenase Clostridium histolyticum (Xiaflex) injection
    • → Fails → Nesbit’s technique/16-dot technique.
  • Mnemonic: His closed (Clostridium histolyticum) → Flexed (Xiaflex) → Nice butt (Nisbit)

Priapism

  • Prolonged erection >4 hours.
  • Erection >6 hours → Ischemia/necrosis of penis.
  • High-Flow Priapism:
    • Increased blood flow into penis.
    • Secondary to trauma, spinal injury, Papaverine injection.
    • Painless.
    • Penile ABG: Oxygenated blood.
  • Low-Flow Priapism:
    • Venous obstruction (Most common).
    • Hypercoagulable states: Children, Leukemia, Sickle cell anemia.
    • Painful.
    • Penile ABG: Deoxygenated blood.
  • Investigation: 
    • Angiography for low-flow priapism.
  • Management: 
    • Sedate patient → Adrenaline injection → Fails → Shunt -
      • Grey-Hack shunt (corporo-saphenous).
      • Hack 50 shades of Grey (Grey Hack)