Adolescent Health Care: A Practical Guide
William P. Adelman
Male Genital Examination
Examination of the male genitalia is a crucial part of the examination of the teenager. It is a relatively easy examination to learn because the male genitalia are readily accessible for palpation and the anatomy is straightforward (Fig. 28.1). Once the anatomy is understood, a history and physical examination is often all that is required to make an accurate diagnosis. If the anatomy of the presenting condition is unclear, because of inability to perform a complete examination, or loss of usual landmarks, ultrasonography is a simple, noninvasive method. Female examiners should note that in a study of male adolescents (Neinstein et al., 1989), males felt equally comfortable with either male or female examiners during this part of the examination. Before beginning the examination, the examiner should make sure that his or her gloved hands are warm.
- Inspect pubic hair area and underlying skin: Note sexual maturity rating (Tanner stage) and local pathological conditions such as folliculitis, herpes, scabies, crabs, warts, or molluscum contagiosum. Shaving of the pubic hair is becoming more prevalent, often aiding the practitioner in visual diagnosis, but confounding pubic hair sexual maturity rating.
- Inspect groin and inner aspect of thighs: Note swelling from lymphadenopathy or hernias or the presence or absence of fungal or bacterial infection.
- Inspect penile meatus: Check for presence of discharge, erythema, warts, or hypospadias.
- Inspect prepuce: Check for phimosis.
- Inspect penile glans: Check for redness (Candidainfection, balanitis, contact dermatitis) or ulcerations (herpes, syphilis, trauma). Uncircumcised males have higher prevalence rates of pearly penile papules as well as ulcerative sexually transmitted infections. It is best to have the uncircumcised patient retract his own foreskin. Male genital piercing is becoming more prevalent. Observe for signs of infection or contact dermatitis.
- Inspect corona: Check for pink, pearly penile papules. These are benign, uniform-sized papules that arise most commonly along the corona, during Tanner stage 2 or 3, in as many as 15% of teenagers (Neinstein and Goldenring, 1984).
- Inspect shaft: Check closely for ulcers or warts.
- Inspect scrotum: Check for redness, scabies, candidiasis, folliculitis, or epidermal inclusion cysts. Contraction of the dartos muscle of the scrotal wall produces folds or rugae, most prominent in the younger adolescent. An underdeveloped scrotum may indicate an ipsilateral undescended testicle. With a retractile testicle, the scrotum is normally developed.
- Inspect testes: The left testicle is usually lower than the right. Check for gross enlargement (tumor, infection, hydrocele, hernia) or for gross asymmetry suggesting possible atrophy or cryptorchidism on one side or unilateral enlargement as seen in tumor. Check for a “transverse lie” or “horizontal lie” of the testis suggesting a “bell clapper deformity” and increasing the risk for torsion.
FIGURE 28.1 Male genitalia showing inguinal area, spermatic cord, epididymis, and testis.
- Palpate inguinal area: Check for lymphadenopathy or hernia.
- Palpate the spermatic cord: This fascial-covered structure contains blood vessels, lymphatics, nerves, the vas deferens, and the cremaster muscle. Apply gentle traction on the testis with one hand and palpate the structures of the cord with the index or middle finger and thumb of the opposite hand. The vas deferens feels like a smooth, rubbery tube and is the most posterior structure in the spermatic cord. Absence of the vas deferens bilaterally is associated with cystic fibrosis. Unilateral absence of the vas deferens is associated with ipsilateral renal agenesis. Thickening and irregularity of the vas deferens may be caused by infection. Check for a varicocele (dilated pampiniform plexus of veins) within the spermatic cord.
- Palpate epididymis: The epididymis lies along the posterolateral wall of the testes. The head of the epididymis attaches at the superior pole of the testicles and runs down the back of the testicles to the tail that lies near the inferior pole. The epididymis becomes the vas deferens and leaves the testicle as part of the spermatic cord. The easiest way to find the epididymis is to follow the vas deferens toward its junction with the tail of the epididymis. Tenderness, induration, and swelling in this area usually indicate epididymitis. A well-localized, nontender, spherical enlargement of the epididymal head is a spermatocele.
- Palpate testes: Check size, shape, and presence of tenderness or masses. The adult testes are approximately 4 to 5 cm long and 3 cm wide but vary from one person to another. Stabilize the testis with one hand and use the other hand's thumb and first two fingers to palpate the entire surface. The testes should be roughly the same size (within 2 mL in volume of each other). Testicular volume could be quantified with the use of an orchidometer, or by ultrasound. See Chapter 1 for testicular volumes at different pubertal stages.Any induration within the testis is suspicious of testicular cancer until proved otherwise. The appendix testis, present in 90% of males, can sometimes be palpated at the superior pole of the testis.
- Palpate external inguinal ring: Palpate the external inguinal ring by sliding your index finger along the spermatic cord above the inguinal ligament while having the patient cough or strain to check for a hernia.
Cryptorchidism refers to an undescended testis that cannot be drawn into the scrotum. The normal testicular descent occurs in the eighth month of gestation. If a testis cannot be drawn into the scrotum by the third or fourth month of life, there is little evidence to suggest that it will spontaneously descend later.
The prevalence of cryptorchidism in newborns is 3.4%, decreasing to 0.7% by 9 months of age. This prevalence remains the same throughout childhood and adolescence. Cryptorchidism is the most common genitourinary disorder of childhood.
When a testis is not palpable in the scrotum, gentle massage should be performed along the line of descent from the anterosuperior spine, medially, and downward to the pubic tubercle. If the testis is not truly undescended, it should become palpable in the scrotum. If cryptorchidism is present, the teen should be examined for stigmata of associated disorders (i.e., Noonan, Klinefelter, or Kallmann syndrome or trisomy 13, 18, or 21).
Data suggest that potential fertility in the cryptorchid testis may be significantly impaired compared with normal testicular fertility, regardless of patient age at the time of discovery of the undescended testis. The fertility index of the descended mates of unilateral undescended testes may also be somewhat impaired in certain age-groups. Fertility is significantly hampered in patients with bilateral cryptorchid testes if the condition is not corrected by 6 years of age. In one study of 100 azoospermic, nonvasectomized men referred to a Danish fertility clinic, 27% had infertility secondary to cryptorchidism (Fedder et al., 2004).
Five percent to 12% of all malignant testicular tumors occur in males with a history of an undescended testis. The relative risk of tumors in such individuals is increased approximately 10 to 40 times that of a male without cryptorchidism. Moreover, the risk is increased even if the testis is brought down into the scrotum. In the United Kingdom Testicular Cancer Study (1994), a significant association of testicular cancer with undescended testis (odds ratio, 3.82; 95% confidence interval, 2.24 to 6.52) was found. In this study, the excess risk associated with undescended testis was eliminated in men who had had an orchidopexy before the age of 10 years.
Therapy for cryptorchidism in teenagers should be corrective surgery. These teens should be aware of the increased risk of testicular cancer and should be taught testicular self-examination (TSE).
Scrotal Swelling And Masses
This section discusses the general approach to the adolescent with a scrotal mass or a painful scrotum (Fig. 28.2).
The adolescent should be questioned regarding the following:
- Pain: Abrupt onset is suggestive of torsion; gradual onset suggests epididymitis or orchitis; lack of pain suggests a tumor or cystic mass.
FIGURE 28.2 Diagnostic approach to scrotal masses (Adapted from Schlossberger N. Male reproductive health:I. Painful scrotal masses. Adolesc Health Update 1992;4:1; Klein BL, Ochsenschlager DW. Scrotal masses. in children and adolescents: a review for the emergency physician. Pediatr Emerg Care 1993;9:351.)
- Recent change in testicular size or scrotum. Reactive hydroceles are common secondary to trauma, orchitis, testicular cancer, and epididymitis.
- Sexual activity: Epididymitis in adolescence is usually sexually transmitted.
- Prior history of pain: Torsion is often preceded by episodes of mild pain.
- Inspect testes.
- In torsion, the affected testis is often higher than on the contralateral side. With infections, the affected testis is often lower.
- In torsion, the affected testis and often the contralateral testis lie horizontally instead of in the usual vertical position, secondary to the congenital defect involved.
- In torsion, the epididymis is usually displaced anteriorly, as the testis twists on its vascular pedicle.
- Carefully palpate the testicular surfaces, the epididymis and cord (posterior structures), and the head of the epididymis (lateral structure).
- Isolated swelling and tenderness of the epididymis suggests epididymitis.
- A tender, pea-sized swelling at the upper pole of the testis suggests torsion of the appendix testis.
- Generalized swelling and tenderness of both the testis and the epididymis can be found in either testicular torsion or epididymitis with orchitis.
- Presence of a cremasteric reflex makes torsion unlikely. However, it is often present in torsion of the appendix testis.
- Prehn sign: Relief of pain with elevation of the testis suggests epididymitis. Lack of pain relief with elevation of the testis is not a reliable test for torsion.
- Nausea or vomiting with testicular pain is usually caused by torsion.
- If a painless mass is present (Fig. 28.2):
- Palpate to assess location.
- A mass within the testis is a tumor until proved otherwise.
- A mass palpable separate from the testis is unlikely to be a tumor.
- A “bag of worms” or “squishy tube” on left spermatic cord is a varicocele.
- A mass located near the head of the epididymis, above and behind the testis is probably a spermatocele.
- A mass anterior to the testis or surrounding the testis is probably a hydrocele.
- A mass that is separate from the testis/epididymis, intensifies with straining (Valsalva), and is reducible is probably a hernia.
- Transilluminate the mass with a light source: clear transillumination suggests a hydrocele or a typical spermatocele. Absence of transillumination suggests a testicular tumor or, if the mass is separate from the testis/epididymis, a hernia, or a large spermatocele.
- Urinalysis: In cases of a painful scrotum, or dysuria, a urine dipstick test that is positive for leukocyte esterase or the presence of leukocytes on microscopy (especially if there are >20 white blood cells/high-power field) is suggestive of epididymitis rather than torsion.
- Gram stain: In cases of a painful scrotum and a history of urethritis or dysuria, a urethral Gram stain is helpful. Gram-negative diplococci suggest a gonococcal epididymitis. A Gram stain with white blood cells without gram-negative bacteria, suggests a chlamydial epididymitis; a gram-negative stain suggests an orchitis, or torsion.
- Color flow Doppler ultrasound and nuclear scans: In cases of a painful scrotum where torsion is suspected, a Doppler flow study, a nuclear scan, or both can be used in equivocal cases, but should be obtained only after consultation with a urologist. If a reasonable suspicion of torsion exists, the primary therapy should be surgical exploration, without delaying to order diagnostic tests. In cases of torsion, the scan and Doppler study will show a decreased flow to the affected side.
- Painless scrotal mass or swelling (Fig. 28.2)
- Testicular tumor
- Idiopathic scrotal edema
- Painful scrotal mass or swelling
- Torsion of spermatic cord
- Torsion of appendix testis
- Trauma resulting in hematoma
- Henoch-Schönlein syndrome
- Cellulitis or infected piercing
- Hymenoptera sting or insect bite
- Testicular tumor with bleeding or infarction
Testicular torsion is a twisting of the testis and spermatic cord that results in venous obstruction, progressive edema, arterial compromise, and, eventually, testicular infarction. Normally, the testes are covered anteriorly with a mesothelial structure, the tunica vaginalis. In some males, the tunica vaginalis is abnormally enlarged and engulfs the testes. This causes the testis to lie like a “bell clapper” in the scrotal cavity. With this deformity, a testis can twist on the spermatic cord, compromising circulation. Aside from torsion at the spermatic cord, appendages of the testes or of the epididymis can occasionally undergo torsion (Fig. 28.3A). Torsion can be difficult to differentiate from epididymitis (Table 28.1).
Two thirds of cases occur between 12 and 18 years, with incidence peaking at 15 to 16 years. The risk of developing torsion by age 25 is estimated to be approximately 1 in 160.
FIGURE 28.3 A: Torsion. B: Epididymitis. C: Testis tumor. D: Hydrocele. E: Varicocele. F: Spermatocele. (From Kapphahn C, Schlossberger N. Male reproductive health: I. Painful scrotal masses. Adolesc Health Update 1992;4:1.)
- Onset is usually abrupt.
- Fifty percent of teenagers have had brief prior episodes of scrotal pain.
- Pain may be isolated to the scrotum or may radiate to the abdomen.
- Nausea and/or vomiting may occur.
- Physical examination shows the following:
- The testis is tender and swollen.
- The affected side is often higher than the contralateral side because of the elevation from the twisted spermatic cord. The testis that undergoes torsion usually twists so that the anterior portion turns medially. In inflammatory conditions, the affected side is often lower.
- The epididymis, if palpable, is often out of the usual posterolateral location.
- The affected testis and often the contralateral testis lie in a horizontal plane rather than in the normal vertical plane.
- The cremasteric reflex is absent.
- Fever and scrotal redness are usually absent.
Testicular torsion is a surgical emergency. The diagnosis of torsion should be suspected in any adolescent with a painful swelling of the scrotum. If the history (acute onset of pain, nausea or vomiting, prior episodes of pain, lack of fever, lack of dysuria or urethral discharge) and physical examination (patient in distress, high-riding testis, horizontal position of testis, generalized swelling of the testis) are consistent with torsion, a urology consultation should be immediately obtained and decisions made for further testing or direct surgical exploration (Table 28.1).
Therapy involves immediate surgery. Saving testicular function depends on early surgical intervention. If surgery is performed within 6 hours of onset of symptoms, recovery is the rule; if surgery is performed between 6 and 12 hours, 62% of patients have recovery of testicular function. After 12 hours, the success rate falls to 20% to 38% and after 24 hours, only up to 11% of testicles survive.
Epididymitis is an inflammation of the epididymis caused by infection or trauma; it is primarily a problem of sexually active adolescents and is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae. Epididymitis due to Escherichia coli or other bowel flora can be secondary to unprotected insertive anal intercourse. Uncommonly, it can be caused by urinary pathogens in males with or without genitourinary abnormalities.
Non–sexually transmitted epididymitis may be caused by instrumentation, surgery, catheterization, or anatomical abnormalities. Epididymitis can be difficult to differentiate from torsion (Table 28.1).
- Uncommon in prepubertal males
- Uncommon in non–sexually active males without a history of genitourinary tract abnormalities
The diagnosis is suggested by the presentation of a sexually active teenager with subacute onset of pain in the hemiscrotum, inguinal area, or abdomen with epididymal swelling and tenderness, a reactive hydrocele, urethral discharge, dysuria, possibly fever, and pyuria (Fig. 28.3B). Approximately two thirds of individuals see a physician after 24 hours of pain—later than those who have testicular torsion. Swelling of the epididymis alone is more common with epididymitis than with torsion of the testes (59% versus 15%). The laboratory evaluation should include:
- Gram staining of an endourethral swab specimen for diagnosis of urethritis and for presumptive diagnosis of gonococcal infection
- A culture of intraurethral exudates or a nucleic acid amplification test on an intraurethral swab or urine for N. gonorrhoeaeand trachomatis
- Examination of first void urine for leukocytes. If the urethral Gram stain is negative, then send urine for Gram stain and culture.
- Syphilis serology and human immunodeficiency virus (HIV) counseling and testing
In the absence of a urethral discharge, leukocytes on a gram-stained endourethral swab specimen (on microscopy) or urine dip for leukocyte esterase, or pyuria, an urgent urology consultation is called for as the likelihood of torsion increases. If one of the preceding tests shows abnormal findings but the teen has any risk factors suggesting torsion (i.e., prepubertal teen, non–sexually active teen, elevated or rotated testes, history of prior pain episodes, or acute onset with rapid progression), an immediate urology consultation should be obtained and a nuclear scan or a color flow Doppler ultrasonography should be considered. Orchitis can cause similar symptoms, but it usually occurs without dysuria or urethral discharge. Mumps infection is the most common cause. Mumps orchitis is usually unilateral and occasionally occurs without a history of parotitis. Other viruses (e.g., adenovirus, Coxsackie virus, ECHO virus, Epstein-Barr virus) may also cause orchitis, but with less frequency.
Information on sexually transmitted disease (STD) guidelines is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/std/treatment.
- Scrotal support, bed rest, and analgesics are an adjunct to antimicrobial therapy.
- Ceftriaxone, 250 mg, is given intramuscularly once, and doxycycline, 100 mg, is given orally twice a day for 10 days. If the problem is thought to be caused by enteric organisms or the patient is allergic to ceftriaxone or tetracyclines, alternative drugs are ofloxacin 300 mg twice daily for 10 days, or levofloxacin 500 mg orally once a day for 10 days.
- Failure to improve within 3 days requires reevaluation.
- Sexual partners should be treated.
- In HIV/acquired immunodeficiency syndrome (AIDS) infection or for other immunocompromised states, therapy is the same except that fungal and mycobacterial infections are more common than in immunocompetent patients.
Most testicular neoplasias are malignant and of germ-cell origin (95%). Seminomas are the most common testicular cancer of a single cell type (40% of germ-cell tumors) with a peak incidence in the 25 to 45 year age-group; nonseminoma tumors (embryonal cell, choriocarcinoma, teratoma, yolk sac, and mixed forms) peak in the 15 to 30 year age-group (Fig.28.3C).
- Testicular tumors are the most common solid tumor in males aged 15 to 35 years.
- The incidence is 2.3 to 10 in 100,000 males.
- Testicular cancer is 4.5 times more common among White men than African-American men.
- The risk of a testicular tumor is increased 10 to 40 times in a teenager with a history of cryptorchidism.
The diagnosis of tumor should be suspected in any male with a firm, circumscribed, painless area of induration within the testis that does not transilluminate. Swelling is noted in up to 73% of cases at presentation, but is usually considered asymptomatic by the patient. Testicular pain is the presenting symptom in 18% to 46% of patients who have germ-cell tumors.
Therapy involves a direct biopsy for confirmative diagnosis and cell type. Definitive therapy is beyond the scope of this book and involves a coordinated effort among the urologist, the primary care specialist, and the oncologist.
This mass is actually a collection of fluid between the parietal and visceral layers of the tunica vaginalis, which lies along the anterior surface of the testicle and is a remnant of the processus vaginalis—the embryonic sleeve through which the testes descend. If the processus vaginalis remains fully open, an inguinal hernia will result. If a small opening remains, a hydrocele will form in the scrotum (Fig. 28.3D). If an opening remains proximally but is closed distally before the scrotum, a hydrocele of the spermatic cord will form.
A hydrocele is usually a soft, painless, fluctuant, scrotal mass that is anterior to the testis, transilluminates, and appears cystic on ultrasonography. Hydroceles often decrease in size by morning and increase in size by evening. Long-standing hydroceles are usually benign. The presence of a new hydrocele should alert the examiner to check for a possible underlying cause such as a hernia, testicular tumor, trauma, or infection.
Usually, no therapy is required for an asymptomatic long-standing hydrocele. Indications for treatment include a painful or tense hydrocele that might reduce circulation to the testis, a bulky mass that is uncomfortable and uncosmetic for the teenager, or a hydrocele associated with a hernia (a communicating hydrocele). Definitive therapy involves resection of the parietal tunica vaginalis.
A varicocele, or dilated scrotal veins, results from increased pressure and incompetent venous valves in the internal
spermatic veins (Fig. 28.3E). Anatomical reasons explain why varicocele is most often noted on the left side. Recent studies suggest that the incidence of bilateral varicocele is underestimated and that percutaneous retrograde venography usually reveals bilateral disease in those with clinically evident unilateral disease.
- Varicocele is common in the 10 to 20 year age-group, with a prevalence of 15%.
- Eighty-five percent of varicoceles are clinically evident on the left side, and 15% are bilateral.
Varicoceles are detected in adolescents either on routine examination or secondary to a patient's discovery of more “stuff” filling one hemiscrotum than the other. Occasionally, a patient complains of an ache or pain from the varicocele. On examination, a visible varicocele (grade 3 or large) has a “bag of worms” appearance and feel above the testes. A varicocele that is palpable but not visible is classified as grade 2 (moderate). More subtle varicoceles may feel like a thickened or asymmetric spermatic cord. The distension usually decreases when the patient lies down. If there is no decrease in the size of a varicocele in the supine position, an ultrasonogram or intravenous pyelogram is indicated to eliminate the possibility of intraabdominal disease.
It is reasonable to obtain a semen analysis, the true test of potential fertility, on willing patients once they reach Tanner stage 5. An adolescent with a normal semen analysis need not be referred for treatment of his varicocele. However, semen analysis is not often a practical test to perform on teenage boys.
Loss of testicular volume or failure of the testis to grow during puberty has been the traditional indication for surgical correction of a varicocele during adolescence. Several recommendations have been suggested as indications for varicocele repair, but definitive answers to who should be referred and when during adolescence, remain elusive.
Kass and Reitelman (1995) recommended varicocele repair in adolescents in the following instances:
- The results of semen analysis are abnormal.
- The volume of the left testis is at least 3 mL less than that of the right.
- The response of either luteinizing hormone (LH) or follicle-stimulating hormone (FSH) to gonadotropin-releasing hormone stimulation is supranormal.
- Bilaterally palpable varicoceles are detected.
- A large, symptomatic varicocele is present.
Skoog et al. (1997) recommended surgery for patients with any of the following findings:
- A difference of >2 mL in testicular volume as noted on serial ultrasonic examinations
- A testicular size that is smaller by 2 standard deviations when compared with normal testicular growth curves
- Scrotal pain
A recent study by Guarino et al. (2003) suggests that nonstimulated LH and FSH levels may be helpful in identifying patients with testicular dysfunction in association with varicocele, who may benefit from varicocelectomy. It is also common practice to refer those with varicocele associated with one testis to urology, but little evidence exists to support or refute such a practice.
The earlier in life the varicocele appears, the higher the risk of testicular growth arrest; varicocelectomy during adolescence usually results in “catch-up growth” of the involved testis. Although varicoceles may cause a progressive loss of fertility during the reproductive years in some men, >80% of men with varicoceles are fertile. Although a preponderance of the literature supports a favorable effect of varicocelectomy on fertility, several recent articles, including a systematic review, have questioned whether there is any such effect. A definitive statement about which adolescents need surgery cannot be made.
There are a variety of surgical techniques in addition to nonsurgical embolization and sclerotherapies. A review of the various techniques, as well as a full discussion of the controversies inherent to varicocele management is beyond the scope of this chapter. However, the “References and Additional Readings” section contains several articles addressing these subjects.
A spermatocele is a retention cyst of the epididymis that contains spermatozoa. Most are small (<1 cm in diameter), painless, cystic, freely movable, and will transilluminate (Fig.28.3F). If large, the patient may present complaining of a “third testicle,” and turbidity from increased spermatozoa may prevent transillumination. It is usually felt as a smooth, cystic sac located above and posterior to the testis, at the head of the epididymis. No therapy is indicated, unless it is large enough to annoy the patient, in which case a urologist may excise it.
TSE is simple to teach, simple to perform, has negligible cost, and is of unproven effectiveness. There are inconsistent national recommendations regarding implementing TSE as a screening tool for testicular cancer because it is unknown whether screening by either physician examination or patient self-examination actually affects the stage of cancer at detection, or impacts morbidity or mortality from the disease. Although females are commonly taught to examine their own breasts, fewer than 10% of men have been taught how to examine their testicles. However, teaching of TSE by a physician increases the likelihood of performing TSE. Testicular cancer is the most common solid tumor in young adults, and the American Medical Association and the American Urological Association promote and support public awareness and education of TSEs for early detection of testicular cancer. The recommendations for TSE by the American Cancer Society are as follows:
- Examine the testes during or after a hot bath or shower.
- Examine each testicle with the fingers of both hands, using the index and middle fingers on the underside of the testicle and the thumbs on the top of the testicle.
- Gently roll the testicle between the thumbs and fingers.
- Be on the lookout for lumps, irregularities, change in size, or pain in the testicles.
- The epididymis should not be mistaken for an abnormality.
- If any abnormality such as a lump is found, it should be reported immediately.
- TSE should be performed once a month.
For Teenagers and Parents
http://www.nlm.nih.gov/medlineplus/testiculardisorders. html. Epididymitis and male reproductive system.
http://tcrc.acor.org/tcexam.html. Testicular Cancer Self Examination.
http://keepkidshealthy.com/adolescent/adolescentproblems/varicocele.html. Varicocele information from keepkidshealthy.com.
http://kidshealth.org/teen/sexual_health/guys/tse.html. Testicular Cancer Self-Examination.
http://www.emedicine.com/emerg/topic573.htm. Testicular torsion information.
References And Additional Readings
Adelman WP, Joffe A. The adolescent male genital examination: what's normal and what's not. Contemp Pediatr 1999;16:76.
Adelman WP, Joffe A. The adolescent with a painful scrotum. Contemp Pediatr 2000;17:111.
Adelman WP, Joffe A. Controversies in male adolescent health: varicocele, circumcision, and testicular self-examination. Curr Opin Pediatr 2004;16:363.
Adelman WP, Joffe A. Genitourinary issues in the male college student: a case-based approach. Pediatr Clin North Am 2005;52:199.
Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics 2000;105:604. Available at http://www.pediatrics.org/cgi/content/full/105/3/604.
Berger RE. Epididymitis. In: Holmes K, Sparling PF, Mardh PA et al., eds. Sexually transmitted diseases. New York: McGraw-Hill, 1999.
Burgher SW. Acute scrotal pain. Emerg Med Clin North Am 1998;16:781.
Cass AS, Cass BP, Veeraraghan K. Immediate exploration of the unilateral acute scrotum in young male subjects. J Urol 1980;124:829.
Cayan S, Kadioglu A, Orhan I, et al. The effect of microsurgical varicocelectomy of serum follicle stimulating hormone, testosterone, and free testosterone levels in infertile men with varicocele. BJU Int 1999;84:1046. Available at http://www.blackwell-synergy.com/journals.
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Morbid Mortal Wkly Rep 2002;51(RR-6):1.
Chehval MJ, Purcell MH. Deterioration of semen parameters over time in men with untreated varicocele: evidence of progressive testicular damage. Fertil Steril 1992;57:174.
Colodny AH. Undescended testes: is surgery necessary? N Engl J Med 1986;314:510.
Cornud F, Belin X, Amar E, et al. Varicocele: strategies in diagnosis and treatment. Eur Radiol 1999;9:536.
Diamond DA. Adolescent varicocele: emerging understanding. BJU Int 2003;92(Suppl 1):48.
Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995;154:1148.
Dunne PJ, O’Loughlin BS. Testicular torsion: time is the enemy. Aust N Z J Surg 2000;70:441. Available at http://www.blackwellsynergy.com/journals.
Evers JLH, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Lancet 2003;361:1849.
Fedder J, Cruger D, Oestergaard B, et al. Etiology of azoospermia in 100 consecutive nonvasectomized men. Fertil Steril 2004;82:1463.
Galejs LS, Kass EJ. Color doppler ultrasound evaluation of the acute scrotum. Tech Urol 1998;4:182.
Gat Y, Zukerman Z, Bachar GN, et al. Adolescent varicocele: is it a unilateral disease? Urology 2003;62:742.
Gerscovich EO. High-resolution ultrasonography in the diagnosis of scrotal pathology: I. Normal scrotum and benign disease. J Clin Ultrasound 1993;21:355.
Gershbein AB, Horowitz M, Glassberg KI. The adolescent varicocele: I. Left testicular hypertrophy following varicocelectomy. J Urol 1999;162:1447.
Goldenring JM, Purtell E. Knowledge of testicular cancer risk and need for self-examination in college students: a call for equal time for men in teaching of early cancer detection techniques. Pediatrics 1984;74:1093.
Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 1993;59:613.
Goroll AH, May LA, Mulley AG, eds. Evaluation of scrotal pain, masses, and swelling. In: Primary care medicine: office evaluation and management of the adult patient. Philadelphia: JB Lippincott Co, 1995.
Guarino N, Tadini B, Bianchi M. The adolescent varicocele: the crucial role of hormonal tests in selecting patients with testicular dysfunction. J Pediatr Surg 2003;38:120.
Gutierrez CS. Cryptorchidism. West J Med 1995;163:67.
Hadziselimovic F, Herzog B, Jenny P. The chance for fertility in adolescent boys after corrective surgery for varicocele. J Urol 1995;154:731.
Hamm B. Differential diagnosis of scrotal masses by ultrasound. Eur Radiol 1997;7:668. Available at http://link.springer-ny.com/link/service/journals/00330/papers/7007005/70070668.pdf.
Hoover DL. How I manage testicular injury. Phys Sportsmed 1986;14:127.
Horstman WG, Haluszka MM, Burkhard TK. Management of testicular masses incidentally discovered by ultrasound. J Urol 1994;151:1263.
Jefferson RH, Perez LM, Joseph DB. Critical analysis of the clinical presentation of acute scrotum: a 9-year experience at a single institution. J Urol 1997;158:1198.
Joly-Guillou ML, Lasry S. Practical recommendations for the drug treatment of bacterial infections of the male genital tract including urethritis, epididymitis, and prostatitis.Drugs 1999;57:743.
Junnila J, Lassen P. Testicular masses. Am Fam Physician 1998;57:685.
Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 1998;102:73. Available at http://pediatrics.org/cgi/content/full/102/1/73.
Kapphahn C, Schlossberger N. Male reproductive health: I. Painful scrotal masses. Adolesc Health Update 1992;4(3):1–8.
Kapphahn C, Schlossberger N. Male reproductive health: II. Painless scrotal masses. Adolesc Health Update 1992;5(1):1–8.
Kass EL, Freitas JE, Salisz JA, et al. Pituitary gonadal dysfunction in adolescents with varicocele. Urology 1993;42:179.
Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am 1997;44:1251.
Kass EL, Reitelman C. Adolescent varicocele. Urol Clin North Am 1995;22:151.
Klein BL, Ochsenschlager DW. Scrotal masses in children and adolescents: a review for the emergency physician. Pediatr Emerg Care 1993;9:351.
Lau MW, Taylor PM, Payne SR. The indications for scrotal ultrasound. Br J Radiol 1999;72:833.
Laven JSE, Haans LCF, Mal WPTM, et al. Effects of varicocele treatment in adolescents: a randomized study. Fertil Steril 1992;58:756.
Lewis AG, Bukowski TP, Jarvis PD, et al. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30:277.
Mazzoni G, Fiocca G, Minucci S, et al. Varicocele: a multi-disciplinary approach in children and adolescents. J Urol 1999;162:1755.
McAleer IM, Packer MG, Kaplan GW, et al. Fertility index analysis in cryptorchidism. J Urol 1995;153:1255.
Nagar H, Mabjeesh NJ. Decision-making in pediatric varicocele surgery: use of color Doppler ultrasound. Pediatr Surg Int 2000;16:76. Available at http://link.springer-ny.com/link/service/journals/00383/bibs/0016001/00160075.htm.
Neinstein LS, Goldenring JG. Pink pearly papules: an epidemiological study. J Pediatr 1984;105:594.
Neinstein LS, Shapiro J, Rabinowitz S, et al. Comfort of male adolescents during general and genital examination. J Pediatr 1989;115:494.
Noske HD, Weidner W. Varicocele: a historical perspective. World J Urol 1999;17:151. Available at http://link.springer-ny.com/link/service/journals/00345/papers/9017003/90170151.pdf.
Paltiel HJ, Connolly LP, Atala A, et al. Acute scrotal symptoms in boys with an indeterminate clinical presentation: comparison of color Doppler sonography and scintigraphy.Radiology 1998;207:223.
Papanikolaou F, Chow V, Jarvi K, et al. The effect of adult microsurgical varicocelectomy on testicular volume. Urology 2000;56:136. http://www.sciencedirect.com/science/journal/00904295.
Pinto KJ, Kroovand RL, Jarow JP. Varicocele-related testicular atrophy and its predictive effect upon fertility. J Urol 1994;152:788.
Podesta ML, Gottlieb S, Medel R Jr, et al. Hormonal parameters and testicular volume in children and adolescents with unilateral varicocele: preoperative and postoperative findings. J Urol 1994;152:794.
Pyorealea S, Huttunen NP, Uhari M. A review and meta-analysis of hormonal treatment of cryptorchidism. J Clin Endocrinol Metab 1995;80:2795.
Rabinowitz R, Hulbert WC Jr. Acute scrotal swelling. Urol Clin North Am 1995;22:101.
Rajfer J. Congenital anomalies of the testes and scrotum. In: Walsh PC, Retik AB, Vaughn ED Jr et al., eds. Campbell's urology. Philadelphia: WB Saunders, 1998:2172.
Rozanski TA, Bloom DA. The undescended testis: theory and management. Urol Clin North Am 1995;22:107.
Schlesinger MD, Wilets IF, Nagler HM. Treatment outcome after varicocelectomy: a critical analysis. Urol Clin North Am 1994;21:517.
Siegel MJ. The acute scrotum. Radiol Clin North Am 1997;35:959.
Silber SJ. New concepts in operative andrology: a review. Int J Androl 2000;23(Suppl 2):66. Available at http://www.blackwell-synergy.com/journals.
Singer AJ, Tichler T, Orvieto R, et al. Testicular carcinoma: a study of knowledge, awareness, and practice of testicular self-examination in male soldiers and military physicians.Mil Med 1993;158:640.
Skoog SJ, Roberts KP, Goldstein M, et al. The adolescent varicocele: what's new with an old problem in young patients? Pediatrics 1997;100:112.
United Kingdom Testicular Cancer Study Group. Aetiology of testicular cancer: association with congenital abnormalities, age at puberty, infertility, and exercise. United Kingdom Testicular Cancer Study Group. Br Med J 1994;308:1393.
Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds? Br J Urol 1996;78:623.
Wilbert DM, Schaerfe CW, Stem WD, et al. Evaluation of the acute scrotum by color-coded Doppler ultrasonography. J Urol 1993;149:1475.
Witt MA, Lipshultz LT. Varicocele: a progressive or static lesion? Urology 1993;42:541.