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.
FIGURE 28.1 Male genitalia showing inguinal area, spermatic cord, epididymis, and testis.
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:
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.)
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.)
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).
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:
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.
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).
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.
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:
Skoog et al. (1997) recommended surgery for patients with any of the following findings:
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:
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
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