Clinical features

Clinical features

When assessing a child with suspected testicular maldescent, it is helpful to have the boy as relaxed as possible in a warm room, usually in a supine position. The important di ff erential diagnosis is the so-called ‘retractile testis’. During childhood the testes are mobile and the cremasteric reflex is active, so that, in some boys, any stimulation of the skin of the scrotum or thigh causes the testis to ascend and to temporarily disappear into the inguinal canal. When the cremaster relaxes, the testis reappears only to vanish when the scrotal skin is touched again. In comparison with a true undescended testis, the scrotum in the retractile testis is normal as opposed to underdeveloped, - and the retractile testis can be gently milked from its position in the inguinal region to the bottom of the scrotum. A diagnosis - of true incomplete descent should be made only if this is not possible. For r etractile testes, a yearly physical examination is recommended because of the 2–50% reported risk of a retrac - tile testis becoming an acquired undescended testis. More than 70% of cryptorchid testes are palpable by physical examination. In the remaining 30% of cases with a non-palpable testis, the challenge is to confirm the absence or presence of the testis and to identify the location of the viable non-palpable testis. Ultrasound has a high positive pr edictive value for inguinal located testes, but only 45% sensitivity in localising all non-palpable testes. The cost and ionising radi ation exposure associated with computed tomography (CT) scanning preclude its use. Magnetic resonance imaging (MRI) has been more widely used with greater sensitivity and specific ity but has cost and availability issues, and may require anaes thesia in the paediatric popula tion. At this time, there is no radiological test that can conclude with 100% accuracy that a testis is absent. Instead, laparoscopy has become the gold stan dard diagnostic method for a non-palpable testis. In addition, laparoscopy provides an option for treatment of this condition. Summary box 86.2 Retractile testis /uni25CF /uni25CF /uni25CF /uni25CF

Figure 86.3 Adult undescended testis. The undescended inguinal testis is mobilised and retained in a pouch constructed between the dartos muscle and skin (courtesy of the author and Dr Mohamed Abdellatif). Retractile testes should be differentiated from true undescended testes This is most easily done with the child relaxed in a warm room Retractile testes are more common than true undescended testes Retractile testes require no treatment but should be monitored

Clinical features

Testicular torsion is most common between 10 and 25 years of age, although a few cases occur outside this age range. Typically there is sudden severe pain in the groin and the lower abdomen - and the patient feels nauseated and may vomit. The scrotum is swollen and tender, while the skin is usually not erythematous initially (although it may become so with a prolonged history) and the patient is apyrexial. The testis itself is swollen and tender and seems high within the scrotum, while the tender twisted cord can often be palpated above it. The cremasteric reflex is lost. Clinical features

While most varicoceles are asymptomatic, those that are symp - tomatic tend to present in adolescence or early adulthood, when there may be a dragging discomfort that is worse on standing at the end of the day . When examined in the erect on the a ff ected side often hangs lower position, the scrotum than normal ( Figure 86.7a ); on palpation, with the patient standing, the varicose plexus feels like a bag of worms. There may be a cough impulse. If the patient lies down the veins empty by gravity and this provides an opportunity to ensure that the underlying testis is normal to palpation. In longstanding cases the a ff ected testis is smaller and softer than the opposite side owing to atrophy . Ultrasound can be helpful in the diagnosis of small varico - celes ( Figure 86.7b ), and in the less common right/bilateral varicoceles (and older men with an apparently recent onset of a renal tumour. The following classification of varicocele is useful in clinical practice: /uni25CF subclinical: not palpable or visible at rest or during a Valsalva manoeuvre, but can be shown by special tests (Doppler ultrasound studies); /uni25CF grade 1: palpable during Valsalva manoeuvre, but not oth erwise; /uni25CF grade 2: palpable at rest, but not visible; /uni25CF grade 3: visible and palpable at rest. Clinical features

Examination of a scrotal swelling should be undertaken in both the upright and supine position. The examiner should ask: 1 Is it possible to get above the swelling to palpate a normal cord? If not the swelling may represent an inguinal hernia that has entered the scrotum. 2 Is the testicle or epididymis palpable or is the swelling enclosing both of those structures? A hydrocele encloses the testis and epididymis such that they may be impalpa ble, and it is possible to get ‘above’ it to palpate a normal spermatic cord. 3 Does the swelling transilluminate? Hydroceles are typically translucent. In almost all cases of scrotal swelling an ultrasound is a useful adjunct to clarify the nature of the swelling and assess whether the testis itself is diseased. A primary hydrocele ( Figure 86.9 ) is seen most commonly in middle and later life, but can also occur in older childr Because the swelling is usually painless it may reach a signif icant size before the pa tient presents for treatment. Be wary Anton Nuck , 1650–1692, Professor of Anatomy and Medicine, Leiden, The Netherlands. Peter Herent Lord , contemporary , formerly surgeon, Wycombe General Hospital, High Wycombe, UK. Mathieu Jaboulay , 1860–1913, Professor of Surgery , Lyons, France. testicular tumour. In congenital hydrocele, the processus vaginalis – the com - munication with the peritoneal cavity – is usually too small to allow herniation of intra-abdominal contents. Pressure on the hydrocele does not always empty it but the hydrocele fluid may drain into the peritoneal cavity when the child is lying down; thus, the hydrocele may be intermittent. Ascites should be checked for if the swellings are bilateral. A hydrocele of the cord is a smooth oval swelling that lies above the testis near the spermatic cord, which is liable to be mistaken for an inguinal hernia. The swelling moves down - wards and becomes less mobile if the testis is pulled gently downwards. Hydrocele of the canal of Nuck is a similar con - dition in females. The cyst lies in relation to the round ligament and is always at least partially within the inguinal canal.

(a) (b) Figure 86.9 A right-sided hydrocele (a) . Ultrasound image (b)

Clinical features

Usually the patient presents with a painless testicular lump. A sensation of heaviness can occur if large, but few patients expe rience pain. Occasionally , an episode of trauma calls attention to the swelling. Some cases may simulate epididymo-orchitis and, rarely , acute painful enlargement of the testis occurs because of haemorrhage into the tumour, which can mimic testicular torsion. Rarely , the predominant symptoms are those of metastatic disease. Intra-abdominal disease may cause abdominal or lum bar pain. Lung metastases are usually silent, but they can cause chest pain, dyspnoea and haemoptysis in the la ter stages of the disease. The primary tumour may not have been noticed by the patient, and indeed may be detected only b y ultrasound ( Figure 86.15 ). On examination there is an intratesticular solid mass. A secondary hydrocele may be present. The epididymis can become more di ffi cult to feel. Around 5% of cases have gynaecomastia (mainly NSGCT). Metastatic disease is rarely appar ent clinically and is more usually identified by formal staging investigations. In 1–2% of cases the tumour is bilateral at diagnosis. Clinical features

The hallmark of Fournier’s gangrene is intense pain and tenderness in the genitalia. The clinical course usually progresses through the following phases: 1 prodromal symptoms of fever and lethargy for 2–7 days; 2 intense genital pain usually associated with oedema of the overlying skin; pruritus may be present; 3 increasing genital pain with progressive erythema of the overlying skin; 4 dusky appearance of the overlying skin; subcutaneous crepitation; 5 obvious gangrene of part of the genitalia; purulent dis - charge from wounds. - Early on, pain may be out of proportion to the physical findings. As gangrene develops, pain may subside as nerve tissue becomes necrotic. Systemic e ff ects of this process vary from local tender ness to massive septic shock, with the greater the necrosis the more severe the systemic e ff ects.