PEDIATRIC TESTICULAR PROBLEMS

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The diagnosis and treatment of many pediatric testicular abnormalities can be both challenging and frustrating to the primary care physician. Additionally, these problems, if not evaluated and treated in a timely manner, can have significant sequelae. This article focuses on the diagnosis, evaluation, indications for referral, and treatment for some of the more common pediatric testicular problems that may be encountered.

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CRYPTORCHIDISM

Cryptorchidism or hidden testis is the most common congenital genitourinary abnormality in males. This anomaly results when the testis does not descend into its normal intrascrotal position and should be differentiated from the ectopic testis (descended testis situated in an abnormal location) or the retractile testis (descended testis which retracts into the upper scrotum owing to a hyperactive cremasteric reflex). Cryptorchidism can be either unilateral (66%) or bilateral (10%), with

MONORCHIDISM AND ANORCHIDISM

Unilateral testicular absence, or monorchidism, occurs in 1 in 5000 males. Multiple theories have been postulated to explain the pathogenesis of monorchidism. Absence of the testis may be owing to agenesis or may be owing to an intrauterine vascular accident such as torsion (extravaginal).29 In total testicular agenesis, there is an absence of all testicular structures (testis, testicular vessels, vas deferens). In cases of testicular torsion, remnants of the architecture can be seen on

POLYORCHIDISM AND TRANSVERSE TESTICULAR ECTOPIA

Polyorchidism is a very rare abnormality that occurs when the gonadal ridge divides during early embryogenesis resulting in testicular duplication. Usually the duplicate testes are small and each has its own vas deferens and epididymis. Often, one testis is in a cryptorchid location; however, both hemi-scroti may have masses present. Patients are usually asymptomatic.6, 68, 74 In transverse testicular ectopia, an ectopic testis is present in the contralateral hemi-scrotum. In contrast to

MICRO-ORCHIDISM

Micro-orchidism may be found in children with a history of cryptorchidism, varicocele, torsion, or early hernia repair. Additionally, micro-orchidism is a common finding in many syndromes such as Klinefelter's syndrome and hypogonadotropic hypogonadism. In the normal child, the right testis is larger than the left.

Size discrepancy between the testes is difficult to measure in infancy. Testicular volume, in young prepubertal patients, may be directly measured with an orchidometer or may be

MACRO-ORCHIDISM

Macro-orchidism can be either unilateral or bilateral. Unilateral testicular enlargement may represent compensatory hyperplasia owing to an absent or undescended contralateral gland.42 The degree of compensatory testicular enlargement in patients under 3 years of age with a unilateral impalpable testis, compared to normal testicular size for the child's age, may help to predict whether the patient has cryptorchidism or monorchidism. In patients with monorchidism, the contralateral descended

ACUTE SCROTAL SWELLING

The differential diagnosis of acute scrotal swelling includes testicular torsion, appendiceal torsion, epididymitis, orchitis, trauma, tumor, incarcerated hernia, acute hydrocele, and idiopathic scrotal edema. Since many of the latter conditions are covered in other articles in this issue, this article concentrates on torsion, epididymitis, and orchitis.

OTHER ACUTE SCROTAL PATHOLOGY

Testicular or scrotal trauma is easily ascertained by history. One must carefully examine the scrotum and attempt to palpate its contents. If there is excessive edema, ecchymosis, or if the examination is suboptimal, a diagnostic modality such as ultrasound may be used to better discern scrotal anatomy. If the history of trauma is unclear or questionable, the physician must entertain the possibility of child abuse and should do a thorough evaluation for this.

Tumors, usually presenting as

VARICOCELE

Varicoceles are simply collections of venous varicosities within the scrotum. Ninety-five percent of varicoceles present on the left side; however, up to 22% may be bilateral.32 Varicocele formation occurs when there is venous stasis or retrograde flow within the spermatic vein, subsequently causing dilatations within the papiniform plexus. The obstruction of flow may be owing to incompetent valves within the spermatic vein or from a more proximal obstruction of the left renal vein. This

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    Address reprint requests toGail E. Besner, MD Department of Surgery Children's Hospital700 Children's Drive Columbus, OH 43205

    *

    Department of Surgery, The Ohio State University College of Medicine, Children's Hospital, Columbus, Ohio

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    Copyright © 1998 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.