STEPTRACKERREPRODUCTIVE | PATHOLOGY + ANATOMY + EMBRYOLOGY | HIGH-YIELD REVIEW

Testis & Scrotum — Non-Neoplastic

Testes that don't descend or twist, inflamed epididymis, swollen veins and fluid collections — and the causes of male infertility.

FOCUS ON
Torsion: teen, sudden pain, high horizontal testis, absent cremasteric reflex, no flow → surgery within 6 h. Epididymitis: gradual pain, fever, reflex present, relief with elevation; chlamydia/gonorrhea (young) vs E coli (older). Cryptorchidism: ↓ sperm, ↑ cancer risk → orchiopexy by 1 year. Varicocele: left, "bag of worms"; hydrocele transilluminates.
DISORDER
MECHANISM
FEATURES
CLUE · TREATMENT
Cryptorchidism
Testis fails to descend (gubernaculum, androgens); preterm infants; usually unilateral
Empty scrotum; ↓ spermatogenesis (temperature) → ↑ FSH, ↓ inhibin; testosterone usually normal
↑ germ cell tumor (both testes) · orchiopexy by 6–12 months
Testicular torsion
Twisting of the spermatic cord; bell-clapper deformity (testis not fixed to tunica vaginalis)
Adolescent: sudden severe pain, nausea, high-riding horizontal testis, absent cremasteric reflex
Doppler: no flow · detorsion + bilateral orchiopexy within 6 h
Torsion of appendix testis
Vestigial remnant twists
Localized upper-pole tenderness, "blue dot" sign; cremasteric reflex present
Self-limited
Epididymitis
Ascending infection: C trachomatis, N gonorrhoeae (< 35, sexually active); E coli (older, BPH, instrumentation)
Gradual unilateral pain, swelling, fever, dysuria; Prehn sign (relief on elevation); reflex intact
Ceftriaxone + doxycycline (young)
Orchitis
Mumps after puberty; with epididymitis
Painful testicular swelling days after parotitis
Atrophy; bilateral → infertility (rare)
Varicocele
Dilated pampiniform plexus; left testicular vein drains at a right angle into the left renal vein (nutcracker compression)
"Bag of worms," worse standing/Valsalva, ↓ lying down; does not transilluminate
↓ fertility (↑ temperature) · right-sided or non-reducing → RCC / IVC block
Hydrocele
Fluid in the tunica vaginalis: congenital (patent processus vaginalis, communicating) or acquired (infection, tumor, trauma)
Painless scrotal swelling that transilluminates
Infant hydroceles usually close by 1 year
Spermatocele
Cystic dilation of the epididymis containing sperm
Painless mass above and behind the testis; transilluminates
Separate from the testis
Indirect inguinal hernia
Patent processus vaginalis → bowel through the deep ring
Scrotal mass that doesn't transilluminate; bowel sounds; can't get above it
Incarceration risk
Fournier gangrene
Polymicrobial necrotizing fasciitis of the perineum; diabetes, immunosuppression
Pain out of proportion, crepitus, rapidly spreading necrosis, sepsis
Emergency debridement + broad antibiotics
Klinefelter syndrome (47,XXY)
Hyalinized seminiferous tubules → ↓ inhibin (↑ FSH); Leydig dysfunction → ↓ testosterone (↑ LH)
Tall, small firm testes, gynecomastia, infertility (azoospermia)
↑ breast cancer · most common cause of hypogonadism

Mechanism — torsion to infarction

Bell-clapper testisFreely mobile
→
Cord twists
→
Venous outflow blockedCongestion
→
Arterial inflow blocked
→
Hemorrhagic infarctionSalvage falls after 6 h

The deformity is usually bilateral — fix the other testis at the same operation.

Sorting a scrotal mass

MASS
TRANSILLUMINATES
PAIN
CLUE
Hydrocele
Yes
No
Surrounds testis
Spermatocele
Yes
No
Above/behind testis
Varicocele
No
Dull ache
Bag of worms, left
Germ cell tumor
No
Usually painless
Firm, within testis
Torsion
No
Severe, sudden
No cremasteric reflex
Epididymitis
No
Gradual
Prehn sign, fever

How it's tested

COMMON CONFUSIONTorsion and epididymitis both cause acute scrotal pain. Torsion: sudden, no cremasteric reflex, no flow. Epididymitis: gradual, fever, reflex intact, increased flow.
THE TRAPDon't delay surgery for imaging when the clinical picture is classic torsion — testicular salvage drops sharply after 6 hours.
YOUR APPROACHPainful or painless → sudden or gradual → cremasteric reflex → transillumination → Doppler → age and sexual history for the organism.

If you see… think…

14-year-old with sudden testicular pain, absent cremasteric reflex → testicular torsion
Torsion predisposing anatomy → bell-clapper deformity
Small tender blue spot at the upper pole → torsion of appendix testis
25-year-old with gradual scrotal pain, fever, relief on elevation → epididymitis (chlamydia/gonorrhea)
70-year-old with BPH and epididymitis → E coli
Scrotal "bag of worms" that empties lying down → left varicocele
New right varicocele that doesn't reduce → retroperitoneal mass / IVC obstruction
Painless scrotal swelling that glows with a penlight → hydrocele
Undescended testis left until age 10 → infertility + ↑ seminoma risk
Tall man, small firm testes, gynecomastia, ↑ FSH and LH → Klinefelter (47,XXY)