1. Disorders of the testis & spermatic cord

2. Ectopy &cryptorchidism
In ectopy the testis has strayed from the path of the normal descent;
In cryptorchidism, it is arrested in the normal path of descent.
Ectopy may be due to an abnormal connection of the distal end of gubernaculum testis that leads the gonads to abnormal position.

3. The ectopic sites are as follow
1- superficial inguinal (most common).
2- perineal (rare).
3- femoral or crural (rare).
4- transverse or paradoxic both testes descend the same inguinal canal.
5- pelvic.

4. Cryptorchidism is a condition in which the testicle is arrested at some point in its normal descent anywhere between the renal & scrotal areas.
Unilateral arrest is more common than bilateral arrest.
At the time of birth (9 months gestation) the incidence of maldescent is 3.4% half of such testicle descend in the first month of life.
The incidence of cryptorchidism in adults is %.
in premature infants, it is 30% .
Chromosomal studies in cryptorchidism have revealed no abnormalities.

5. Etiology
The cause of maldescent testis is not clear.
The following possibilities must be considered.
A –abnormality of the gubernaculum testis.
Testicle descent is guided by gubernaculum (cord like structure that extend from the lower pole of the testis to the scrotum).
Absence or abnormality of this structure may be a cause of maldescent.

6. B –intrinsic testicular defect.
Congenital gonadal (dysgenetic) defect that make the testicle insensitive to gonadotropins.
Best explanation for unilateral cryptorchidism & why many patients with bilateral cryptorchidism are sterile, even when given definitive therapy at optimal age.

7. C –deficient gonadotropic hormonal stimulation
C –deficient gonadotropic hormonal stimulation. Testicular descent is androgen mediated event regulated by pituitary hormones.
Best explanation of bilateral cryptorchidism, & more incidence of undescent testis in premature infant who depend on mother gonadotropins which remains low level until the last 2 weeks of gestation.

8. Pathogenesis & pathology.
The scrotum is an effective temperature regulator for the testis, which are kept 1 `C cooler than body temperature.
The spermatogenic cells are sensitive to body temperature.
Studies of the ultrastructure of the cryptorchid testis found deleterious changes in the 1st year of life. By the age of 4 yr massive collagen deposition was evident.
So the testis has to be in the scrotum by the age of 6 months. Fortunately, the leydig cells are not affected by body temperature.

9. Clinical findings.
The cardinal feature is the absence of one or both testes from the scrotum. So the scrotum on the affected side is atrophic.
The testis either non palpable or felt external to the inguinal ring.
The patient may also complain of pain from trauma to the testis due to abnormal position.
Adult pt with bilateral cryptorchidism may present with infertility.
Hormonal studies, ultrasound, MRI, & laparoscope aid in the diagnosis.

10. Complications.
1- torsion of the spermatic cord.
2- tumor, cancer is times more common in misplaced testis than normal testis.
Most are dysgenetic testis orchiopexy facilitate early detection rather than decrease the incidence of malignancy.
3- trauma, due to vulnerable position (eg over pubic bone) more prone for trauma.

11. Treatment.
Since definite histologic change can be demonstrated by age 1 yr placement of the testis in the scrotum should be as early as 6 months.
A successful surgery doesn’t ensure fertility if the testis is congenitally defective.
For bilateral undescend testis hormonal therapy may be of benefit.

12. Disorders of the spermatic cord

13. Spermatocele
Is a painless cystic mass containing sperms.
It lies just above & posterior to the testis but is separate from it.
Most spermatoceles are less than 1 cm in diameter, although occasionally quite large & may be mistaken for hydrocele.
They may be firm simulating solid tumor. The cause is not entirely clear, although they probably arise from the tubules connect the rete testis to the head of epididymis.
Spermatocele require no surgery unless it is large annoy the patient. In which case it should be excised.

14. Varicocele
Dilatation & tortuousity of veins within the pampiniform plexus above the testis it consist the most surgically corrected cause of subfertility.
A left side Varicocele is found in 15% of young healthy men. In contrast the incidence of Varicocele in subfertile men approaches 40%.

15. Incompetent valves are more common in the left internal spermatic vein ( left side drain into the renal vein while right side drain to the IVC).
This condition combined with the gravity may lead to poor drainage of the pampiniform plexus the veins of which gradually undergo dilatation & elongation.

16. Examination of man with varicocele when he is upright reveal mass of dilated, tortuous veins lying posterior to & above the testis.
The degree of dilatation can be increased by valsalva maneuver.
In the recumbent position , venous distention abates.
Testicular atrophy from impaired circulation may be present.

17. Sperm concentration & motility are significantly decreased in 65-75% of subject.
Infertility is often observed & can be reversed in high percentage of patients by correction of varicocele.
The effect of varicocele on testicle remain unclear several theories have been postulated.
1- hormonal imbalance due to decrease testosterone secretion by leydig cell which lead to pituitary- gonadal hormonal dysfunction.

18. 2- internal spermatic vein reflux, may lead to reflux of potentially toxic renal & adrenal metabolites which may damage the testis.
3- venous reflux lead to increase hydrostatic pressure which reduce the efficiency of blood return & testis hypoxia.
4- inhibition of spermatogenesis by increase scrotal temperature due to reflux of warm corporeal blood into the pampiniform plexus.
The cornerstone of diagnosis of varicocele is accurate physical examination, both Doppler &color Doppler ultrasound can be aid the diagnosis

19. Treatment.
Surgical ligation of the internal spermatic veins. Percutaneous methods like injection of sclerosing fluid may be of value.

20. Hydrocele
Collection of fluid within the tunica or processus vaginalis.
Although it may occur within the spermatic cord, its most often seen surrounding the testicle.
1- Hydrocele may develop rapidly secondary to local injury, radiotherapy, acute nonspecific or tuberculous epididymo-orchitis, or it may complicate testicular neoplasm.

21. 2- more commonly its chronic idiopathic hydrocele
2- more commonly its chronic idiopathic hydrocele. Of unknown cause affect male above 40 yr. the fluid is clear & yellow.
3- communicating hydrocele occur in infant & childhood due to patent processus vaginalis communicate with the peritoneal cavity.

22. Clinical findings
Young boys with hydrocele commonly have cystic mass that is small & soft at the morning but larger &more tens at night.
It is usually painless unless accompanied by epididymitis.
Diagnosis made by finding a rounded cystic intrascrotal mass that is not tender unless underlying inflammatory disease is present.
The mass transilluminate.

23. If the hydrocele is enclosed within the spermatic cord, a cystic fusiform swelling is noted in the groin or in the upper scrotum.
Sonography should be done if the diagnosis is in question.
A tens hydrocele must be differentiated from infection or tumor of the testis, which does not transilluminate.

24. Treatment.
Surgical therapy indicated if tens hydrocele may embarrass circulation to the testicle or for cosmetic reason.
In infant spontaneous closure can occur within the first year if not ligation of patent processus vaginalis through inguinal incision.

25. Torsion of the spermatic cord
Torsion of the testicle is uncommon usually affect adolescent males.
It cause strangulation of the blood supply to the testis.
Unless treatment is given within 5-6 hr testicular atrophy may occur.

26. Causes.
1- undescend testis is more prone for torsion.
2- trauma may be the initiating factor.
3- congenital anomalies of the tunica vaginalis or spermatic cord.
Voluminous tunica vaginalis that insert well up on the cord. This allow the testis to rotate within the tunica.
The initiating factor is spasm of the cremaster muscle which insert obliquely on the cord.

27. Clinical findings.
The diagnosis is suggested when young boy suddenly develops severe pain in one testicle.
Followed by swelling of the organ, reddening of the scrotal skin, lower abdominal pain, & nausea & vomiting.
However, torsion of the cord may be accompanied only by moderate scrotal swelling & little or no pain.

28. Examination usually reveals
a swollen, tender organ that is retracted upward as a result from shortening of the cord by volvulus.
The testis lie horizontally with the pt standing.
Pain may increase by lifting the testis up over the symphysis. ( the pain from epididymitis is usually decreased by this maneuver.

29. The diagnosis may be made in the early stages if the epididymis can be felt in an abnormal position eg anterior.
After few hrs however, the entire organ become so swollen that the epididymis cannot be distinguished from the testis by palpation.
Color doppler & radioisotope can aid the diagnosis.
D.Dx
Acute epididymitis,
acute orchitis,
trauma.

30. Treatment.
Early surgical detorsion + fixation of the affected testis & the contralateral testis as prophylactic procedure should be done as early as 1st 5-6 hours.