Step 1 · Reproductive

Testicular Torsion, Non-Germ-Cell Tumors & Penile Disease

Name: Testicular Torsion, Non-Germ-Cell Tumors & Penile Disease
Creator: Veli Bakalov, MD

Race the clock on torsion and priapism, and know the testis tumors that are not germ cell

Reproductive·Male Reproductive Pathology·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

Study materialsNo account needed

Card deckActive-recall cards · quick checks · quiz

High-yield

Testicular torsion stems from the bell-clapper deformity: sudden severe pain, high horizontal testis, absent cremasteric reflex and no relief with elevation.
Torsion needs immediate surgical detorsion with bilateral orchiopexy; salvage is best within about 6 hours, and imaging must not delay surgery.
Epididymitis has gradual pain, fever and dysuria, an intact cremasteric reflex, relief with elevation and increased flow (chlamydia/gonorrhea under 35, E. coli if older).
Appendix testis torsion shows a blue dot at the upper pole in a prepubertal boy and is treated conservatively; a spermatocele is a transilluminating sperm-filled epididymal cyst.
Leydig cell tumor: golden-brown, Reinke crystals, secretes androgens (precocious puberty) or estrogens (gynecomastia).
Testicular lymphoma (DLBCL) is the most common testicular tumor after 60 and the most common bilateral one; solid testicular masses are removed by inguinal orchiectomy.
Ischemic priapism (sickle cell, trazodone, α1-blockers, intracavernosal injections, PDE5 inhibitors) is a painful emergency treated with aspiration and phenylephrine; nonischemic priapism is painless and follows arterial trauma.
Peyronie disease is a fibrous tunica albuginea plaque causing curvature; paraphimosis is a constricting emergency.
Penile SCC is linked to HPV-16/18, lack of circumcision and smoking; in situ precursors are Bowen disease, erythroplasia of Queyrat and bowenoid papulosis.

The acute and swollen scrotum

Testicular torsion. A congenitally high attachment of the tunica vaginalis leaves the testis without posterior fixation, so it hangs horizontally and can rotate (bell-clapper deformity, usually bilateral). Twisting of the spermatic cord blocks venous outflow first and arterial inflow next, producing edema, ischemia and hemorrhagic infarction. Torsion peaks in adolescence; neonates have extravaginal torsion. Pain is abrupt and severe, often waking the patient, with nausea and vomiting; the testis rides high with a horizontal lie, the cremasteric reflex is absent and elevation brings no relief.

Management. Torsion is a clinical diagnosis. Surgical exploration with detorsion and bilateral orchiopexy follows immediately, because the other testis shares the defect; a nonviable testis is removed. Salvage is high within about 6 hours and falls steeply after 12–24 hours. Doppler ultrasound (absent flow) is reserved for genuinely uncertain cases and must not delay surgery; manual outward detorsion ("opening a book") only buys time.

Causes of acute scrotal pain

Feature	Testicular torsion	Epididymitis	Appendix testis torsion
Typical patient	Adolescent	Sexually active man or older man	Prepubertal boy
Onset	Sudden, severe, vomiting	Gradual, fever, dysuria	Gradual or sudden, focal
Examination	High, horizontal testis	Tender posterior epididymis	Upper-pole nodule, blue dot
Cremasteric reflex	Absent	Present	Present
Elevation	No relief	Relief (Prehn sign)	Variable
Doppler flow	Absent or reduced	Increased	Normal testicular flow
Management	Emergency surgery	Antibiotics	Rest, analgesics

Epididymitis and orchitis. In sexually active men under about 35, C. trachomatis and N. gonorrhoeae predominate; in older men or after urinary instrumentation, E. coli and other enteric organisms. Mumps orchitis affects postpubertal males several days after parotitis, is usually unilateral and leaves atrophy; bilateral disease impairs fertility. The appendix testis is a Müllerian (paramesonephric) remnant whose torsion is self-limited.

Painless swellings. A spermatocele is a smooth epididymal cyst, usually in the head, filled with milky, sperm-rich fluid; it lies above and behind the testis, separate from it, and transilluminates. A hydrocele surrounds the testis within the tunica vaginalis (in infants, from a patent processus vaginalis) and also transilluminates, whereas a varicocele is a nontransilluminating "bag of worms" that enlarges on standing or Valsalva.

Non-germ-cell testicular tumors

Leydig cell tumor. The most common sex cord–stromal tumor of the testis and usually benign. The cut surface is golden-brown; polygonal cells have eosinophilic cytoplasm, lipid and rod-shaped Reinke crystals (not the fried-egg cells of seminoma or the Schiller–Duval bodies of yolk sac tumor) and stain for inhibin and calretinin. Androgen secretion causes peripheral precocious puberty in boys with a unilateral testicular mass, and estrogen secretion causes gynecomastia and low libido in men.

Sertoli cell tumor. Forms tubules or cords, is usually benign and mostly hormonally silent, although some produce estrogen or overexpress aromatase and cause gynecomastia, as in large-cell Sertoli tumors of Peutz–Jeghers syndrome or Carney complex. Sex cord–stromal tumors do not raise AFP or hCG.

Testicular lymphoma. The most common testicular neoplasm after age 60 and the most common bilateral testicular tumor, usually an aggressive diffuse large B-cell lymphoma (CD20-positive) with normal AFP and hCG. Because it spreads to the opposite testis and the CNS, treatment adds CNS prophylaxis and contralateral scrotal radiation.

Any solid testicular mass is removed by radical inguinal orchiectomy, never scrotal biopsy: testes drain to para-aortic nodes, but scrotal skin drains to superficial inguinal nodes.

Penile disorders

Peyronie disease. A fibrous plaque in the tunica albuginea causes painful erections early, then curvature (often dorsal), shortening and erectile dysfunction. It is benign, is associated with Dupuytren contracture, and is managed by observation, intralesional collagenase or verapamil, or surgery for stable severe curvature.

Priapism: erection lasting more than 4 hours

Feature	Ischemic (low-flow)	Nonischemic (high-flow)
Mechanism	Venous outflow fails; blood trapped	Unregulated arterial inflow via a post-traumatic fistula
Exam	Painful, rigid shaft, soft glans	Painless, partly rigid
Corporal blood	Dark, hypoxic, hypercapnic, acidotic	Bright red, well oxygenated
Causes	Sickle cell disease, trazodone, α1-blockers, intracavernosal injections (alprostadil, papaverine), PDE5 inhibitors, cocaine, leukemia	Perineal or straddle injury tearing a cavernous artery
Treatment	Emergency aspiration and intracavernosal phenylephrine; surgical shunt if refractory	Observation or selective arterial embolization

Foreskin disorders and balanitis. Phimosis, a foreskin that cannot retract over the glans, is normal in young boys and pathologic after scarring from balanitis or lichen sclerosus. Paraphimosis, a retracted foreskin trapped behind the glans (often after catheterization), forms a constricting band with glans edema and ischemia and needs urgent manual reduction or a dorsal slit. Balanitis is often candidal in diabetic or uncircumcised men, so recurrences prompt a glucose check; circinate balanitis suggests reactive arthritis.

Penile squamous cell carcinoma. Risk factors are an uncircumcised foreskin with phimosis and poor hygiene, HPV-16/18, smoking and lichen sclerosus; neonatal circumcision is protective. Older men present with an ulcerated or exophytic lesion of the glans or prepuce that spreads to inguinal nodes. In situ precursors are Bowen disease (a gray-white scaly plaque on the shaft or scrotum), erythroplasia of Queyrat (a red velvety plaque on the glans or prepuce) and bowenoid papulosis (multiple reddish-brown papules in younger men, linked to HPV-16, rarely invasive).