Infections of the Testis

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Infections of the testis commonly also involve the epididymis

Infection of the testis (orchitis) is often associated with an infection that enters through the epididymis (epididymitis), resulting in epididymo-orchitis. The most important infections of the testis and epididymis are acute bacterial epididymo-orchitis, viral orchitis, and tuberculous epidydimo-orchitis.

Acute infection is usually due to gonococci and Chlamydia (sexually transmitted) or Escherichia coli and other Gram-negative bacilli. Infection spreads from the urethra and lower urinary tract.
Clinically the testis and epididymis are greatly enlarged and very tender. Histologically there is extensive infiltration of the seminiferous tubules and interstitium by neutrophils, later followed by lymphocytes and plasma cells; interstitial oedema is considerable, and there is often patchy haemorrhage. Successful treatment with antibiotics is followed by healing and scarring, but there may be permanent damage to seminiferous tubules and epididymis, with consequent impairment of fertility.
Tuberculous epididymitis may be the result of bloodstream spread of mycobacteria to the testis during a phase of active pulmonary TB. It may also be caused by spread of infection from the kidney and lower urinary tract. The bacteria are sequestered in the epididymis, and produce slowly progressive caseous destruction over a period of many years, often continuing long after the initial pulmonary tuberculous lesion has healed.

Viral orchitis is usually the result of infection by the mumps virus after puberty. The disease is usually unilateral, and is associated with tender enlargement of the testis. The inflammatory infiltrate is mainly composed of lymphocytes and plasma cells. In a small proportion of cases, bilateral disease after puberty can result in reduced fertility.
Tuberculous epididymitis may be the result of bloodstream spread of mycobacteria to the testis during a phase of active pulmonary TB. It may also be caused by spread of infection from the kidney and lower urinary tract. The bacteria are sequestered in the epididymis, and produce slowly progressive caseous destruction over a period of many years, often continuing long after the initial pulmonary tuberculous lesion has healed.

The testis is rarely involved in tertiary syphilis, being the site of gumma formation. Granulomatous orchitis,} a condition of unknown aetiology, is an inflammatory disease in which there is a histiocytic and giant-cell inflammatory reaction associated with seminiferous tubule destruction.

The epididymis is converted into a mass of caseous necrosis, and there is often associated tuberculous prostatitis & cystitis.

Torsion of the testis causes venous infarction

Torsion of the testis, which is mainly seen in children and adolescents, occurs when the testis twists on its pedicle, obstructing the venous return. Blood continues to enter the testis and, with venous return mechanically obstructed, venous infarction occurs. A torted testis is swollen and painful and, clinically, may simulate orchitis in the early stages. With advanced torsion, the testis is swollen and almost black in colour because of the vascular congestion. As such cases are non-viable, surgical removal is required to treat advanced disease. Early detection and surgical relief of torsion is required to save testicular viability. Similar clinical features may be caused by torsion of hydatids of Morgagni.

The ductal system from the testis is mainly affected by cysts, inflammatory disorders and, rarely, tumour

There are few important disorders that affect the tubular system between the epididymis and the prostatic urethra. Among the most common are epididymal cysts(spermatoceles) which are cystic dilatations of the head of the epididymis. The cyst is usually thin-walled and translucent, containing watery or slightly milky fluid, in which spermatozoa can be identified. Varicoceles are composed of a dilated pampiniform plexus of veins, which expands within the scrotal sac.
Benign tumours of support tissues (e.g. lipoma, fibroma) may occur, particularly in tissues of the spermatic cord. Lipomas are the most common followed by fibromas.

Sperm granuloma is a tender, indurated nodule, usually found alongside the vas deferens. Histologically it shows a chronic inflammatory reaction to remnants of spermatozoa, and is thought to represent a reaction to spermatozoa that have leaked out of the ductular system. It may also be found in the region of the head of the epididymis, but a location close to the vas deferens is most common. These lesions are often seen as nodules at the site of operative vasectomy.
Adenomatoid tumour is a benign neoplastic growth, which develops in or close to the epididymis. The tumour is a small, well-circumscibed, firm, white nodule, most commonly arising in middle-aged men. These lesions are thought to be of mesothelial origin.

Paratesticular sarcomas are uncommon tumours that develop from support tissues of the epididymis, especially in childhood. The most common are rhabdomyosarcoma and leiomyosarcoma.

Inflammation of the ductular system} may occur secondary to urinary tract infection or specifically in association with gonorrhoea.
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